Special Needs Plans — D-SNP, C-SNP & I-SNP

A Special Needs Plan (SNP) is a type of Medicare Advantage (Part C) plan that limits enrollment to a specific group of people and coordinates their care. All SNPs are coordinated care plans and, unlike standard MA plans, all SNPs must include Part D prescription drug coverage. There are three kinds:

• D-SNP — for people who have both Medicare and Medicaid ("dual eligible")
• C-SNP — for people with a qualifying chronic condition
• I-SNP — for people who live in or need the care level of a long-term care institution for 90+ days (usually enrolled directly with the carrier)

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D-SNP — Dual Eligible Special Needs Plans

Who they're for

A dual-eligible person is entitled to both Medicare and Medicaid. Roughly 1 in 5 Medicare-eligible people are dual eligible. When someone has Medicare and qualifies for Medicaid, their state may pay the Part B premium and some Medicare costs (deductibles, copays, coinsurance), depending on the state and their eligibility category.

To create a D-SNP, a private insurer must hold a contract with both Medicare (CMS) and the state Medicaid agency, and must coordinate the member's Medicare and Medicaid benefits.

Benefits a D-SNP may offer

Benefits vary by state but often include:

• Care coordination
• Low-to-no monthly premiums
• Over-the-counter (OTC) allowances
• Dental, vision, and hearing benefits
• Transportation benefits
• Gym memberships / wellness programs
• Telehealth

Dual-eligibility categories (Medicare Savings Programs)

A dual-eligible person falls into a category based on how much help they get with Medicare premiums and cost-sharing. Four of these are Medicare Savings Programs (MSPs):

• QMB (Qualified Medicare Beneficiary): Medicaid pays Part A (if any) and Part B premiums and Medicare deductibles, coinsurance, and copays. Income up to ~100% of the Federal Poverty Level (FPL).
• SLMB (Specified Low-Income Medicare Beneficiary): Medicaid pays the Part B premium. Income ~100–120% FPL.
• QI (Qualifying Individual): Medicaid pays the Part B premium. Income ~120–135% FPL.
• QDWI (Qualified Disabled & Working Individual): Medicaid pays the Part A premium for certain working people under 65 who lost premium-free Part A. Income up to ~200% FPL.

"Plus" versions and FBDE: Some people get full Medicaid benefits on top of an MSP — shown as QMB+ and SLMB+. FBDE (Full-Benefit Dual Eligible) is a catch-all for people who get full Medicaid but don't fall under an MSP.

• Full-benefit duals: QMB+, SLMB+, FBDE
• Partial-benefit duals: QMB-only, SLMB-only, QI, QDWI

See Medicaid & Dual-Eligible Levels at a Glance for the income/asset thresholds.

Types of D-SNPs

D-SNPs are categorized three ways:

1. By network: HMO (in-network, PCP + referrals, lower cost) or PPO (out-of-network allowed at higher cost). Most D-SNPs are HMOs.
2. By Medicaid level served: Full-Benefit Dual Eligible, Medicare Zero Cost Sharing, Dual Eligible Subset, and Dual Eligible Subset Medicare Zero Cost Sharing — each accepts certain eligibility categories.
3. By integration with Medicaid: how tightly the plan coordinates with the state's Medicaid managed care:

• FIDE-SNP (Fully Integrated) — most integrated; one entity provides Medicare and Medicaid, including long-term services and supports.
• HIDE-SNP (Highly Integrated) — Medicare and Medicaid contracts under the same parent company.
• CO D-SNP (Coordination-Only) — least integrated; coordinates with Medicaid at a basic level.

Eligibility note

To enroll, a person needs Medicare Parts A and B, must live in the plan's service area, and must meet the Medicaid eligibility category the plan serves. Medicaid eligibility is verified, and a member can be disenrolled if eligibility can't be confirmed. (CMS rules continue to tighten the link between D-SNPs and their affiliated Medicaid plans over the coming years.)

Agents should not help clients enroll in Medicaid itself unless trained to do so — instead, direct people to their state Medicaid agency (Medicaid.gov).

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C-SNP — Chronic Condition Special Needs Plans

Who they're for

A C-SNP is a Medicare Advantage plan for people with one or more qualifying chronic conditions. These plans tailor their benefits, provider networks, and drug formularies to the condition and emphasize care coordination, often providing a care manager and special programs. There are no income or asset limits, and C-SNPs do not require medical underwriting — insurers must accept anyone who meets the eligibility criteria.

The qualifying chronic conditions (CMS list)

A doctor must document at least one of these (CMS may revise the list over time):

1. Chronic alcohol and other drug dependence
2. Certain autoimmune disorders (e.g., rheumatoid arthritis, lupus, polymyalgia rheumatica, polymyositis, polyarteritis nodosa)
3. Cancer (excluding pre-cancer/in-situ)
4. Certain cardiovascular disorders (e.g., cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder)
5. Chronic heart failure
6. Dementia
7. Diabetes mellitus
8. End-stage liver disease
9. End-stage renal disease (ESRD) requiring dialysis
10. Certain severe hematologic disorders (e.g., hemophilia, sickle-cell disease, aplastic anemia, immune thrombocytopenic purpura, myelodysplastic syndrome)
11. HIV/AIDS
12. Certain chronic lung disorders (e.g., asthma, chronic bronchitis, emphysema, pulmonary fibrosis, pulmonary hypertension)
13. Certain chronic/disabling mental health conditions (e.g., bipolar disorders, major depressive disorders, schizophrenia, schizoaffective disorder, paranoid disorder)
14. Certain neurologic disorders (e.g., ALS, epilepsy, MS, Parkinson's, Huntington's, extensive paralysis, polyneuropathy, spinal stenosis, stroke-related deficit)
15. Stroke

The most common C-SNPs are for diabetes, heart conditions, and chronic lung disease (COPD); kidney/ESRD plans are growing, especially in larger metro areas.

How a C-SNP can be structured

CMS allows three designs:

1. One approved condition — every member has that single condition.
2. An insurer-defined group of multiple conditions — members must have all of the listed conditions.
3. A CMS-defined group of commonly co-occurring conditions — members need only one of the listed conditions. CMS's five recognized groups combine diabetes, chronic heart failure, cardiovascular disorders, and stroke.

Verifying eligibility

The member must have Parts A and B, live in the service area, and have a qualifying condition that a provider can confirm. Carriers require a prequalification step; if the condition can't be verified, the member may be disenrolled.

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I-SNP — Institutional Special Needs Plans

I-SNPs are for people who have, or are likely to need, the level of care provided in a long-term care skilled nursing facility, nursing facility, intermediate care facility, or inpatient psychiatric facility for 90 days or longer. These are generally enrolled directly through the carrier rather than through independent agents.

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When you can enroll in an SNP

SNPs use the normal MA windows (ICEP, AEP, MA OEP), plus important Special Enrollment Periods:

• D-SNP: becoming newly dual-eligible opens an SEP; integrated D-SNP eligibles generally get a monthly opportunity to elect an integrated plan while they keep both Medicare and Medicaid.
• C-SNP: a newly documented chronic condition opens an SEP to join a C-SNP; it's used once and then closes.

Full detail in Medicare & ACA Enrollment Windows.

See also: Medicare Advantage (Part C), Medicaid & Dual-Eligible Levels at a Glance, Part D Prescription Drug Coverage, Medicare & ACA Enrollment Windows.