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What is a Medicare Special Needs Plan?

Posted by David Ghiorso, CPA, January 25, 2023

The goal of a healthcare plan is always to help you obtain the healthcare you need while managing out-of-pocket expenses. And because healthcare needs are highly unique depending upon each individual, it’s no wonder that there is no single healthcare plan that is right for everyone. That is especially true with regard to Medicare plans, because we tend to develop a variety of needs later in life. A Medicare Special Needs plan is designed to suit you as an individual.

Medicare Special Needs plans are Medicare Advantage plans that have been designed specifically to provide for the needs of people diagnosed with certain medical conditions. These HMO or PPO plans are arranged around the benefits, providers, and medications best suited to a group of people who share certain diagnoses or characteristics.

The following Medicare beneficiaries might qualify for a Special Needs Plan:

  • Those who live in a nursing home or who live at home but require in-home nursing care
  • Those who qualify for both Medicare and Medicaid
  • Those who are diagnosed with certain conditions, such as diabetes, HIV/AIDS, end-stage renal disease, dementia, or chronic heart failure

 

A Special Needs Plan will provide benefits targeted to member needs, including care coordination services. All of these plans provide prescription drug benefits (Medicare Part D). Some will require you to have a primary care doctor, while others will not. If you qualify on the basis of enrollment in both Medicare and Medicaid, you should check to be sure your preferred providers accept Medicaid.

A Special Needs Plan can help those with certain conditions manage their care more effectively and affordably, but the plan might not be right for every person in every geographic area. Consult with one of our qualified brokers to learn more about Special Needs Plans before making the decision to enroll in one.

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