If you have a chronic health condition there may be a Medicare Advantage plan available that is designed to meet the needs of individuals who struggle with complex health issues. These plans, known as Chronic Condition Special Needs Plans (C-SNP’s) are intended to lower your out of pocket costs for medications and specialists that treat your condition. They may also offer extra benefits such as additional days of hospital coverage and access to a care coordinator. A care coordinator can be a valuable partner in helping to coordinate many aspects of your care including medications and medical appointments.
What Conditions Are Eligible for a C-SNP
A C-SNP may cover just one chronic condition, or it may cover multiple related conditions.
- Chronic alcohol and other dependence
- Certain autoimmune disorders
- Cancer (excluding pre-cancer conditions)
- Certain cardiovascular disorders
- Chronic heart failure
- Dementia
- Diabetes mellitus
- End-stage liver disease
- End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
- Certain severe hematologic disorders
- HIV/AIDS
- Certain chronic lung disorders
- Certain chronic and disabling mental health conditions
- Certain neurologic disorders
- Stroke
A more detailed list of specific chronic conditions can help clarify eligibility for a C-SNP. It’s important to note that C-SNP’s are sold by private insurers, and not all plans are available in all areas of the country. You can use Medicare’s plan finder tool to search for plans in your zip code. You can filter your search by Special Needs Plans / Have a chronic or disabling condition.
Other Things to Consider
If there is a plan available in your area there are some other things to keep in mind to help you determine if the plan is right for you:
Provider Network: Because C-SNP’s are Medicare Advantage plans you must use providers in the plans network. You need to confirm that all of the doctors you see and any hospitals where you wish to receive treatment are in the plans network. Some insurers may offer PPO plans that allow you to go out of network for a higher out of pocket cost. An HMO plan will offer no coverage outside of the plans service area other than emergency room and urgent care.
Drug Formulary: All C-SNP’s include prescription drug coverage, so you want to check each of your drugs and be sure it is listed on the insurer’s drug formulary. The formulary is a list of the medications the insurance company will cover. It includes brand name and generic medications. The formulary will indicate what tier the medications falls on and this will determine your out of pocket costs. The formulary will also list any special requirements for a medication such as:
- Prior authorization – requires your doctor to submit for approval before the drug will be covered.
- Step therapy – requires you try a generic or less expensive “preferred” drug to treat your condition to see if it works as well as the one prescribed.
- Quantity limits – the plan will not cover more than the dosage or quantity it regards as normal to treat your condition unless your doctor says that a higher dosage or quantity is medically necessary for you because a lesser dosage has already proved to be ineffective.
You also want to confirm that the pharmacy where you fill your prescriptions is in the plans network.
Cost: Because these plans are offered by private insurers your out of pocket costs will vary by plan. Costs will include your monthly premium, any deductibles, copays, and coinsurances for medical services and prescriptions. Make sure you know the costs for any ongoing treatments, procedures or tests you receive for your condition. You will still pay your Part A (if you have one) and Part B premiums.
Special Enrollment Period
If you qualify for a C-SNP you will be eligible for a Special Enrollment Period that allows you to change plans outside of Medicare’s usual enrollment periods. You can join a C-SNP at any time and your coverage will be effective the first of the following month. Your doctor must provide verification of your qualifying condition within the first month of your enrollment in the plan. You will be asked to reconfirm your eligibility every year.
In the event you no longer qualify for the C-SNP due to changes in your health you will be granted a Special Enrollment Period to find new coverage.
A Local Medicare Agent Can Help
If you think you might qualify for a C-SNP plan and want to see if one if available in your area, a local licensed Medicare agent or broker can help. They are familiar with the plans available in your locality. If a plan is available they can help you review the benefits to see if it is the right fit for you. If you decide to move forward they can help you enroll in the plan. Silver&Smart’s Medicare Insurance Agent Directory can help connect you with a licensed Medicare Agent in your state.