Special Needs Plans (SNP)

What are Special Needs Plans (SNP)

Special Needs Plans (SNPs) are a subset of Medicare Advantage plans available to people with special needs.
These plans aren’t available in all areas.
SNP provides benefits and services to people with specific severe and chronic diseases, certain health care needs, or who have Medicaid.
SNPs include care coordination services and tailor their benefits, provider choices, and list of covered drugs (formularies) to best meet the specific needs of the groups they serve.
SNPs are either HMO or PPO plan types, and cover the same Medicare Part A and Part B benefits that all Medicare Advantage Plans cover.
All SNPs must provide Medicare drug coverage (Part D)
SNPs might also cover extra services for the special groups they serve. For example, if you have a severe condition, like cancer or congestive heart failure, and you need a hospital stay, an SNP may cover extra days in the hospital.
You can only stay enrolled in an SNP if you continue to meet the special conditions of the plan

You can join SNP if you meet these requirements

You have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
You live in the plan's service area.
You meet the eligibility requirements for one of the 3 types of SNPs:
Dual Eligible SNP (D-SNP)
Chronic Condition SNP (C-SNP)
Institutional SNP (I-SNP)

Chronic Condition SNP (C-SNP)

Common qualifying conditions include diabetes, chronic heart failure, and chronic lung disease depending on the carrier and the plans available in your area:
If you are not currently a C-SNP enrollee, you are eligible for a special enrollment period (SEP) to change to or add C-SNP coverage.
You are also eligible for a SEP for every additional chronic illness that is not covered by any current C-SNP
Your doctor must verify that you have a qualifying health condition
You usually have 30 days or less from enrollment to verify the health condition or you will be dropped from the SNP Plan

Dual Eligible SNP (D-SNP)

To qualify you must be eligible for both Medicare and Medicaid
Eligibility requirements vary by state, check with your state’s Medicaid program to determine eligibility criteria.
For Texas Click on top section MEDICAID - it will give you the the details for the ways to qualify
If you qualify for MEDICAID than you will be get specific category
You must recertify your Medicaid enrollment to continue to receive your Medicare coverage
If your category of Medicaid eligibility changes, your cost-share may also increase or decrease.
It is important to note that the specific benefits offered by a D-SNP will vary depending on the plan

You can enroll in plan if you are in one of these Medicaid categories:

Qualified Medicare Beneficiary (QMB): While QMB status provides you with Medicaid coverage of your Medicare cost-share, you are not eligible for full Medicaid benefits. This means that Medicaid pays only your Part A and Part B premiums, deductibles, and cost-share amounts. Medicaid does not cover your Part D prescription drug copays nor does it pay for services that Medicare Part A or Part B does not cover.

Qualified Medicare Beneficiary Plus (QMB+): As a QMB+, not only is your Medicare cost-share covered by Medicaid, but you also are eligible for full Medicaid benefits. Medicaid pays your Part A and Part B premiums, deductibles and cost-share amounts. This means you pay your Part D prescription drug copays—and nothing else.

Specified Low-Income Medicare Beneficiary (SLMB): You do not have full Medicaid benefits as an SLMB. Medicaid pays only your Part B premium—not any cost-share amounts; however, you may find that some services do not require a member cost-share.

Specified Low-Income Medicare Beneficiary (SLMB+): As a SLMB+, you are eligible for full Medicaid benefits. In addition, Medicaid pays your Part B premium. Further, additional limited assistance from your state Medicaid agency may be available to help you pay any Medicare cost-share amounts. When both Medicare and Medicaid provide coverage for a service you receive, your cost-share is typically 0%; however, when Medicaid does not provide coverage for such service or other benefit, you may be required to pay a cost-share amount.

Qualifying Individual (QI): You do not have full Medicaid benefits as a QI, so Medicaid pays only your Part B premium—not any cost-share amounts; however, you may find that some services do not require a member cost-share.

Qualified Disabled and Working Individual (QDWI): As a QDWI, you do not have full Medicaid benefits. Medicaid pays only your Part A premium. While Medicaid does not pay any cost-share amounts, you may find that some services do not require a member cost-share.

Full Benefits Dual Eligible (FBDE): You are eligible for full Medicaid benefits as an FBDE; further, Medicaid may provide limited assistance with Medicare cost-share amounts. When both Medicare and Medicaid provide coverage for a service you receive, your costshare is typically 0%; however, when Medicaid does not provide coverage for such service or other benefit, you may be required to pay a cost-share amount.

INSTITUTIONAL SPECIAL NEEDS SNP (I-SNP)

People who live in long-term care facilities or who need a facility level of care while living elsewhere for 90 days or more may be eligible

Medicare ISNPs must cover:

Inpatient hospital stays – at least matching Medicare Part A coverage
Medical care – at least matching Medicare Part B coverage, including for doctor visits, preventive care, and durable medical equipment
Prescription drugs – covered medications and costs vary by plan
Care coordination – a care plan developed specifically for the patient’s needs
Localized care – limited travel for appointments, testing, therapies, etc.

Low Income Subsidy (LIS)

“Extra Help," also known as Low Income Subsidy (LIS), is a federally run program through Supplemental Security Income (SSI) that helps members with Medicare pay for Part D prescription drug costs.

It reduces:

●Monthly Part D premiums

●Annual Part D deductibles

●Prescription copays

It also:

Waives the late enrollment penalty (LEP) for those who did not enroll in Part D when they first became eligible.

● Eligibility is based on income and asset limits, with automatic qualification for some

(e.g. dual-eligible, SSI recipients). Full LIS is now available to individuals up to 150% of the FPL.

●Note: A member can have LIS and not be on Medicaid

while many Medicaid recipients automatically qualify for LIS, QDWI members are not automatically eligible for LIS.

It is important to always verify LIS status.

Who qualifies for LIS?

Income requirements:

●As of 2026, the income limit is $23,475 for an individual and $31,725 for a married couple.

●There is no requirement to meet other criteria, such as disability, family status, etc.