By Marc Gilman
📞 Call (800) 927-9326 or email — if you have a chronic condition or think you may qualify for a Special Needs Plan, we can look at what’s available in your area and whether it makes sense for your situation.
Most people on Medicare choose between Original Medicare and a standard Medicare Advantage plan. But there’s a third option that most people have never heard of — and for those who qualify, it’s often a significantly better fit.
It’s called a Special Needs Plan, or SNP. And if you — or someone you care about — has a chronic condition, qualifies for both Medicare and Medicaid, or lives in a nursing facility, a Special Needs Plan may offer coverage that’s specifically designed for that situation rather than the general Medicare population.
SNPs are a growing part of Medicare. Since SNPs became a permanent part of Medicare Advantage in 2018, SNP enrollment has tripled — rising from 2.6 million to 7.3 million enrollees, an increase of nearly 4.7 million people. SNPs now account for 21% of all Medicare Advantage enrollees, up from 13% in 2018. From 2024 to 2025, SNPs accounted for 48% of total Medicare Advantage enrollment growth — a sign that more people with complex health needs are finding their way into plans specifically built for them.
Key Takeaways
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A Medicare Special Needs Plan is a type of Medicare Advantage plan designed specifically for people with complex or ongoing health needs.
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There are three types: C-SNPs for chronic conditions, D-SNPs for dual Medicare and Medicaid enrollees, and I-SNPs for people in institutional settings.
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SNPs now represent 21% of all Medicare Advantage enrollees and accounted for 48% of MA enrollment growth from 2024 to 2025 — driven primarily by C-SNPs.
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Every SNP must operate under a Model of Care approved by the National Committee for Quality Assurance (NCQA) — a formal care management framework not required for standard Medicare Advantage plans.
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SNPs typically offer $0 premiums, condition-specific supplemental benefits, lower cost sharing on related services, and dedicated care management.
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Eligibility is restricted — you must qualify based on your health situation or enrollment status.
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In New Hampshire, the primary SNP option available is the C-SNP for people with qualifying chronic conditions. New Hampshire currently does not have Dual Eligible SNPs (D-SNPs).
What is a Medicare Special Needs Plan?
A Special Needs Plan is a Medicare Advantage coordinated care plan specifically designed to provide targeted care and limit enrollment to special needs individuals. Those individuals fall into one of three categories:
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People who are institutionalized — living in a nursing facility or requiring an institutional level of care
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People who are dual eligible — enrolled in both Medicare and Medicaid
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People with a severe or disabling chronic condition specified by CMS
A SNP may be structured as a health maintenance organization (HMO), an HMO Point-of-Service plan, or a preferred provider organization (PPO). Like any Medicare Advantage plan, it provides all the coverage of Medicare Parts A and B, and all SNPs must provide Part D prescription drug coverage because special needs individuals must have access to prescription drugs to manage and control their special health care needs.
The Model of Care: What Sets SNPs Apart
The most important structural difference between a Special Needs Plan and a standard Medicare Advantage plan is the Model of Care. Every SNP must have a Model of Care approved by the National Committee for Quality Assurance (NCQA). The Model of Care provides the basic framework under which the SNP will meet the needs of each of its enrollees and is a vital quality improvement tool for ensuring that the unique needs of each enrollee are identified by the SNP and addressed through the plan’s care management practices.
In plain terms, this means every SNP enrollee receives:
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A comprehensive health risk assessment — a structured evaluation of their health, functional ability, and psychosocial needs
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An individualized care plan developed from that assessment
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A multidisciplinary care team — including a care coordinator, a physician, and pharmacy support — whose role is to actively manage the member’s care
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Care transition management — coordinated handoffs between hospital, skilled nursing facility, and home to reduce readmissions
A standard Medicare Advantage plan may offer care management services — but they are not required to do so under a formal, externally evaluated, NCQA-approved framework. For someone managing a serious chronic condition or complex care needs, this difference is meaningful.
The Three Types of Special Needs Plans
C-SNP: Chronic Condition Special Needs Plan
A C-SNP is designed for people with a qualifying severe or disabling chronic condition. CMS designates specific conditions that qualify, including:
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Cardiovascular disorders (including chronic heart failure, hypertension with specific conditions)
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Diabetes
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End-stage renal disease (ESRD) and chronic kidney disease
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Chronic obstructive pulmonary disease (COPD)
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Cancer
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Dementia
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Autoimmune disorders
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And others specified by CMS
Why a C-SNP benefits eligible individuals:
The drug formulary is built for the condition. A C-SNP for diabetes will typically include preferred coverage for insulin, diabetic supplies, and monitoring devices. A C-SNP for kidney disease will include the medications used to manage CKD at favorable cost sharing. A general Medicare Advantage plan serves the full Medicare population — the formulary is broad but not optimized for any single condition.
Cost sharing is often reduced for condition-related services. C-SNPs can and frequently do eliminate or reduce copays for specialist visits, lab work, and services directly tied to the qualifying condition. A member with chronic heart failure on a cardiac C-SNP may pay $0 for cardiology visits and $0 for echocardiograms that a standard plan would charge $30 or $50 per visit.
Supplemental benefits are condition-specific. Rather than a general OTC allowance that can be spent broadly, C-SNP supplemental benefits are frequently structured around the member’s actual needs — non-emergency medical transportation to dialysis appointments, meal delivery after a hospitalization, over-the-counter items weighted toward diabetic or cardiac supplies, or in-home safety assessments for members at fall risk.
Care management is proactive, not reactive. A C-SNP’s care management team actively monitors members with the qualifying condition, reaches out before hospitalizations become necessary, and coordinates specialist involvement. For someone managing diabetes, CHF, or COPD, the difference between a care team that responds when you call and one that reaches out when your numbers suggest a problem can be significant.
C-SNPs are the fastest-growing SNP category. C-SNPs comprised 75% of total SNP enrollment growth between 2024 and 2025. C-SNP enrollment increased by 476,300 new enrollees — a 71% jump in a single year — while D-SNP enrollment grew by only 3%. Nearly all C-SNP plans — 97% — cover diabetes or cardiovascular conditions. For New Hampshire residents, where no Dual Eligible SNPs are currently available, C-SNPs represent the primary SNP option.
Why carriers invest heavily in SNPs. MedPAC found that in 2022, average margins for D-SNPs (7.5%) and C-SNPs (7.4%) were double the average margins of Medicare Advantage plans overall (3.6%). Those higher margins flow from the Medicare Advantage risk adjustment system, which pays more for members with more complex health needs — the exact population SNPs serve. Higher margins give SNP carriers more resources to offer supplemental benefits that general MA plans cannot match.
C-SNPs also serve many dual-eligible individuals. In 2023, 25% of C-SNP enrollees were dual-eligible individuals — people with both Medicare and Medicaid. In New Hampshire, where no D-SNPs exist, many dual-eligible individuals with qualifying chronic conditions may be enrolled in a C-SNP as their primary managed care option.
C-SNP carrier landscape. UnitedHealth Group and Humana together account for 54% of all SNP enrollments; UnitedHealth Group accounts for half of all C-SNP enrollees, with Humana (20%) and Elevance Health (12%) comprising most of the remainder.
The premium is typically $0. Many C-SNPs carry no monthly premium beyond the standard Medicare Part B premium, making them accessible for individuals on fixed incomes who are already managing the costs of a chronic condition.
D-SNP: Dual Eligible Special Needs Plan
A D-SNP is for people who are enrolled in both Medicare and Medicaid at the same time — often called “dual-eligibles.”
For dual-eligible individuals, navigating two separate programs with two separate sets of rules, two ID cards, and two billing systems creates real administrative burden and gaps in care coordination. A D-SNP addresses this by wrapping both programs into a single plan that coordinates Medicare and Medicaid benefits together — including long-term services and supports, behavioral health, and social services.
For most D-SNP members, cost sharing is reduced to near zero. Medicaid covers what Medicare doesn’t, eliminating most copays and deductibles. The integrated care management structure coordinates the full picture of the member’s care across both programs.
Important note for New Hampshire residents: New Hampshire does not currently have Dual Eligible Special Needs Plans or Medicare-Medicaid Plans available. Dual-eligible New Hampshire beneficiaries currently navigate Medicare and Medicaid as separate programs. If D-SNPs become available in New Hampshire in future plan years, we will notify clients who may qualify.
I-SNP: Institutional Special Needs Plan
An I-SNP is designed for people living in a nursing facility or who require an institutional level of care at home — typically individuals with the most complex care needs.
For members in institutional settings, a standard Medicare Advantage plan was designed for someone living in the community. The I-SNP is designed for their actual setting — with a provider network built around the facility, care management embedded in or closely connected to the institution, and a benefit structure aligned with what someone in long-term care actually needs.
I-SNPs reduce care transitions and the gaps that occur when a community plan tries to manage a member who is now institutionally based.
Should You Be in a Special Needs Plan?
If you have a qualifying chronic condition and a C-SNP is available in your county, it’s worth comparing the C-SNP to standard Medicare Advantage plans available to you. The right question is not just “does the C-SNP have a $0 premium” — it’s whether the drug formulary, the provider network, the supplemental benefits, and the care management approach are a better fit for your specific situation than a standard plan.
A few scenarios where a C-SNP often provides clear value:
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You have diabetes and currently pay significant out-of-pocket costs for insulin and supplies
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You have chronic kidney disease or ESRD and need reliable coverage for dialysis-related services and medications
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You have congestive heart failure and would benefit from proactive care monitoring rather than reactive emergency intervention
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You have COPD and regularly see a pulmonologist whose care costs add up under standard plan cost sharing
A few scenarios where a C-SNP may not be the best fit:
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You already have a well-managed relationship with your providers and a standard plan covers them at favorable rates
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The C-SNP’s provider network doesn’t include your preferred specialists or hospital
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The supplemental benefits in a standard MA plan (dental, vision, hearing) are more valuable to you than the condition-specific benefits in the C-SNP
How to Find Out If a Special Needs Plan Is Available to You
SNP availability is limited to specific geographic areas. Not every county has a C-SNP for every qualifying condition. An independent agent can look up what Special Needs Plans are available in your county for your specific qualifying condition and compare them against standard Medicare Advantage plans available in the same area.
If you have a qualifying chronic condition or think you may qualify for a Special Needs Plan, the best next step is a brief conversation to look at what’s actually available where you live.
📞 (800) 927-9326 | ✉️
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