Who Qualifies for Medicare Special Needs Plans: A Brief Guide

May 18, 2023

If you’re eligible for Medicare, you might also be able to qualify for a Medicare Special Needs Plan, which is a health insurance plan designed to meet the specific needs of certain groups of Medicare beneficiaries.

Enrollment in Special Needs Plans (SNPs for short) has tripled over the past decade, with 89% of SNP beneficiaries choosing a dual eligible SNP. This article outlines the requirements to qualify for a Special Needs Plan through Medicare.

What is a Medicare SNP?

A Medicare Special Needs Plan has all the benefits of a Medicare Advantage plan with some additional health care coverage to address individual and specialized needs that don’t come standard with Original Medicare or a Medicare Advantage Plan.

In general, Medicare beneficiaries with Special Needs Plans are required to get health care services exclusively from providers within the SNP network in their area. The provider networks will include medical professionals who specialize in the area of health care needed.

If you meet the requirements of a Special Needs Plan, it’s a good idea to enroll because the federal government provides additional funding to these plans. The surplus funding helps to cover health costs and extra coverage that is needed to provide medical care with low monthly premiums (or no premiums for those with both Medicare and Medicaid eligibility.  

What Makes SNPS Different?

One of the differentiating factors of Special Needs Plans is the degree of care coordination for managing one’s health and medical conditions. You’ll select a primary care physician who will work to coordinate your care and arrange for referrals to see any relevant specialists.

Unlike traditional Medicare Advantage plans, individuals can enroll in a Special Needs Plan at any time throughout the year. You do not have to wait for the Special Enrollment Period. If you already have a Medicare Advantage Special Needs Plan, you can switch plans at any time during the first three quarters of the year.

Types of Special Needs Plans

There are three different types of Special Needs Plans, and each has different requirements. Despite their differences, they do have some similarities. For example, each Special Needs Plan has a care coordinator designated to help you develop custom care plans and maintain health.

Below, we outline the characteristics of each of the three Medicare Special Needs Plans so that you can understand what each offers and find out whether you might be eligible for one (or more) SNP.

  1. Chronic Condition Special Needs Plan (C-SNP): For someone with chronic disabling conditions, a chronic condition SNP may be the best coverage option. 

    Eligible chronic conditions for Medicare Advantage C-SNP include congestive or chronic heart failure, cardiovascular disease, cancer, diabetes, dementia, end-stage renal disease, intellectual disabilities, and autoimmune conditions, including HIV and AIDS. A C-SNP can be invaluable for those who have been turned away by private insurance companies due to preexisting conditions.
  2. Institutional Special Needs Plan (I-SNP): If you are institutionalized in a nursing home or assisted living facility, you may be eligible for an Institutional SNP.

    In addition to residing in a skilled nursing facility, a resident of an inpatient psychiatric facility could also be eligible, as is someone who requires in-home nursing care.
  3. Dual-Eligible Special Needs Plan (D-SNP): A dual-eligible SNP requires that you have dual eligibility for both Medicare and Medicaid benefits due to low income or limited financial resources.

    This dual Special Needs Plan includes extra benefits at no cost, including prescription drug coverage. If your income qualifies you to be dual eligible for Medicare and Medicaid, then you can add D-SNP coverage to your existing plan.

Eligibility Requirements for Medicare Advantage Special Needs Plans

If you have a chronic medical condition or you experience a sudden development of a severe illness, you may be eligible for one or more Special Needs Plans.

For example, someone can simultaneously qualify for an I-SNP if they are housed in a skilled nursing facility and a D-SNP if they are eligible for both Medicare and Medicaid.

The three major requirements to qualify for an SNP include:

  1. You must already be eligible for Original Medicare (Part A and B)
  2. Meet the Special Needs Plan’s requirements (whether C-SNP, I-SNP, D-SNP, or a combination)
  3. Live in the SNP’s service area because not all areas of the country have Special Needs Plans

To sum up, you can meet eligibility requirements by requiring care in a long-term care facility, having a chronic condition, or having dual special eligibility for Medicare and Medicaid.

Advantages of Special Needs Plans

If you have Original Medicare and are considering a Special Needs Plan, consider the following advantages:

  • Expanded coverage options
  • Coverage for prescription drugs provided
  • Extra support for challenging health conditions
  • Full Medicaid benefits are available to those who meet income eligibility
  • More flexible enrollment (no special enrollment period)

Frequently Asked Questions About Special Needs Plans

The Medicare landscape can be confusing to navigate, so we’ve answered the most common questions about SNPs below.

Do Medicare Advantage SNPs charge a monthly premium?

Special Needs Medicare Advantage Plans tend to charge a premium on top of your Medicare Part B premium, but if you are eligible for Medicaid services, then the costs will be covered for you.

Do they include prescription drug coverage?

Yes, prescription drug coverage is a required benefit for all SNPs.

Do you have to stay in-network?

It depends. Some Medicare Advantage C-SNPs require you to stay in-network, but the exact terms will depend on your specific plan. Other plans allow you to seek care outside of the network.

What conditions qualify for a Chronic Condition SNP?

A Chronic Condition SNP-C is appropriate for people living with one or more chronic conditions that include chronic heart failure, congestive heart failure, cancer, HIV/AIDS, end-stage renal disease (ESRD), and more. You can find a complete list on the Medicare website here.


Medicare Advantage Advisors are practiced at explaining Medicare in terms anyone can understand. If you have questions about qualifying for an SNP or need help optimizing your Medicare coverage, contact us for further assistance.