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Medicare Special Needs Plans

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What are Medicare Special Needs Plans?

Special Needs Plans are a set of plans under Medicare Part C.

Special Needs plans cover the same healthcare services as Medicare Part A and Part B. However, they are designed for Part C enrollees with chronic health conditions who may require special care. Special Needs Plans offer inpatient and outpatient hospital and medical coverage to enrollees with certain health conditions.

Most Special Needs Plans in Washington also offer coverage for prescription drugs, in addition to extra services like care management, extra days at a hospital, and some social services. Special Needs plans are restricted to beneficiaries with specific diseases or conditions. There are three types of special needs plans: Chronic Condition Special Needs Plans, Institutional Special Needs Plans, and Dual Eligible Special Needs Plans.


  • Chronic Condition Special Needs plans are designed for people with severe or chronic health conditions such as HIV, stroke, cancer, type 2 diabetes, end stage liver disease, and chronic heart failure. People with these health conditions need special healthcare services, which this Part C plan offers.
  • Institutional Special Needs Plans are suitable for Part C beneficiaries who need to be admitted in a medical institution for 90 days or more. Institutional Special Needs plans cover skilled nursing facility care, long-term care facilities, and immediate care. People with intellectual disabilities and people who need psychiatric care are eligible to purchase this type of plan.
  • Dual Eligible Special Needs Plans offer coverage to Part C enrollees who are dual eligible. This refers to Part C enrollees who qualify for both Medicare and Medicaid. This is the most complex special needs plan but it is suitable for enrollees with special healthcare needs who cannot afford the costs as a result of low income or other qualifying factors.
Shot of a smiling woman and man standing inside a coffee shop looking at something on their touchscreen
Shot of a smiling woman and man standing inside a coffee shop looking at something on their touchscreen

Eligibility and How to Enroll

To qualify for Special Needs Plans, you must be enrolled in Original Medicare and must be eligible for Medicare Part C. You also need to reside within the service area and must continue paying your Part B premiums to stay enrolled. Each Special Needs Plan has its eligibility requirement. For example, to enroll in a dual eligible special needs plan, you must be enrolled in Medicare and must prove your Medicaid eligibility.

Before you can enroll in a chronic condition special needs plan, you are required to provide a physician’s diagnosis which qualifies you to apply. There are listed health conditions that qualify you to enroll in a chronic condition special needs plan.

To enroll in an institutional special needs plan, you must need facility care for at least 90 days and must meet other requirements. After proving your eligibility, you can then start the enrollment process. There are usually special enrollment periods for special needs plans. You can also enroll during the Part C open enrollment period.

Interested in learning more about special needs plans? Call one of our agents who can review the special needs plan offered in your area in Washington. 

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