Medicare Chronic Special Needs Plan [A Complete guide]

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The Medicare chronic special needs plan, also known as C-SNP’s, are Medicare Advantage Plans designed to cater to certain diseases. The most common ones are for heart disease, diabetes, and COPD. Just because you have the diagnoses does not mean one of the plans is the best for you, but you definitely should compare.

CHRONIC SPECIAL NEEDS PLAN (C-SNP)

Chronic conditions aren’t always catered for by regular Medicare plans. Special needs individuals as defined by the U.S health Act are individuals with one or more co-morbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and requires specialized delivery systems across domains of care.

Medicare Chronic Special Needs Plans are a type of Medicare Advantage plan (like an HMO or PPO) that offers special benefits to individuals that meet its eligibility criteria. In other words, Medicare C-SNP Plans limit membership to people with specific diseases and special needs. The plan provides special benefits, provider choices and drug formularies to best meet those special needs of the group of beneficiaries they serve.

Medicare C-SNP are therefore a perfect choice for individuals with disabilities and seniors with chronic health conditions.

ELIGIBILTY AND BENEFITS

The eligibility criteria for C-SNP includes – those enrolled in Medicare Part A and Part B (You can, however, sign up for Medicare Advantage plan straight from the government instead of getting Medicare Part A and B). Individuals eligible for Medicare Parts A and B include seniors 65 years or older and persons with disabilities who are receiving Social Security Disability Insurance (SSDI).

Also, to be eligible, individuals must either have a chronic condition, be eligible for Medicaid (and Medicare), live in the service area of the Special Needs Plan, or need institutional-level care to get coverage for C-SNP.

Here are many of the Chronic Conditions that you can find Special Needs Plans for: 

1. Chronic Alcohol and other drug dependence
2. Autoimmune disorders limited to: Polyartetritis nodosa, Polymyalgia rheumatic, Polymyositis, Rheumatoid arthritis, Systemic lupus erythematosus
3. Cancer, excluding pre-cancer conditions or in-status
4. Cardiovascular disorders limited to: Cardiac arrhythmias, Corona Artery Disease, Peripheral Vascular Disease, Chronic Venous thromboembolic disorder.
5. Chronic Heart Failure
6. Dementia
7. Diabetes mellitus
8. End-stage liver disease
9. End-stage renal disease (ESRD) requiring dialysis 
10. Severe hematologic disorders limited to: Apastic Anemia, Hemophilia, Immune thrombocytopenic purpura, Myelodysplastic syndrome, Sickle cell disorder (excluding sickle cell traits)
11. HIV/AIDS
12. Chronic lung disorders limited to: Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, Pulmonary hypertension.
13. Chronic and disabling mental health conditions limited to: Bipolar disorders, Major depressive disorders, Paranoid disorder, Schizoaffective disorder.
14. Neurologic disorders limited to: Epilepsy, Amyotropic lateral sclerosis (ALS), Extensive Paralysis (i.e., hemiplegia, quadriplegia, paraplegia, monoplegia), Huntington’s disease, Multiple sclerosis, Parkinson’s disease, Polyneuropathy, Spinal stenosis, Stroke-related neurologic deficit.
15. Stroke.

Certainly, if you have one of these conditions, check to see if an Special Needs Plan for your condition is offered in your area.

BENEFITS

Special Needs Plans are meant for individuals with chronic health conditions and offer benefits that better serve their healthcare needs at their most vulnerable state.

For example:

An insurance company may offer an Special Needs Plan for people with Chronic Heart Disease. The plan benefits may include more coverage for the heart medications, a network of doctors who specialize in Heart Disease and more preventive care than non Special Needs Plans.

A Chronic Special Needs Plan (C-SNP) combines hospital, medical and prescription drug benefits which makes it easier to coordinate care for vulnerable individuals. Likewise, these plans make it easy for members to follow doctor’s advice and prescriptions. C-SNP’s can also help beneficiaries get coordinated help from the community. All these benefits are provided under a single plan, making it easy for enrollees to get care.

The Chronic Special Needs Plan is therefore, most beneficial to the following groups:

• Individuals with permanent disability
• Individuals with chronic or multiple conditions such as diabetes, or diabetes and cardiovascular problems
• Elderly people with dementia who need institutional care

Most persons are able to drop their MEDIGAP policies when they join a Special Needs Plan because the plan fills in the gaps not covered by Medicare Parts A and B.

MEDICARE ADVANTAGE PLANS FOR DIABETICS

In a Medicare chronic care special needs plan, you get additional coverage for diabetic treatment.

Medicare provides coverage for various diabetes medications, supplies and services to help treat diabetes and maintain healthy blood glucose levels. Part B of Medicare provides coverage for diabetic test supplies, screenings, and education for beneficiaries with diabetics as well as those at risk of diabetes. Medicare Advantage or Medicare Part C covers the same diabetic supplies and screening that Medicare Part B covers.

It covers blood sugar (or blood glucose) self-testing equipment and supplies such as durable medical equipment, even if you don’t use insulin. Self testing supplies include:

• Blood sugar monitors
• Blood sugar test strips
• Lancet devices and lancets 
• Glucose control solution for checking the accuracy of testing equipment and test strips
• Up to 300 test strips and 300 lancets every 3 months if you use Insulin
• Up to 300 test strips and 100 lancets every 3 months if you do not use insulin
• Additional diabetic test strips if they are “medically necessary”.
• Glucose control solutions that checks the accuracy of your test equipment
• Flu and pneumococcal shots
• If you meet certain criteria, you’ll also get coverage for therapeutic continuous glucose monitors and related supplies approved for use in place of blood sugar monitors for making diabetes treatment decisions like changes in diet and insulin dosage.
• Therapeutic shoes or sole inserts.

Medicare will require that:

• a podiatrist or other qualified health care providers prescribe the shoes
• a doctor or other qualified individual like a pedorthist, orthoptist, or prosthetist fits and provides the shoes.

Medicare provides coverage for diabetic services such as:

• Diabetics screening test like twice a year If your Doctor indicates you are at risk for diabetes. After the first diabetics screening, your doctor can schedule a follow-up test.
• Up to 10 hours of out patient training within a 12-month period and 2 hours of follow-up training each year after that. This training helps beneficiaries manage their diabetes.
• Glaucoma test every 12 months for people at risk for high glaucoma. High risk in this regard means one of the following is true for you:

• Diabetic
• African-American and over the age of 50
• Hispanic and over the age of 65
• Glaucoma runs in your family

• Foot exams every six months 
• Medical Nutrition therapy

Medicare Advantage prescription drug plan covers the cost of items such as:

• External insulin pumps (Pumps worn outside the body)
• Anti-diabetic drugs used to maintain blood sugar (glucose) levels
• Insulin-related supplies such as syringes, alcohol swabs, needles, gauze, and insulin inhalers.
• Anti-diabetic drugs such as; Sulfonylureas, Biguanides, Thiazolidinediones, Meglitinides, Alpha glucosidase inhibitors (like Precose), Glucagon-like peptide 1 (GLP-1) receptor agonists (like Adlyxin) and many others.

MEDICARE ADVANTAGE PLANS FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Medicare Advantage plan provides coverage for oxygen therapy, nicotine patches, and Pulmonary Rehab (that includes counselling to stop smoking) which is equal to what you will get with Original Medicare (Part B). However, the cost might differ depending on your Medicare advantage plan. You may be required to use specific doctor’s or facilities within your plan’s network.

Medicare typically provides coverage for up to 36 pulmonary rehab sessions. Your doctor may, however, be able to request coverage for up to 72 sessions if they are deemed medically necessary for your care.

If you have COPD, you may likely have endured years of elevated rates and expensive medical necessities. Medicare Advantage plans do not have underwriting. Therefore they are a great option for someone with COPD or other disqualifying diseases. What this means is – your premiums and rates cannot grow based on your COPD. That’s a w big bin!

Enrolling in a Medicare Advantage plan could be the best choice, especially if you have the option for a low $0 premium plan.

Medicare and Oxygen Treatment

Also, some Medicare Advantage plans covers Oxygen therapy. This is given through nasal prongs or a mask for severe COPD cases and may be needed either infrequently or constantly. It helps pay for the rental of oxygen equipment as durable medical equipment (DME) and all oxygen supplies. If the equipment is owned, Medicare will cover the cost for oxygen and supplies for qualified beneficiaries. Medicare will only cover the cost for oxygen therapy provided by a contracted DME supplier.

The Medicare Advantage prescription drug plan covers for COPD Medications and Bronchodilators. Bronchodilators, inhaled steroids or both may be prescribed, depending on the severity of symptoms. Both of these medications help open airways to make breathing easier.

You can detect COPD early enough if you get tested and treatment works best during this period… it can also help you understand the risk for severe illness if you contract COVID-19. Medicare part B provides coverage for lung cancer screening with Low Dose Computed Tomography (LDCT) once per year if you meet the following conditions:

• You’re within the age range of 55 – 77
• You’re a smoker or have quit smoking in the last 15 years
• Do not have signs or symptoms of lung cancer (or you are asymptomatic)
• You have tobacco smoking history of at least 30 pack years (an average of one pack a day for 30 years)
• You have a written order from your doctor.

MEDICARE ADANTAGE PLANS FOR HEART DISEASE

Therefore, it’s important to have a Medicare Advantage Plan that caters to this need.

To clarify, these plans are all-in-one replacements for Original Medicare and will provide coverage for:

• Cardiovascular screening blood tests (which checks for cholesterol levels, lipid levels, triglyceride levels)
• Cardiac rehabilitation programs for qualifying conditions. Medicare Advantage plans covers some intensive cardiac rehabilitation programs if you’ve been referred by your doctor. These programs include a more intense physical workout, as well as counseling and education.
• Cardiovascular behavioral therapy. This therapy is designed to help you lower your risk of cardiovascular disease. It could include, among other things, a blood pressure check and information on heart-healthy eating.
• Chronic care management services. Medicare may provide coverage if you have two or more serious chronic conditions expected to last a year or longer. Examples of chronic conditions as defined by Medicare include: heart disease. Asthma, diabetes and hypertension.

Note that, Medicare doesn’t cover 100% of all costs. Have a conversation with your doctor about your needs and expected out-of-pocket payments, including cost of medications. However, Medicare Advantage plans helps you reduce your out-of-pocket expenses.

SPECIAL ENROLLMENT PERIOD (SEP) FOR C-SNP

Whenever certain circumstances occur that alter your healthcare coverage, you may have a chance to make changes to your Medicare Advantage plan. These chances to make changes are called Special Enrollment Periods (SEPs).

There are rules guiding when such changes can be made and the type of changes you can make. The changes can include: 

• change in where you live;
• you lose your current coverage; 
• you have a chance to get other coverage;
• your plan changes its contact with Medicare;
• other special situations.

You may be eligible for a special enrollment period (SEP) to join an SNP if you:

• Have Medicare and Medicaid. The Special Enrollment Period lasts as long as you have Medicare and Medicaid.
• Have a severe, disabling, or chronic condition. You can enroll in a C-SNP that specifically serves people with that condition at any time as long as you have the condition.
• Are entering an institution that qualifies you for a C-SNP coverage, or develop the need for a nursing home-level of care.

Consequently, If you have a severe disabling condition and there is a Medicare Chronic Care Special Needs Plan (C-SNP) available that serves people with your condition, you can enroll at anytime of the year, but once you enroll, your chances to make changes using that SEP ends.