Special Needs Plans

A Special Needs Plan is a special type of Medicare Advantage plan which is designed for three categories of Medicare Beneficiaries: (1) Dual Eligible - those with both Medicare and Medicaid, (2) Chronic Illness - those with Chronic Illnesses as defined by the plan and (3) Institutional -those confined to a long term care facility. A special needs plan can either be an HMO or a PPO plan. This means that there will be a provider network. Depending on the plans available in your area, some of the plans may include dental, vision, hearing or gym memberships. The plan will also include the Medicare prescription drug benefit.

Is this option right for me?

• If you have a qualifying special needs situation (Dual Eligibility, Chronic Illness or Long Term Care Facility), this could be a good choice.
• If you like having care coordination services to assist you with a chronic condition, this could be a good choice.
• If you like having your drug benefits included in with your other medical services (hospital and doctor), this could be a good choice.
• If you enjoy value added benefits, like hearing, vision, dental, gym memberships, this could be a good choice.
• If you are very satisfied with the Provider network for your basic and extended healthcare needs, this could be a good choice.

Advantages

• Financial Exposure to Part A and Part B cost sharing can be capped depending on the specifics of the plans in your area.
• Premiums can be waived (dual eligible plans).
• Additional Value Added benefits may be available (like Dental, Vision, Hearing and Gym benefits) depending on the specifics of the plans in your area.
• Drug benefit is integrated into plan, so you only have one card and one plan.
• There is no additional premium for the Medicare prescription drug benefit.
• Limits exposure to cost for Medicare covered Prescription drugs.
• Avoids Late Enrollment Penalty (LEP) for Medicare Part D Prescription Drug Benefits.

Disadvantages

• Unknown Out of Pocket costs depending on your level of utilization of services (except for dual eligible plans).
• Must use network providers.
• Medicare Advantage plans are not Guaranteed Renewable like Medicare Supplement plans. In addition, the benefits can be changed on a calendar year basis.
• You do not have the ability to select a specific drug plan based on your prescription drug needs. You get the prescription drug benefit which is bundled in the plan.

Costs — Medical and Hospital

• Premium for a Special Needs Plan
  • For those with a Dual Eligible Plan, the premium will be waived.
  • For those with a Chronic Illness or Institutional plan, the premium will vary based on the county of your residence and the plan you choose to enroll in.
• Cost Sharing for Hospitalization, Doctor Office Visits, diagnostic tests, x-rays, therapy, etc.
  • For those with a Dual Eligible plan, the cost sharing is generally waived.
  • For those with a Chronic Illness or Institutional plan, you will need to review the summary of benefits for each of the specific plans in your area to determine the exact out of pocket costs.
• Plans include a Maximum out of Pocket limit which is a calendar year maximum. This would not apply to a Dual Eligible plan.