Healthcare Educators


Medicare Special Needs Plans for Chronic Conditions

by | Jun 12, 2023

CMS reports that an estimated 117 million adults have one or more chronic health conditions and 25% of adults have two or more chronic health conditions. To help Medicare beneficiaries who fall into these groups achieve better health outcomes, Medicare offers Special Needs Medicare Advantage Plans (SNPs) designed specifically for individuals with chronic or disabling health conditions. These plans are called Chronic Condition Special Needs Plans (C-SNPs).

What Conditions Are Covered by C-SNPs?

To be eligible for a C-SNP, you must have one or more of the following chronic health conditions:

  • Chronic alcohol dependence or other drug dependence
  • Certain autoimmune disorders
  • Cancer (excluding pre-cancer conditions)
  • Certain cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-state liver disease
  • End-stage renal disease requiring dialysis
  • Certain severe hematologic disorders
  • Certain chronic lung disorders
  • Certain chronic and disabling mental health conditions
  • Certain neurologic disorders
  • Stroke

CMS has a detailed list of specific conditions and diagnoses covered by C-SNPs.

The Benefits of a C-SNP

Most C-SNPs offer extra services or benefits for the group they serve. The plans provide access to hospitals and doctors who specialize in the condition and may have low or no copayments for visits to a primary care doctor or specialist. They may also offer lower costs for the medications required to treat your condition.

A C-SNP may provide you with a Care Coordinator who will help monitor your condition. This Care Coordinator will offer personal support and help coordinate the many aspects of your medical care, including by making sure you have the right prescriptions and are taking them correctly and by helping you set up doctors appointments. Your Care Coordinator can be an important healthcare partner who ensures you are receiving the treatment you need to see better health outcomes.

Eligibility Requirements

You must have Medicare Parts A and B to enroll in a C-SNP. (The plan includes Part D drug coverage.) When you apply, you must prove you meet the eligibility criteria. You will need documentation from your doctor confirming you have the specific condition covered by the C-SNP. You may be asked periodically to prove you continue to meet the criteria.

To be eligible, you must live in the insurance plan’s service area – not all plans are offered in all areas. Plans can vary greatly depending on the insurance company and where you live. You can use Medicare’s Plan Finder to search for plans in your ZIP code.

Special Enrollment Periods

If you are newly diagnosed or have a worsening condition that makes you eligible, you qualify for a Special Enrollment Period and can sign up at any time. Once your doctor confirms your condition, your new plan will be effective on the first day of the following month.

If you no longer qualify and lose eligibility, you will have a grace period of at least one month to remain in the plan while you look for other coverage. You will have another Special Enrollment Period to select another plan. You can choose a new plan starting from the time you lose your special needs status and up to three months after your C-SNP’s grace period ends.

Is a C-SNP Right for You?

If you qualify for a C-SNP and there is one available in your area, you still need to be sure it’s right for you.

  • Make sure your preferred doctors, hospitals, and pharmacies are in the network. If you want out-of-network coverage, you’ll need to pick a plan that allows this.
  • Ask what out-of-pocket costs are associated with any ongoing treatment, tests, or procedures you’ll receive for your condition.
  • Know what your medications will cost based on the insurer’s drug formulary.

If you have become eligible for a C-SNP or have recently lost eligibility, the knowledgeable and experienced team at Medicare Educators can help you find the right plan for your needs. Contact us today.