What are Special Needs Plans?

A Special Needs Plan is a Medicare Advantage coordinated care plan specifically designed to provide targeted care to special needs individuals.

Types of individuals these plans target:

• an institutionalized individual
• a Dual Eligible individual
• or an individual with a severe or disabling chronic condition (as designated by CMS)

Now that we understand who can be eligible for these plans, we need to talk about when these enrollments can be made. A with any Medicare Advantage or Prescription Drug Plan, there are set enrollment timelines beneficiaries and agents need to be aware of. 

There are seven total enrollment guidelines to be aware of with Special Needs Plans.

Chronic Condition:

• The consumer has a severe or disabling chronic condition that an appropriate SNP plan is designed to serve, AND the consumer is not currently enrolled in a Chronic SNP plan serving that condition.
• Begins upon qualification of a disabling condition and ends when the consumer enrolls into a SNP plan.
• Election Code: SEP Special Need/Chronic.

Special Needs Status Change:

• Disenrolled from SNP due to loss of special needs status.
• Begins month of the effective date of disenrollment and ends three months after the date of involuntary disenrollment.
• Election Code: SEP, loss of SNP status.

Chronic SNP Non-Eligibility:

• The consumer enrolled in a Chronic SNP who is not verified for enrollment and is disenrolled two months after the effective date.
• Begins upon notification of non-eligibility and ends two months after notice is received.
• Election Code: SEP, loss of SNP status.

Dual and LIS Eligible (maintaining):

• Medicaid and/or LIS Eligible.
• One election per calendar quarter for the first nine months of the year.

Q1: Jan- March

Q2: April-June

Q3: July-September

• Election Code: SEP, Dual LIS Maintaining.

Loss, Gain, or Change in Dual/LIS Status:

• Became eligible for any type of dual or LIS, losing/lost eligibility of any type of assistance, and/or have a change in the level of assistance received.
• Allows an opportunity to make an election within three months of any gain, loss, or change in level.
• Election Code: SEP, Change in Dual/LIS Status.

Institutionalized:

• Moves in, resides in, or moves out of a Skilled Nursing Facility, Nursing Facility, Immediate Care Facility, Psychiatric Hospital, Rehabilitation Hospital, or Long-Term Care Hospital with an expecting stay of at least 90 days.
• Begins first day institutionalized and ends two months after discharge.
• Begins first day discharged and ends two months later.
• Election Code: OEPI.