What Is a Medicare Advantage Special Needs Plan?

Medicare Advantage plans are private health insurance plans available to seniors who qualify for Medicare. These plans cover Parts A and B of Medicare insurance and typically also include prescription drug coverage and other services such as hearing and dental that Original Medicare does not cover. Medicare Advantage Special Needs Plans are one of four common kinds of Medicare Advantage plans. The other three common types are:

· Health Maintenance Organization (HMO) Plans

· Preferred Provider Organization (PPO) Plans

· Private Fee-for-Service (PFFS) Plans

A Medicare agent at PBC can help you learn about whether a Medicare SNP is right for you, where they are offered and what type of plan is available in Hawaii. In this article we’re going to take an overall look at SNPs and how they work.


What is a Medicare Advantage Special Needs Plan

How Medicare SNPs work

Medicare SNPs are a type of Medicare Advantage Plan that only admits members who have specific diseases or characteristics. The reason for this is that Medicare SNPs provide benefits, provider choices, and drug formularies that are meant to meet the specific needs of the groups they serve.

Can I join a Medicare SNP?

You can join a Medicare SNP if you meet the following criteria:

  • You have Medicare Part A and Medicare Part B.

  • You live in the plan’s service area.

  • You have both Medicare and Medicaid. This is called a dual Eligible SNP (D-SNP). A Medicare agent overseeing this plan will ensure that all the plan health care providers you use accept Medicaid.

On a Medicare SNP Do I have to get care within the SNP network?

It’s important to know whether you can seek medical care from any medical provider or hospital or if you must remain within a network. When it comes to a Medicare SNP, you will generally need to get your care and medical services from physicians and/or hospitals within the Medicare SNP network. This is at least partly because Medicare SNPs usually have specialists in the diseases or health conditions that affect their members. The exceptions to the rule are for emergency or urgent care and if you need out of area dialysis for ESRD.

Do I need to have a primary care physician if I choose a Medicare SNP?

Most Medicare SNPs will require that members choose a primary care physician or require you to have a care coordinator to help manage your health care needs. The plan should help members coordinate the care and medical providers they need to manage their condition.

Will I need to get a referral to see a specialist?

Apart from certain cancer screenings* you will generally need to get a referral to see a specialist on a Medicare SNP.

*In-network pap smear and pelvic exam (covered at least every two years) and mammogram (covered every year).

Will I get prescription drug coverage on a Medicare SNP?

Yes, all Medicare SNPs must include Medicare prescription drug coverage.

Contact a PBC Agent for Help

Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.

At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.

email: info@pbchawaii.com

office: 808.738.4500

1221 Kapiolani Blvd PH30

Honolulu, HI 96814

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