Special Needs Program

8/3/2019 Special Needs Program

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C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S

Your Guide to MedicareSpecial Needs Plans (SNPs)

This ofcial government booklethas important in ormation aboutMedicare Special Needs Plans,including the ollowing:

How Medicare SNPs work

Joining and switching aMedicare SNP

Deciding i a Medicare SNPis right or you



Te in ormation in this guidewas correct when it was printed.Changes may occur a erprinting. Call 1-800-MEDICARE(1-800-633-4227), or visitwww.medicare.gov to get the mostcurrent in ormation. Y usersshould call 1-877-486-2048.

“Your Guide to Medicare Special Needs Plans (SNPs)” isn’t a legal document. Ofcial MedicareProgram legal guidance is contained in the relevant statutes, regulations,and rulings.

http://www.medicare.gov/




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Table o ContentsIntroduction to Medicare Special Needs Plans (SNPs). . . . . . . . . . . . . . . 4

About Medicare Special Needs Plans. . . . . . . . . . . . . . . . . .5What Is a Medicare Special Needs Plan?. . . . . . . . . . . . . . . . . . . .5Who Can Join a Medicare SNP?. . . . . . . . . . . . . . . . . . . . . . . .5How Medicare SNPs Work. . . . . . . . . . . . . . . . . . . . . . . . . .6How Much Do Medicare SNPs Cost?. . . . . . . . . . . . . . . . . . . . . .7Extra Help or People with Limited Income and Resources. . . . . . . . . . . . 8Where Are Medicare SNPs O ered?. . . . . . . . . . . . . . . . . . . . . .8

Medicare SNP Services and Benefts. . . . . . . . . . . . . . . . . . . . . .9 Joining and Switching Medicare SNPs. . . . . . . . . . . . . . . . . .11

When Can You Join a Medicare SNP?. . . . . . . . . . . . . . . . . . . . . .11When Can You Leave a Medicare SNP?. . . . . . . . . . . . . . . . . . . . .12How to Join a Medicare SNP. . . . . . . . . . . . . . . . . . . . . . . . .12

Your Appeal Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . .13How to Switch Your Medicare SNP. . . . . . . . . . . . . . . . . . . . . . .13Your Rights When You Join a Medicare SNP. . . . . . . . . . . . . . . . . . .13How to Appeal a Medicare SNP Coverage Decision. . . . . . . . . . . . . . . .13What I Your Services Are Ending too Soon?. . . . . . . . . . . . . . . . . . .14Advance Coverage Decisions. . . . . . . . . . . . . . . . . . . . . . . . .14

Medigap Policies and Medicare SNPs. . . . . . . . . . . . . . . . . .15Can You Keep Your Medigap Policy i You Join a Medicare SNP?. . . . . . . . . .15I You Drop Your Medigap Policy When You Join a Medicare SNP, What MedigapProtections Do You Have?. . . . . . . . . . . . . . . . . . . . . . . . . . .15What Happens i Your Medicare SNP Coverage Ends?. . . . . . . . . . . . . . .15

For More In ormation about Medicare SNPs. . . . . . . . . . . . . .17



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Introduction to MedicareSpecial Needs Plans (SNPs)Medicare Special Needs Plans area type o Medicare Advantage Plan(Part C) or people with certainchronic diseases and conditions orwho have specialized needs (suchas people who have both Medicareand Medicaid or people who livein certain institutions). MedicareSNPs provide their members withall Medicare Part A (HospitalInsurance), Medicare Part B(Medical Insurance) services,and Medicare prescription drugcoverage (Part D). Medicare SNPswere created to give certain groupso people better access to Medicarewith plans designed to meet theirunique needs.

Joining a Medicare SNP is yourchoice i you quali y to join one.For in ormation about othertypes o Medicare health plansyou can join, look at your copy o the “Medicare & You” handbook,or visit www.medicare.gov . You

can also call 1-800-MEDICARE(1-800-633-4227), and ask aboutMedicare health plan options inyour area. Y users should call1-877-486-2048.





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About Medicare Special Needs Plans

What Is a Medicare Special Needs Plan?Medicare Special Needs Plans (SNPs) are a type o MedicareAdvantage Plan (like an HMO or PPO). Medicare SNPs limitmembership to people with speci c diseases or characteristics,and tailor their bene ts, provider choices, and drug ormularies(list o covered drugs) to best meet the speci c needs o thegroups they serve.

Who Can Join a Medicare SNP?

You can join a Medicare SNP i you have Medicare Part A andPart B, live in the plan’s service area, and meet the plan’s eligibility requirements, such as one o the ollowing:

You have one or more speci c chronic or disabling conditions■(like diabetes, congestive heart ailure, a mental healthcondition, or HIV/AIDS).You live in an institution (like a nursing home), or you require■nursing care at home.You have both Medicare and Medicaid.■

Each Medicare SNP limits its membership to people in one o these groups, or a subset o one o these groups.

For example, a Medicare SNP may be designed to serve only people diagnosed with congestive heart ailure. Te plan wouldinclude access to a network o providers who specialize intreating congestive heart ailure, and it would eature clinicalcase management programs designed to serve the special needs

o people with this condition. Te plan’s ormulary would bedesigned to cover the drugs usually used to treat congestive heartailure. People who join this plan would get bene ts specially

tailored to their condition, and have all their care coordinatedthrough the Medicare SNP.

Contact the plan you’re interested in or review plan materials tosee i you meet the plan’s conditions or membership. For morein ormation about joining a Medicare SNP, see page 11.



6 About Medicare Special Needs Plans

How Medicare SNPs WorkMedicare SNPs are approved by Medicare and run by private companies.When you join a Medicare SNP, you get all your Medicare hospital,medical health care services, and prescription drug coverage through thatplan.

Because they o er all health care services through a single plan, MedicareSNPs can help you manage your di erent services and providers. Tey can make it easier or you to ollow your doctor’s orders related to dietand prescription drug use. Medicare SNPs or people with both Medicare

and Medicaid may also help people get help rom the community andcoordinate many Medicare and Medicaid services.

Just like with other Medicare health plans, i you join a Medicare SNP,you will have to see providers who belong to the plan, or use certainhospitals to get covered services. In most cases, you will need re errals tosee specialists. Te Medicare SNP will still cover emergency or urgently needed care, even i you’re out o the plan’s service area.

I you decide to join a Medicare SNP, you should know the ollowing:I you have Medicare and Medicaid, or have limited income and■resources, some or all o your plan’s out-o -pocket costs may becovered. Contact your State Medical Assistance (Medicaid) ofce tolearn more. Call 1-800-MEDICARE (1-800-633-4227) or the phonenumber. Y users should call 1-877-486-2048.You’re still in the Medicare Program.■You still have Medicare rights and protections.■You still get complete Medicare Part A and Part B coverage through the■

plan.You get Medicare prescription drug coverage through the plan.■Te plan may o er extra bene ts tailored to the groups it serves, such as■diabetes services, care coordination, and/or other health and wellnessprograms.You generally still pay the Part B premium (in some cases the plan■may cover part or all o the Part B premium as a plan bene t). Yougenerally will also pay a Medicare SNP premium that helps cover costso providing Part A and Part B bene ts, prescription drug coverage, andany other extra bene ts the plan o ers.



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How Much Do Medicare SNPs Cost?I you have Medicare and Medicaid, most o the costs o joining aMedicare SNP will be covered or you. Contact your State MedicalAssistance (Medicaid) ofce or more in ormation and to see i you quali y or Medicaid bene ts. Visitwww.medicare.gov , or call1-800-MEDICARE (1-800-633-4227) to get the phone number oryour local Medicaid ofce. Y users should call 1-877-486-2048.

I you join a Medicare SNP and you don’t have both Medicare andMedicaid (or get other help rom your state paying or your Medicare

premiums), your exact costs will vary depending on the plan youchoose. In general, you will pay the ollowing:

Your monthly Medicare Part B premium.■Any additional monthly premium the Medicare SNP charges above■the Medicare Part B premium or Medicare Part A and B services.Any additional monthly premium the Medicare SNP charges or■prescription drug bene ts.Any additional monthly premium the Medicare SNP charges or■extra bene ts.Any plan deductible, coinsurance, or copayment amounts the■Medicare SNP charges. For example, the plan may charge a setcopayment amount, like $10 or $20, every time you see a doctor.

Your costs will also depend on the type o health care services youneed, how o en you get health care services, whether you ollow theplan’s rules, and what your plan charges or any extra bene ts youmay need. I you have Medicare and Medicaid, the SNP can’t chargeyou higher cost-sharing amounts than you would pay in OriginalMedicare. Before you decide to join, contact the Medicare SNP tolearn about your exact costs.

About Medicare Special Needs Plans






Extra Help or People with Limited Income and ResourcesAll Medicare SNPs include Medicare prescription drug coverage.Usually, you pay a copayment or your prescriptions. I you havelimited income and resources, you may be able to get Extra Helppaying your prescription drug coverage costs. People who quali y may be able to get their prescriptions lled and pay little or nothing out o pocket. You can apply or Extra Help at any time. Tere is no cost orobligation to apply or Extra Help, so anyone who thinks they mightquali y should apply.

o apply or Extra Help paying or Medicare prescription drugcoverage, call Social Security at 1-800-772-1213, or visitwww.socialsecurity.gov . Y users should call 1-800-325-0778.You can also visit your State Medical Assistance (Medicaid) ofce.A er you apply, you will get a letter in the mail letting you know whatto do next. If you have Medicare and Medicaid, you qualify for thisExtra Help automatically and don’t need to apply.

Where Are Medicare SNPs O ered?Insurance companies decide where they will do business, so MedicareSNPs may not be available in some parts o the country. Insurancecompanies can decide that a plan will be available to everyone withMedicare in a state, or only in certain counties. Insurance companiesmay also o er more than one plan in an area, with di erent bene tsand costs. Each year, insurance companies o ering Medicare SNPs candecide to join or leave Medicare.

Here’s how you can nd the Medicare SNPs in your area:Look at the “■ Medicare & You ” handbook mailed to you each all.Te Medicare SNPs in your area are listed in the back.Visit■ www.medicare.gov . Select “Health & Drug Plans.” I you don’thave a computer, your local library or senior center may be able tohelp you access the Medicare Web site.Call■ 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

http://www.socialsecurity.gov/



http://www.socialsecurity.gov/



9About Medicare Special Needs Plans

Medicare SNP Services and BeneftsWhat Services Do Medicare SNPs Cover?Medicare SNPs must cover all medically-necessary and preventiveservices covered under Medicare Part A and Part B, and prescriptiondrug coverage under Part D. Medicare SNPs may also cover extraservices tailored to the special groups they serve, like extra days in thehospital. Contact your plan to learn exactly what bene ts and servicesthe plan covers.

Do Medicare SNPs Cover Prescription Drugs?Yes. All Medicare SNPs must provide Medicare prescription drugcoverage. Medicare SNP ormularies may be designed to cover thedrugs most needed to treat the special needs o its members.

Do You Need to Choose a Primary Care Doctor in a Medicare SNP?In most cases, Medicare SNPs may require you to have a primary caredoctor, or the plan may require you to have a care coordinator to helpwith your health care.

What Is a Care Coordinator?Some Medicare SNPs use a care coordinator to help you stay healthy and ollow your doctor’s orders. A care coordinator is someone whohelps make sure people get the right care and in ormation.For example, a Medicare SNP or people with diabetes might use a carecoordinator to help members monitor their blood sugar, ollow theirdiet, get proper exercise, schedule preventive services such as eye and

oot exams, and get the right prescriptions to prevent complications.A Medicare SNP or people with both Medicare and Medicaid mightuse a care coordinator to help members access community resourcesand coordinate their di erent Medicare and Medicaid services.




When You Join a Medicare SNP, Can You Get Health Care rom Any Doctor or Hos

No. Generally, you must get your care and services rom doctors orhospitals in the Medicare SNP’s network (except emergency or urgentcare, such as care you get or a sudden illness or injury that needsmedical care right away, or i you have End-Stage Renal Disease (ESRD)and need out-o -area dialysis). Medicare SNPs typically have specialistsin the diseases or conditions that a ect their members.

Do You Have to Get a Re erral to See a Specialist in a Medicare SNP?In most cases, you will have to see your primary care doctor to get

a re erral. However, women don’t need a re erral to get a yearly mammogram or an in-network pap test and pelvic exam (covered atleast every other year).

How Do You Know i the Plan Covers a Service You Need?Medicare SNPs must use Medicare’s coverage rules to decide whichservices are medically necessary and covered by Medicare. Tis meansthat i a service is considered medically necessary under OriginalMedicare, the Medicare SNP must cover the service. You can also ask

the plan or an advance coverage decision to make sure the service ismedically necessary and will be covered be ore you get the service.(See page 14 or more in ormation about advance coverage decisions.)I you ask or an advance coverage decision, you have the right to get adecision rom the Medicare SNP.

Do Medicare SNPs Cover Services that Medicare Doesn’t Consider MedicallyNecessary?Medicare SNPs generally don’t cover the costs o services that aren’t

considered medically necessary under Medicare. I you need a servicethat the Medicare SNP decides isn’t medically necessary, you may haveto pay all the costs o the service. However, you have the right to appealthe plan’s decision. See page 13 or more in ormation on appeals.



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Joining and Switching Medicare SNPs

When Can You Join a Medicare SNP?Te chart lists the times you may be able to join a Medicare SNP or switchout o a Medicare SNP to a di erent plan.

Who can join or switch? When can you join or switch?

I you have Medicare and get helpfrom Medicaid (your state), or youlive in an institution like a nursinghome or hospital…

You can join any Medicare SNP you quali y or orswitch plans at any time.

I you’renewly eligible orMedicare…

You can join any Medicare SNP you quali y orduring your Initial Enrollment Period, which isusually the 7-month period that starts 3 monthsbe ore you turn age 65, includes the month inwhich you turn age 65, and ends 3 months a eryou turn age 65.You can join rom 3 months be ore to 3 monthsa er your 25th month o disability.

I youhave Medicare … You can join any Medicare SNP you quali y orduring the Annual Enrollment Period betweenNovember 15–December 31. Your coverage willbegin on January 1.NOTE: In 2011, the Annual Enrollment Periodwill be between October 15–December 7, withcoverage beginning January 1, 2012.

I you have Medicare AND youdevelop certain severe or disabling conditions …

You can join a Medicare SNP designed to servepeople with those conditions at any time, but onceyou join a plan, this Special Enrollment Periodends.

I you join a Medicare SNP and youmove out of your plan’s servicearea …

You can switch plans when you move, or you willbe automatically returned to Original Medicare.

I you belong to a MedicareSNP that leaves the MedicareProgram …

You can switch plans when your MedicareSNP noti es you that it’s leaving the MedicareProgram.



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When Can You Leave a Medicare SNP?You can stay enrolled in a SNP only i you continue to meet the specialconditions served by the plan. For example, i you joined a Medicare SNP thatonly serves members with both Medicare and Medicaid and you lose yourMedicaid eligibility, Medicare requires the plan to disenroll you i you don’tget your Medicaid eligibility back within the plan’s grace period. Te graceperiod is at least 1 month long, but plans can choose to have a longer graceperiod. I you lose eligibility or the plan, you will have a Special EnrollmentPeriod to make another choice.

Tis Special Enrollment Period starts when your Medicare SNP noti es youthat you are no longer eligible or the plan. It continues during the plan’s graceperiod, and i you’re disenrolled rom the plan at the end o the grace period,it continues or 2 months a er your coverage ends. It’s very important toreview your coverage options at this time to make sure you continue to havethe Medicare coverage you want and you continue to have prescription drugcoverage.

How to Join a Medicare SNPOnce you choose a Medicare SNP, you may be able to join in any o theseways:

By paper application.■ Contact the plan to get an application, ll it out, andreturn it to the plan. All plans must o er this option.On the plan’s Web site.■ Visit the plan’s Web site to see i you can join onlinBy phone.■ Call the plan you want to join, or call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048.Medicare’s Web site.■ I you have Medicare and Medicaid, you may be able

to join a Medicare SNP through the Online Enrollment Center by visitingwww.medicare.gov .

Joining and Switching Medicare SNPs





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Your Appeal Rights

How to Switch Your Medicare SNPI you’re in a Medicare SNP and want to switch to Original Medicare,contact your current plan, or call 1-800-MEDICARE. Y usersshould call 1-877-486-2048.

I you’re in a Medicare SNP, you may only be able to switch at certaintimes o the year. Seepage 11 to learn when you may be able to joinand switch Medicare SNPs.

I you’re in a Medicare SNP and you want to switch to a new MedicareSNP or other Medicare health plan, simply join the new plan. I you’reeligible to switch plans, you will be disenrolled automatically romyour old plan when your new plan coverage begins.

Your Rights When You Join a Medicare SNPMedicare SNPs must use Medicare’s coverage rules to decide whichservices are medically necessary and covered by Medicare. Tis meansthat i a service is considered medically necessary under OriginalMedicare, the Medicare SNP must cover the service.

I your plan won’t pay or, or doesn’t allow, a service you think shouldbe covered, you can le an appeal. You have the right to appeal any decision about your Medicare-covered services or extra bene ts. Tisis true whether you’re in Original Medicare or a Medicare SNP.

How to Appeal a Medicare SNP Coverage DecisionI you’re in a Medicare SNP, you can le an appeal i your plan won’tpay or, doesn’t allow, stops, or limits a service you think should be

covered or provided. I you think your health could be seriously harmed by waiting or a decision about a service, ask the plan or a astdecision. Tey must answer you within 72 hours.

Your Medicare SNP must tell you in writing how to appeal. A er youle an appeal, the plan will review its original decision. I your plan

doesn’t decide in your avor, the appeal is reviewed by an independentorganization that works or Medicare, not or the plan. Read yourplan’s membership materials or contact your plan or details aboutyour Medicare appeal rights.



14 Your Appeal Rights

What I Your Services Are Ending too Soon?I you believe you’re being discharged rom a hospital too soon,you have a right to immediate review by the Quality ImprovementOrganization (QIO) in your area. A QIO is a group o doctors andhealth pro essionals who monitor and review complaints about quality o care. You may be able to stay in the hospital at no charge while theQIO reviews your case. Te hospital can’t orce you to leave be ore theQIO reaches a decision. Call 1-800-MEDICARE (1-800-633-4227) toget the phone number or the QIO in your area, or visitwww.medicare.gov and select “Help & Support.” Y users should call1-877-486-2048.

I you think your services in a skilled nursing acility, home healthagency, or comprehensive outpatient rehabilitation acility are endingtoo soon, you also have the right to a ast-track appeal. Contact yourprovider or plan, and they will tell you how to ask or an appeal i youthink these services are ending too soon. You will be able to get a astreview o this decision, with independent doctors looking at your caseand deciding i your services need to continue.

Advance Coverage DecisionsI you aren’t sure whether your plan will cover a service you think youneed, you can ask the plan or a decision in advance to make sure theservice is medically necessary and will be covered. I you ask or anadvance coverage decision, you have the right to get a decision romthe Medicare SNP.

Be ore you join a Medicare SNP, ask the plan or check plan materialsto see how they handle medically-necessary services and advancecoverage decisions.





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Medigap Policies and Medicare SNPs

Can You Keep Your Medigap Policy i You Join a Medicare SNPYes, you can keep your Medigap (Medicare Supplement Insurance)policy i you join a Medicare SNP. However, it may cost you a lot, andyou will get little bene t rom it while you’re in the Medicare SNP.You may want to keep your Medigap policy until you’re sure you’rehappy with the Medicare SNP. I you’re already in a Medicare SNP,or i you’re covered by Medicaid, you don’t need a Medigap policy.Generally, it’s illegal or anyone to sell you one in these cases.

I You Drop Your Medigap Policy When You Join a Medicare SNWhat Medigap Protections Do You Have?I you drop your Medigap policy when you join a Medicare SNP, youmay have the right to get another Medigap policy later i either o the

ollowing is true:Your Medicare SNP coverage ends through no ault o your own.■You join a Medicare SNP or the rst time (and haven’t been in■another Medicare health plan), and you leave the plan within oneyear o joining.

I you were new to Medicare when you joined the Medicare SNP, youmay be able to choose any Medigap policy you want. I you already had a Medigap policy be ore you joined the plan and you dropped it,you may be able to get the same policy back.

What Happens i Your Medicare SNP Coverage Ends?I your Medicare SNP coverage ends, or your plan stops providing carein your area, you can join another Medicare plan, i one is available,or you can return to Original Medicare. Generally, i you return toOriginal Medicare, you may also have the right to buy a Medigappolicy.



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Notes



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For More In ormation about Medicare SNPs

Tere are several places you can go to get more in ormation about

Medicare SNPs or to nd out what Medicare SNPs are available inyour area:Look at the “Medicare & You” handbook mailed to you in the all.■Te Medicare SNPs in your area are listed in the back.Visit■ www.medicare.gov and select “Health & Drug Plans.” I youdon’t have a computer, your local library or senior center may beable to help you access the Medicare Web site.Call 1-800-MEDICARE (1-800-633-4227). Y users should call■1-877-486-2048.Call the company o ering the Medicare SNP you’re interested in to■answer any questions you have about the plan. Tey can send youin ormation about the plan and explain the plan’s bene ts.Call your local State Health Insurance Assistance Program (SHIP)■

or help with choosing and joining a Medicare SNP, paymentdenials or appeals, Medicare rights and protections, complaintsabout your care or treatment, or Medicare bills. For the phonenumber o the SHIP ofce near you, visit www.medicare.gov andselect “Help & Support.” You can also call 1-800-MEDICARE.







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Notes





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Special Needs Program