What are Medicare Special Needs Plans and who qualifies?

Patrice King Brown: Whether you’re new to Medicare, exploring your options, or just want to keep up with the latest in Medicare news, we’ve got you covered.

Stacy Smith: No fluff, no jargon. Just real conversations to help you navigate Medicare with confidence. I’m Stacy Smith.

Patrice King Brown: And I’m Patrice King Brown. Welcome to “Medicare for the Record,” brought to you by UPMC for Life.

Hello, and welcome back to “Medicare for the Record.” Stacy, so many options and so much planning goes into Medicare.

Stacy Smith: Yeah. You know, when people think about Medicare Advantage plans, they may not realize that there are certain plans specifically designed for individuals who have unique healthcare or financial needs. So in this episode, we will explain what Special Needs Plans are, who may qualify, and how they differ from other Medicare Advantage plans, and why they can provide additional support for eligible members.

Patrice King Brown: Our guest today is Margaret Carrocia, and Margaret is the senior director of Medicare Special Needs Plan at UPMC Health Plan. I understand you joined UPMC Health Plan in 2022.

Margaret Caroccia: Yes.

Patrice King Brown: You know a lot about this. Lifetime Pittsburgher, Margaret?

Margaret Caroccia: Yes, I am.

Patrice King Brown: You went to University of Pittsburgh as well?

Margaret Caroccia: Yes.

Patrice King Brown: I know you've got a lot of good information for us today.

Margaret Caroccia: Yes. Nice to meet you.

Stacy Smith: Margaret, let's jump right into it. What is a Special Needs Plan?

Margaret Caroccia: A Special Needs Plan is actually a specialized Medicare Advantage plan, specifically for people who either have a chronic condition or are in a skilled nursing facility or other type of long-term care institution or are dually eligible for Medicare and Medicaid services.

Patrice King Brown: So how do these plans differ from regular Medicare Advantage plans?

Margaret Caroccia: The big difference is care coordination, specialized benefits, and also in many cases, specialized provider networks to really be targeted to those members' needs.

Patrice King Brown: So can you explain each types of plans, these Special Needs Plans and their eligibility requirements?

Margaret Caroccia: Sure. So there are Institutional Special Needs Plans, or it's I-SNPs, and they are for people who are in a skilled level of care or other type of long-term care situation for more than 90 days. There are Chronic [Condition] SNPs or C-SNPs, and those are targeted towards specific chronic conditions—whether it's diabetes, COPD, heart failure—and they have very specialized programs for people that meet those medical requirements. And then Dual [Eligible] SNPs or D-SNPs are for people who are eligible for Medicaid and for Medicare and have certain income threshold requirements or disability requirements that make them eligible for both.

Stacy Smith: What extra benefits are available for SNP members?

Margaret Caroccia: There is care coordination, which is crucial. Also, especially for the dual SNPs who have dual coverage for Medicaid and Medicare, having a centralized care manager, care concierge for customer service, and then specialized benefits such as assistance with healthy food or transportation to medical appointments or even nonmedical appointments. And in some C-SNPs, there could also be special coverage for certain drugs or health coaching, personal coaching specific to that person's chronic condition.

Stacy Smith: You just mentioned drugs. Do these Special Needs Plans offer prescription?

Margaret Caroccia: Yes. All Special Needs Plans offer prescription drug coverage, just like all of the Medicare Advantage plans do. And it's really important from a pharmacy perspective that we're making sure that you check your formulary, that you check your plan's pharmacies, and really to make sure that the plan continues to serve your needs as your situation changes.

Patrice King Brown: Now, Margaret, we've been hearing about something called—and I want to make sure I get this right—special supplemental benefits for the chronically ill. And that is—sometimes they use the initials SSBCI. Now, what is this program? And then what does it mean for people who are on a special need program?

Margaret Caroccia: When CMS ended what was called the value-based insurance design program or VBID, that program allowed health plans to offer nonmedical benefits to their members. And when that program was ended, many of the plans switched to this other benefit program called the SSBCI. And what that does is allows health plans to offer nonmedical benefits such as healthy food, utilities assistance, things that can really help the members of the health plan manage their living situation and contribute to their better health through these nonmedical benefits.

Stacy Smith: So are there special eligibility requirements for this plan?

Margaret Caroccia: Yes, there are special requirements for this program that you have a chronic condition, that you're under the care of a physician for that condition or multiple conditions, and that you have low-income subsidy or Extra Help.

Patrice King Brown: You mentioned earlier that someone needs to have Medicare and Medicaid then to be considered dual eligible. So can you explain a little bit more about that?

Margaret Caroccia: In Pennsylvania, the Medicaid program is administered for the adults under what's called the Community HealthChoices program. And so a member who is dually eligible for Medicare and Medicaid would have a Community HealthChoices plan, as well as their D-SNP Medicare Advantage plan.

Patrice King Brown: Can someone choose the same insurance carrier for Medicare and Medicaid?

Margaret Caroccia: Yes, they can. And it's actually preferred. It gives you the opportunity to have both of your benefits administered and managed by the same health plan. So you get a single ID card. It makes things easier for your provider for billing and where to go for questions regarding your benefits. And you have a personal care manager that is able to coordinate and help you through any of your daily living needs and your covered benefits under both of the programs.

Stacy Smith: So are there specific times that you can enroll in the special needs program?

Margaret Caroccia: There is the time of the year called Annual Enrollment Period when all Medicare Advantage members are able to select another plan. And there's also times throughout the year when, especially for people who become newly eligible for Medicaid or a new chronic condition or have some other type of life change that would give them the opportunity to enroll in a D-SNP throughout the year.

Stacy Smith: So you don't have to wait if something new pops up into your life, a chronically ill disease of some sort, you don't have to wait till the next enrollment period?

Margaret Caroccia: You do not have to wait. You could do it any month.

Patrice King Brown: What should someone consider before enrolling in a Special Needs Plan?

Margaret Caroccia: I think it's really important to make sure that your doctors are participating, your other providers are participating. The formulary, make sure that your prescription drugs are covered by the plan, and also what the extra supplemental benefits are, and are they benefits that you will actually use and need? It's important that you meet the eligibility requirements for the plan, as well as that that plan will address your medical needs and provide financial protections.

Patrice King Brown: It's really hard sometimes. There's so much information on so many different levels. What advice would you give to someone who is thinking at this time, "Maybe I do need to sign up for a Special Needs Plan?"

Margaret Caroccia: I think it's really important to talk with a Medicare broker or a healthcare advisor or contact the health plan's member services. They can give you the information that you need to make a good decision.

Stacy Smith: All right. We have a couple of things that you should probably remember about what we talked about here in this particular episode, and that is that Special Needs Plans are designed specifically for people who meet certain eligibility requirements. Now these plans still include extra benefits and prescription drug coverage.

Patrice King Brown: If you think you may qualify for one of these plans, go to your plan's website or talk to a Medicare Advisor for help reviewing your options. And for more information, you can visit medicare.gov, cms.gov, or of course the UPMC for Life website, which is upmchealthplan.com/medicare.

Stacy Smith: Margaret, thank you for joining us, and thank you for joining us, and we'll see you again in our next episode.

Thanks for tuning in to “Medicare for the Record,” brought to you by UPMC for Life. To learn more about your Medicare options, visit upmchealthplan.com/fortherecord.

This podcast is provided for general informational and educational purposes only. It is not medical care or advice. For questions regarding medical care, please consult with your healthcare provider. Views and opinions expressed by the participants are solely their own and do not necessarily reflect those of UPMC Health Plan, its subsidiaries, parents, or affiliates.