Special Needs Plans #11302

Medicare MAPD Special Needs #SNP

& Chronic Condition  – C-SNP Plan?

 

Medicare SNPs  Special Needs Plans are subtype of Medicare Advantage Plan.  To enroll in a Medicare SNPs you must have one of these specific diseases or characteristics.  Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet your specific needs.   Medicare.gov

There are three different types of SNPs:

  1. Chronic Condition SNP (C-SNP)
  2. Dual Eligible SNP (D-SNP)
  3. Institutional SNP (I-SNP)  cms.govSpecialNeedsPlans  *

Can I get my health care from any doctor, other health care provider, or hospital?

You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).

Prescription drugs 

Yes. All SNPs must provide Medicare prescription drug coverage (Part D).

Do I need to choose a primary care doctor?

Generally, yes.

Do I have to get a referral to see a specialist?

In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.

What else do I need to know about this type of plan?

A plan must limit membership to these groups:

1) people who live in certain institutions (like nursing homes) or who require nursing care at home, or

2) people who are eligible for both Medicare and Medicaid, or

3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia).

Check with us, there might be additional rules [email protected]

Plans will coordinate the services and providers you need to help you stay healthy and follow doctors’ or other health care providers’ orders.

SNP Benefits
Click to enlarge

Chronic Condition Special Needs Plans C SNP

SNP plans may also offer home-delivered meals, transportation for nonmedical needs, pest control, indoor air quality equipment (e.g., air conditioner for someone with asthma), and minor home modifications (e.g., permanent ramps, widening of hallways or doorways to accommodate wheelchairs).

Learn More

Diabetes C SNP

If you have Medicare and diabetes you can enroll in chronic condition special needs plans (C-SNPs).   Surveys show members experience better outcomes than you would in regular Medicare Advantage (MA) plan.  The survey used a claims-based approach to compare member outcomes on five clinical and utilization  measures, Avalere found that enrollees in a diabetes-focused C-SNP were:

• 22 percent more likely to have a primary care visit,
• 10 percent more likely to receive appropriate diabetes testing,
38 percent less likely to have an inpatient hospital admission,
• 32 percent less likely to have a readmission, and
• 6 percent more likely to fill (and refill) a prescription for an antidiabetic medication.

These findings held true when controlling for expected differences in enrollees’ demographics and health status. The analysis suggests that C-SNPs can improve outcomes for beneficiaries with diabetes compared to non-SNPs.   AnthemInc.com * Avalere.com

Los Angeles & Orange  County

Email us [email protected]  for the most current documents or visit Blue Cross’s affiliate website.

No extra charge for our services & expertise.

  •  Summary of Benefits
  •  Evidence of Coverage 
    • See page 7 of the EOC Special eligibility requirements for our plan Our plan is designed to meet the specialized needs of people who have certain medical conditions. To be eligible for our plan, you must have diabetes mellitus.   NIH.Gov *
      • To determine eligibility for a special needs individual to enroll in a C-SNP, CMS requires that the C-SNP contact the applicant’s existing provider – doctor to verify that the enrollee has the qualifying conditions. C-SNPs must reconfirm a beneficiary’s eligibility at least annually.  CMS.gov
    • The Coverage chart is on page 50 of the EOC.  If it changes with annual revisions, just use the table of contents or search feature.
    • SNP FAQ’s from CMS Site  

Try turning your phone sideways to see the graphs & pdf's?

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Travel Insurance

Coverage for Travel - $50k Emergency under Medicare Medi Gap or MAPD Advantage may not be enough!

Chronic Conditions #List

Chronic care management services

 

If you have 2 or more serious, chronic conditions (like arthritis, asthma, diabetes, hypertension, heart disease, osteoporosis, and other conditions) that are expected to last at least a year, Medicare may pay for a health care provider’s help to manage those conditions.

This includes a comprehensive care plan that lists your health problems and goals, other health care providers, medications, community services you have and need, and other information about your health. It also explains the care you need and how your care will be coordinated. Your health care provider will ask you to sign an agreement to provide this service. If you agree, he or she will prepare the care plan, help you with medication management, provide 24/7 access for urgent care needs, give you support when you go from one health care setting to another, review your medicines and how you take them, and help you with other chronic care needs. You pay a monthly fee, and the Part B deductible and coinsurance apply.  medicare.gov/10050-Medicare-and-You

Links & Resources

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.  MAPD Plans must cover all A & B services Medicare.Gov *

That's why the premium is very low or ZERO!

2 comments on “SNP Special Needs Plans

  1. 7 comments on “ESRD SNP Caremore Medicare Advantage – Special Needs Plan for Kidney Failure –”

    1. Anonymous says:
      if one gets a transplant and no longer requires dialysis, can they stay on a ESRD SNP Plan?
    2. us says:
      I live in Los Angeles and I’m on a transplant waiting list in Washington State. Will a Medicare Advantage Plan pay my expenses out of state?
      • Steve Shorr says:
        Excellent Question and it’s beyond our pay grade. 

         

        For one, isn’t there a National Kidney registration?

        https://www.kidney.org/atoz/content/transplant-waitlist
        The United Network for Organ Sharing (UNOS) manages the list of all the people across the US waiting for an organ transplant. UNOS ensures that deceased donor organs are distributed fairly using a transparent system

        https://transplantliving.org/kidney/how-could-i-get-a-transplant-sooner/
        There are different kinds of donated kidneys – some with shorter wait times. It will be your job to choose which of these kidneys you’re willing to take – being open to more than 1 kind may make your wait shorter.

        On the other hand:

        http://www.organjet.com/
        OrganJet provides an information service, as well as options for timely and affordable air transport, for patients who are multi-listed or distant listed for organ transplants in the U.S.

        (Did you know that 500+ kidneys are wasted every year while 90000+ people wait on the list? We believe that we can improve the system and are working towards it.)

        In the meantime, you can likely get a transplant earlier by listing smartly.

      • Steve Shorr says:
        Excerpt from Evidence of Coverage 

         

        What are network providers?

        Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals and other health care facilities that have an agreement with us to accept our payment, and any plan cost sharing, as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The most recent list of providers and suppliers is available on our website at https://shop.anthem.com/medicare/ca.

        Why do you need to know which providers are part of our network?

        It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan, you must use network providers to get your medical care and services.

        The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services and cases in which the plan authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical and other covered services) for more specific information about emergency, out-of-network and out-of-area coverage.

        If you don’t have your copy of the Provider/Pharmacy Directory, you can request a copy from Customer Service (phone numbers are printed on the back cover of this booklet). You may ask Customer Service for more information about our network providers, including their qualifications. You can also see the Provider/Pharmacy Directory at https://shop.anthem.com/medicare/ca or download it from this website. Both Customer Service and the website can give you the most up-to-date information about changes in our network providers.

        Getting an exception is pushing the limits of our pay grade. See also our webpages on medical necessity and appeals.

      • Steve Shorr says:
        I checked with “my people” at Caremore and they advise that you NOT change plans as it may put in at the bottom of the waiting list

         

        Thus, I think your “battle” would be with Medi Cal to pay the 20% that Medicare doesn’t pay.

        Medi-Cal pays out of state when:

        540-1 (a) (5) When an out-of-state treatment plan has been proposed by the beneficiary’s attending physician and the proposed plan has been received, reviewed and authorized by the Department before the services are provided; and the proposed treatment is not available from resources and facilities within the State.

        https://www.law.cornell.edu/cfr/text/42/431.10

        Medi Cal Treatment Authorization Request

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