Special Needs Plan (SNP)

Special Needs Plans (SNP) are like an HMO or PPO and are a type of Medicare Advantage Plan that limits its membership to patients with specific diseases. The plan arranges benefits, providers, and prescription drug formularies to meet the very specific needs of the patients it treats. Prescription drug coverage is mandatory in a SNP.

Special Needs Plans restrict their membership to certain groups:

  • Patients who live in certain institutions (like a nursing home) or who require home-based nursing care
  • Dual-Eligibles – Patients who are eligible for both Medicare and Medicaid
  • Patients who have chronic or disabling conditions. [diabetes, HIV/AIDS, chronic heart failure, dementia, or End-Stage Renal Disease (ESRD)]

Generally, SNPs require patients to have a primary care physician and referrals are necessary for specialists except for yearly screening mammograms or in-network pap tests and pelvic exams which are covered as least every other year. Care is required to be obtained from doctors or hospitals in the SNP network except for emergency or urgent care, or if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis.

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