Medicare Special Needs Plans (SNPs)

Medicare SNPs are a type of MAPD that limit enrollment to people with specific diseases or characteristics. As MAPD plans, they all include prescription drug coverage.
SNPs can be LPPO, RPPO, HMO, or HMO-POS.
Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve (Medicare.gov)

There Are 3 Types Of SNPs

Dual SNPs Or D‑SNPs

This plan type is designed to enrolled exclusively beneficiaries with Medicare and Medicaid coverage.

Chronic SNPs Or C‑SNPs

This plan type is designed for individuals with specific severe or disabling chronic conditions.

Institutional SNPs Or I&#8209SNPs

This plan type is designed for Medicare beneficiaries in need of nursing level of care.

D-SNPs

Managed Care Organizations (MCO) already contracting with the state Medicaid program coordinate the care for this population through a single plan. Premium and cost sharing payment by Medicaid depends on the level of assistance the beneficiary gets through the Medicare Saving Program (MSP) administered by each state. MSP benefit groups are as follows:

Qualified Medicare Beneficiaries (QMBs) without Medicaid (Partial Duals):
This group is comprising of individuals with income up to 100% of FPL and resources up to 3-times the limit for Supplementary Security Income (SSI) eligibility. Medicaid pays Part A premium, if applicable, Part B premium, and Part A & B cost sharing (deductible, co-pay and coinsurance). This group automatically qualifies for Part D Low Income Subsidies (LIS), known as Extra Help, that reduces their payment responsibility further.
QMBs with full Medicaid coverage (QMB Plus or Full Duals):
In addition to the premium and cost sharing assistance to the QMBs, this group has Medicaid coverage and qualifies for Part D extra help.
Specified Low-Income Medicare Beneficiaries (SLMBs) without Medicaid (SMLBs Partial Duals):
This group is comprising of individuals with income between 100% and 120% of the FPL, resources less than 3 times the limit for SSI eligibility and enrolled in Part A. Medicaid pays the Part B premium and also automatically qualifies for Part D extra help.
SMLB with Full Medicaid coverage (SLMB-PLUS or SLMB- Full Duals):
In addition to Part B premium and part D extra help, they have Medicaid services. Some states pay their Part A and B cost sharing.
Qualified Individual (QIs):
This group is comprising of individuals with income between 120% and 135% of the FPL, resources up to 3 times the limit for SSI eligibility and enrolled in Part A. Medicaid pays the Part B premium only, so they are responsible for their Medicare cost sharing. QIs are ineligible for any other Medicaid coverage.
Qualified Disabled and Working Individuals (QDWIs):
This group is comprising of individuals with Income up to 200% of the FPL, resources up to 2 times the limit for SSI eligibility, individuals under 65 with a qualifying disability who lost premium-free Part A coverage after returning to work and now must enroll in and purchase Part A coverage. Similar to the QIs, they are ineligible for any other Medicaid coverage.

C-SNPs

There are currently 15 chronic conditions, defined in chapter 42, part 422 of the Code of Federal Regulations (42 CFR 422.2.), carriers can use to design a C-SNP for a target population. CMS identifies the following 5 commonly co-existing chronic conditions that may be the focus of a C-SNP:

Group 1: Diabetes mellitus and chronic heart failure
Group 2: Chronic heart failure and cardiovascular disorders
Group 3: Diabetes mellitus and cardiovascular disorders
Group 4: Diabetes mellitus, chronic heart failure, and cardiovascular disorders
Group 5: Stroke and cardiovascular disorders.

For Medicare Advantage Organizations (MAOs) that are approved to offer a C-SNP targeting one of CMS defined groups, enrollees need to have only one of the qualifying conditions for enrollment.

A carrier that customizes its group based on some of the 15 chronic conditions is required to verify that enrollees have ALL the conditions included in their customized group. A customized group can be limited to a single condition of the list (List of Chronic Conditions.pdf).

Medicare Special Needs Plans (SNPs)