Seniorstar Insurance Group

Tag: health insurance

Maximizing Your Medicare Advantage: 5 Ways to Optimize AEP Decision-Making
The Annual Election Period (AEP) is a crucial time for Medicare Advantage beneficiaries to review and make changes to their healthcare coverage. AEP occurs annually from October 15th to December 7th, allowing beneficiaries the opportunity to assess their current Medicare Advantage plan and make adjustments if needed.

During AEP, Medicare Advantage beneficiaries have several options available to them:
- Switching Plans: Beneficiaries can change from their existing Medicare Advantage plan to a different one. This could involve transitioning to a plan with different coverage options, network providers, or prescription drug coverage. It’s essential to compare plans to ensure the new choice aligns with their healthcare needs.
- Enrolling in Medicare Advantage: Individuals who are eligible for Medicare but not currently enrolled in a Medicare Advantage plan have the option to join one during the AEP. This is an opportunity for those who have Original Medicare to explore the benefits of Medicare Advantage, which often includes additional coverage like dental, vision, and prescription drugs.
- Returning to Original Medicare: If a Medicare Advantage beneficiary decides that they no longer want the additional benefits provided by their current plan, AEP allows them to switch back to Original Medicare (Part A and Part B). They can also enroll in a standalone Medicare Part D prescription drug plan if needed.
- Changing Prescription Drug Coverage: Beneficiaries can review and adjust their prescription drug coverage during AEP. This might involve switching to a different Medicare Advantage plan that offers better prescription drug coverage or enrolling in a separate Part D prescription drug plan if their current plan doesn’t adequately meet their medication needs.
- Reviewing Costs and Benefits: AEP is an ideal time for beneficiaries to assess their healthcare needs, budget, and any changes in their health status. Comparing plans’ costs, including premiums, deductibles, copayments, and coinsurance, alongside the benefits they offer, can help individuals select a plan that provides the coverage they need at a price they can afford.
In summary, the Annual Election Period offers Medicare Advantage beneficiaries the chance to reevaluate their healthcare coverage and make necessary adjustments. Whether it’s switching plans, enrolling in Medicare Advantage for the first time, returning to Original Medicare, modifying prescription drug coverage, or simply reviewing costs and benefits, beneficiaries should take advantage of this period to ensure their healthcare plan aligns with their evolving needs. It’s advisable to research and compare available plans, considering factors such as coverage options, provider networks, costs, and additional benefits to make an informed decision that suits their individual circumstances.
September 21, 2023
A Clearer Vision: Navigating Medicare Choices for Ophthalmology Care During the AEP

“This case not only underscores the significance of the AEP in reshaping healthcare options but also exemplifies how agents, armed with expertise and compassion, can positively transform lives within the intricate Medicare landscape.”

In the bustling realm of Medicare insurance, the Annual Enrollment Period (AEP) stands as a critical juncture for beneficiaries seeking tailored coverage. This case study shines a light on an instance where an independent Medicare agent from SeniorStar Insurance Group brought meaningful change to a lady in need during the AEP. Faced with a challenging eye condition and an unsatisfactory network, the agent adeptly transformed the situation by orchestrating a switch in her Medicare Advantage Plan.

The lady in question, let’s call her Mrs. Thompson, was grappling with a concerning eye condition that demanded specialized care. However, her existing Medicare Advantage Plan’s network failed to provide convenient access to an ophthalmologist in close proximity. Understanding the urgency and importance of her predicament, the independent Medicare agent embarked on a mission to alleviate her distress.

Employing a blend of industry knowledge, empathy, and resourcefulness, the agent meticulously analyzed the available options. Keeping Mrs. Thompson’s primary care physician unchanged was a pivotal consideration, ensuring the continuity of her general healthcare. After comprehensive research and consultations, the agent proposed an alternative Medicare Advantage Plan that seamlessly accommodated her primary care physician while also featuring an extensive network of ophthalmologists.

With clarity and patience, the agent engaged Mrs. Thompson in a detailed discussion, highlighting the benefits of the new plan and elucidating how the transition would enhance her access to ophthalmology specialists. Empowered by the agent’s guidance, Mrs. Thompson embraced the change, and the agent deftly navigated the enrollment process on her behalf.

In the end, Mrs. Thompson’s experience stands as a testament to the invaluable role played by independent Medicare agents. The agent’s dedication to her well-being and their unwavering commitment to securing the most suitable coverage brought resounding success. This case not only underscores the significance of the AEP in reshaping healthcare options but also exemplifies how agents, armed with expertise and compassion, can positively transform lives within the intricate Medicare landscape.

September 6, 2023
A Breath of Fresh Coverage: Navigating New Medications with an Independent Insurance Agency

“Using his expertise, the advisor delved into researching insurance plans that would not only cover the new drugs but also enable Eve to maintain her relationship with her primary care provider.”

For years, Eve, a 71-year-old woman, had been managing a medical condition with the help of her primary care provider, a compassionate doctor in the town’s local clinic. Recently, this doctor prescribed two new drugs to enhance Eve’s treatment. However, her current Medicare Advantage plan didn’t offer adequate coverage for these crucial medications.

Eve cherished her visits to Dr. Reynolds, valuing the relationship they had built over time. As she faced the prospect of changing her medications and dealing with potential financial strain, Eve’s sense of frustration grew. Determined to find a solution that wouldn’t disrupt her healthcare routine, she began her search for alternatives.

One day, while attending a wellness seminar at the town’s community center, Eve struck up a conversation with a fellow attendee named Alex. Alex had gone through a similar situation and shared his success story about overcoming coverage challenges with the help of an independent insurance agency.

Intrigued and hopeful, Eve decided to visit the agency. Eve was greeted by an experienced insurance advisor who was committed to assisting her in navigating this intricate situation.

Across a cozy desk, the insurance advisor attentively listened to Eve’s concerns about her medications and her desire to continue receiving care from Dr. Reynolds. Using his expertise, the advisor delved into researching insurance plans that would not only cover the new drugs but also enable Eve to maintain her relationship with her primary care provider.

After a thorough analysis, the insurance advisor presented Eve with tailored insurance plan options. These options not only provided coverage for the medications but also ensured that Dr. Reynolds remained within the network. Over a cup of tea, the insurance advisor explained the benefits, costs, and seamless transition process associated with each plan. Eve was relieved to find a solution that aligned with her needs and values.

With a newfound sense of confidence, Eve selected an insurance plan that offered comprehensive coverage for her new medications while allowing her to continue seeing Dr. Reynolds. The insurance advisor guided her through the enrollment process, ensuring a smooth transition from her previous plan.

In the end, Eve’s journey exemplified the impact an independent insurance agency can have on an individual’s life. Through their commitment to personalized care and meticulous research, they not only resolved Eve’s insurance dilemma but also upheld her priorities – her health and her cherished relationship with her primary care provider, Dr. Reynolds.

September 5, 2023
From Group Plans to Medicare: Emily’s Journey to Comprehensive Coverage

“Tom and Emily were paying less for health insurance and getting considerably more coverage than they ever had before even while being covered under Tom’s group plan through work”

Emily, a Seniorstar client, and recent Medicare beneficiary, found herself in a unique situation two years ago regarding her need for health insurance coverage. Prior to becoming eligible for Medicare, Emily’s husband, Tom, another Seniorstar client, had become ill and had to retire early. Ironically, that meant that both Tom and Emily would lose the group employer plan that Tom had and that both were covered by. For Tom, it was less of a problem because he was 67 years old and already eligible for Medicare, but what was Emily going to do?

After getting Tom enrolled in original Medicare with a bundle that included a Medigap plan, a Part D prescription drug plan, and dental coverage, we turned our attention to Emily. We consulted with her about entering the individual marketplace to secure coverage while she waited to become eligible for Medicare. Emily, like so many of our other clients, found it difficult to know what to do or where to look to find the most appropriate and comprehensive coverage at rates she could afford.

The challenge for Emily was now that her husband Tom had retired, and the household income was lower, so she had to keep a close watch on expenses. We discovered that Emily was eligible for premium subsidies in the individual marketplace, which minimized her costs in the plans that were available to her. After realizing that, Emily still needed help finding the plan with the right mix of premiums, deductibles, and out-of-pocket expenses that best suited her needs, and we were right there to help her navigate through the process.

And that’s exactly what we did for Emily again when she recently became eligible for Medicare. After reviewing her many Medicare coverage options with us, Emily decided to go down the same path as her husband, Tom, and enrolled in original Medicare with a bundle that included a Medigap plan, Part D prescription drug plan, and a dental plan. Moreover, because she chose the same Medigap company as her husband they were both eligible for a household discount on the monthly rates and Tom’s premiums went down. Now both Tom and Emily were paying less for health insurance and getting considerably more coverage than they ever had before, even while being covered under Tom’s group plan through work. Emily’s journey from the individual marketplace to Medicare highlights the intricacies and challenges that individuals may face during transitional periods in their healthcare coverage. Her journey underscores the importance of careful planning, informed decision-making, and a comprehensive understanding of the options available. Emily successfully navigated this transition with the educational and consultative support that Seniorstar Insurance Group gave her. We take the time to get a clear assessment of our client’s healthcare and financial needs along with their long-term objectives to give them solutions for peace of mind and security. Emily’s story is a reminder that proactive planning is essential for individuals approaching Medicare eligibility and can help fend off costly and potentially long-lasting mistakes.

September 1, 2023
Medicare and Disabilities: What You Should Know

Medicare and Disabilities: What You Should Know

For most beneficiaries, Medicare eligibility begins near. However, this is not the only qualifier for Medicare eligibility. Certain people with disabilities will qualify for Medicare enrollment before age 65. A few criteria must be met before one is eligible to receive Medicare before the age of 65.

End Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS)

Beneficiaries with either ESRD or ALS do not have to receive Social Security Disability benefits for 24 months to be eligible for Medicare.

A person with ESRD must wait three months after a regular course of dialysis or three months after a kidney transplant to become eligible for Medicare. For ESRD, there are some criteria you must meet to receive benefits. You must have worked the required time and paid Social Security. You can also join the Railroad Retirement Board or have been a government employee. Getting Social Security or Railroad Retirement Board benefits will also qualify you. These two criteria can enable you to be covered if your spouse also meets these criteria.

ALS is different because you are eligible for Medicare when collecting Social Security Disability benefits. There is typically a 5-month window between when a person is diagnosed with a disability and when they begin receiving Social Security Disability benefits.

How Can I Enroll in Medicare If I Have a Disability?

To enroll in Medicare with a disability, if you have been receiving Social Security Disability benefits for 24 months, you will automatically be enrolled. You will receive your Medicare card in the mail and a letter explaining that you are now enrolled in Medicare Part A and Part B. If you meet the standards but don’t qualify for Social Security Disability benefits, you can still purchase Medicare by paying a monthly premium for Part A and B.

What Are the Medicare Benefits People with Disabilities Receive?

The benefits people with disabilities receive through Original Medicare are the same as other beneficiaries who enroll in Original Medicare. This includes Medicare Part A coverage (inpatient care at a hospital, care in a skilled nursing facility, care in a nursing home, hospice care, and home health care) and Medicare Part B coverage (clinical research, ambulance services, durable medical equipment, and mental health care). These services don’t have to relate to a person’s disability. Dual Special Needs Plans are a type of Medicare Advantage (Part C) plan that can offer personal care services and nursing home care that Original Medicare doesn’t cover for beneficiaries with certain conditions.

Are There Other Conditions that Can Disqualify Me from Medicare Enrollment?

Technically, no disabilities, illnesses, or underlying conditions disqualify someone from ever being enrolled in Original Medicare. Once someone meets the criteria for becoming Medicare eligible, they can enroll in Original Medicare. Beneficiaries can’t be denied coverage because of a timetable related to their condition or improvement of that condition. This means that people with mental illness, dementia, and other long-term chronic conditions could still possibly enroll in Medicare.

However, it is crucial to understand the eligibility requirements for Medicare and that not all conditions make an individual eligible for Medicare. If someone does not have conditions or disabilities making them eligible for Medicare before turning 65, they will still become eligible when they are turning 65.

Can Medicare Deny “Maintenance Only” Services?

Even if a service is considered “maintenance only,” meaning it is only expected to maintain a condition or slow deterioration, it can still be covered by Original Medicare. Examples of “maintenance-only services” include physical therapy, which may be critical to maintaining a livable variant of a condition. Some conditions are more at risk of being unfairly denied coverage for services than others.

Beneficiaries with conditions such as Alzheimer’s Disease, mental illness, Multiple Sclerosis, Parkinson’s Disease, and other long-term conditions are entitled to coverage if their provider order care that meets Medicare criteria. Consult with your doctor if you feel coverage has been wrongfully denied.

If I Have a Disability, Can I Still Work and Receive Medicare Coverage?

You can still work and receive Medicare coverage because of your disability. However, one must follow many guidelines while needing Medicare coverage while working with a disability. The Social Security Administration breaks this eligibility down into three time frames: Trial Work Period (TWP), Extended Period of Eligibility (EPE), and indefinite access to Medicare.

Trial Work Period (TWP)

If a disabled individual wants to try and work, they can do so and still receive Medicare during their Trial Work Period. The Trial Work Period consists of 9 months within any rolling 5-year period. A month is considered a month of service for a trial work period if it exceeds 2023’s amount of $1050 a month or if they work over 80 hours of self-employment monthly. It’s important to note that these nine months need not be consecutive. The beneficiary’s ability to perform their job cannot be used to disqualify them from receiving Medicare benefits – during the 9-month Trial Work Period. However, the work may be considered in determining the individual’s disability status and Medicare eligibility once the 9-month period has ended.

Extended Period of Eligibility (EPE)

Beneficiaries whose disability is still active but who’ve earned income meeting or surpassing that of the “Substantial Gainful Activity” level can still receive Medicare coverage after their trial work period is over.

The Substantial Gainful Activity levels are levels of income an individual cannot pass and still receive Medicare benefits. For statutorily blind individuals in 2023, the monthly amount is $2460; for non-blind individuals, the monthly amount is $1470. Read more here.

The Extended Period of Eligibility lasts much longer than the trial work period; it can be extended as long as 93 months after it has ended. The beneficiary will pay no premiums for Medicare Part A; however, they are still responsible for their Medicare Part B premium. An individual’s Social Security Disability (SSDI) cash benefits may also end during this period.

Indefinite Access to Medicare

Suppose an individual remains medically disabled after the Extended Period of Eligibility (8.5 years) is up. In that case, they can still receive access to Medicare benefits if they are still considered medically disabled. They will however be required to pay both the Medicare Part A premium and the Medicare Part B premium. Original Medicare Part A’s premium will be determined by how many quarters you or your spouse worked and paid into Social Security. There is a helpful state-run buy-in program that can help low-income individuals pay these premiums.

Seniorstar Insurance Group can help with any Medicare questions you may have. Contact us today for a free, no-obligation review of your coverage.

April 26, 2023
Will Medicare cover help for back pain?

Will Medicare Cover Help for Back Pain?

Back pain is a common problem among older adults in the United States. Because of this, the Centers for Medicare and Medicaid Services (CMS) has added more coverage in recent years that assists with covering back pain treatments.

What kind of back pain treatments are covered by Medicare?

Medicare will cover a list of non-surgical or minimally invasive treatments and even some required surgeries. Each part of Medicare will cover their respective treatments for back pain, and the costs have many factors that go into them. Even though Medicare has expanded its coverage of back pain, some more invasive treatments can still be difficult to get. Medicare may require treatments to be medically necessary before it is covered. This means they may require your pain to be at a certain level for a while. It could also mean they might make you try less invasive treatments first; if they fail, they will cover further treatment.

What Are the Non-Surgical Treatments Medicare Covers?

Medicare covers most common treatments and has even expanded the coverage in recent years. Below is a chart showing which common back pain treatments are covered by the different parts of Medicare.

What Are the Surgical Treatments Medicare Covers?

Medicare may cover surgeries for back pain but often require less invasive treatment to be tried and unsuccessful first. When it comes to surgery, Medicare looks at it as a last resort and wants it to be medically necessary to cover it.

Always speak with your physicians and surgeons if you suspect you may need surgery to ensure your back pain treatments are covered. Seniorstar Insurance Group can help you get the right Medicare coverage for your needs. Call us for a free, no-obligation review of your coverage today!

April 19, 2023
How Does TRICARE Work with Medicare?

How Does TRICARE Work with Medicare?

TRICARE is a healthcare program that provides coverage to uniformed service members, retirees, and their families globally. On the other hand, Medicare is a government-run healthcare program that provides healthcare to US citizens aged 65 and above, citizens under 65 with certain disabilities, and citizens with end-stage renal disease. It is possible for some individuals to be eligible for both TRICARE and Medicare.

When you turn 65, you must enroll in Medicare to maintain your eligibility for TRICARE unless you meet certain criteria. Within 90 days of becoming Medicare-eligible, you must also change your TRICARE health plan. The health plan you choose will depend on your eligibility for Medicare, your active-duty status or that of your spouse, and your current TRICARE plan. To remain eligible for TRICARE, both parts of Original Medicare are required.

TRICARE for Life

TRICARE for Life is a secondary coverage plan that provides additional coverage to Medicare beneficiaries with both parts of Original Medicare. This coverage is automatic and available worldwide, with no enrollment fees required. TRICARE for Life becomes the primary insurance when you are outside of the US.

TRICARE for Life and Prescription Drug Plans

TRICARE for Life also offers prescription drug coverage, which is considered “creditable coverage”. This coverage is similar to Medicare Part D coverage. If you have a Medicare Part D prescription drug plan, you may still be eligible for TRICARE for Life, but it may be redundant.

TRICARE for Life, Medicare, and Health Care Costs

TRICARE for Life is always the secondary coverage plan to Medicare in the US, but it becomes the primary coverage plan when outside of the US. In the US, Medicare files a claim with the healthcare provider first. After Medicare has paid its portion, the remaining claim is sent to TRICARE for Life, which then pays its portion directly to the provider.

If you have any questions about your coverage, Seniorstar can help you with a free, no-obligation review of your Medicare needs. Contact us today for assistance.

April 12, 2023
What Isn’t Covered by Original Medicare?

What Isn’t Covered by Original Medicare?

If you choose to enroll in Original Medicare, it covers most of your healthcare needs after you turn 65 or if you qualify earlier due to certain disabilities or End Stage Renal Disease (ESRD). Original Medicare Part A covers inpatient hospital stays, surgeries, skilled nursing facilities, and some hospice and home care. Original Medicare Part B covers doctor visits, preventative services, durable medical equipment and supplies, and outpatient care. With all that coverage, Original Medicare still leaves you are responsible for some out-of-pocket costs, and there are still services left uncovered. If you choose to keep your Original Medicare coverage, enrolling in a Medicare Supplement, aka Medigap, plan can help fill in some of these gaps. You also have the option to opt for a Medicare Advantage (Part C) plan; these plans offer at least as much coverage as Original Medicare Parts A & B. They also may include additional benefits as well as prescription drug coverage.

Here are a few things Original Medicare Parts A & B don’t cover.

Prescription Drugs

Original Medicare Part A & Part B do not cover prescription drugs. You will need to enroll in a standalone Medicare Part D Prescription Drug Plan to receive prescription drug coverage (and avoid penalties ) if you plan on enrolling in Original Medicare. You can enroll in Medicare Part D during your initial enrollment period. If you choose to enroll in a Medicare Advantage (Part C) Plan, prescription drug coverage may be included.

Long-Term-Care

Original Medicare Parts A & B do not cover long-term care. While some of the care in a skilled nursing facility may be covered, not all is. The average cost of a nursing home is upwards of $100,000 without any form of insurance. There is long-term care insurance to help individuals cover these costs.

Co-pays and Deductibles

Although Original Medicare covers trips to the doctor’s office, hospital stays, or any outpatient care, you still have to pay co-pays or deductibles. Original Medicare Part A will require a deductible before coverage begins, and you must pay a portion of the cost of a long hospital stay starting at day 61. Original Medicare Part B will also require a deductible, but you also must pay 20% of the costs of doctors’ services with Part B. Medicare Supplements can help ease the burden of some of these costs.

Dental and Vision Care

Most routine dental care is not covered by Original Medicare. Routine visits, cleanings, fillings, extractions, and dentures will have to be covered by a separate insurance plan if you choose to enroll in Original Medicare. Some Medicare Advantage (Part C) Plans can cover these basic cleanings and X-rays, but these plans have an annual coverage cap (as may some standalone dental plans). Routine vision care is also not covered by Original Medicare. There are exceptions to this, such as if you have diabetes or must have cataract surgery; you may get an annual eye exam through this exception. Some Medicare Advantage (Part C) Plans include routine vision care. For those choosing to enroll in Original Medicare, you may want to consider a standalone vision insurance plan.

Hearing Care

Hearing aids are another essential healthcare item for many. However, unfortunately, Original Medicare does not cover hearing aids or routine hearing exams. Just like vision or dental, some Medicare Advantage (Part C) plans may be able to cover hearing care costs. Standalone hearing care plans are also an option.

Traveling Abroad

Any care you receive while abroad will not be covered by Original Medicare. However, some Medicare Supplements offer emergency care coverage when traveling abroad.

Choosing the Best Coverage for Your Needs

It’s important to fully understand the coverage you will receive, regardless of which type of plan you choose to enroll in when the time comes. For some people, Original Medicare and a Medicare Supplement provide the most effective mix of coverage, along with a Medicare Part D Prescription Drug Plan. Others may find the best option for their needs & budget is to enroll in a Medicare Advantage (Part C) plan. If you have questions about evaluating your Medicare options, give us a call for a no-cost, no-obligation coverage review.

April 5, 2023
How to Enroll in Medicare if You Have Retiree Insurance

How to Enroll in Medicare if You Have Retiree Insurance

Retiree insurance is employer-provided health insurance that some employers provide to former employees after retirement. This insurance usually pays second to Medicare so in order to be fully covered, you must be enrolled in Medicare. Depending on your policy, you may be required to sign up for Medicare Part A & Part B when you are Medicare-eligible.

Should I Keep My Retiree Insurance?

There are some instances where keeping your retiree insurance along with your Medicare coverage may be beneficial if you can afford the premium. Some Retiree insurance plans cover things like Medicare deductibles, copayments, and coinsurances. The Retiree plan may also include prescription drug coverage. If you are satisfied with that coverage, call your plan to see if you can delay your Medicare Part D enrollment.

It is also important to know that your spouse or family members are not eligible to enroll in your Medicare coverage. If you choose to drop your retiree insurance, keep in mind they may need coverage of their own.

How Do Medicare and Retiree Insurance Interact?

Medicare and Retiree insurance are intermingled because if you have retiree insurance you must be enrolled in Medicare to be fully covered. There are differences, however, in how Medicare interacts depending on the type of plan you have.

Fee for Service (FFS) Plans

Fee for Service plans act almost like a supplemental insurance policy and cover Medicare cost-sharing. They can pay for healthcare from any hospital or healthcare professional.

HMO or PPO (Managed Care) Plans

Managed care plans, known as HMO or PPO plans, require you and rely on you seeing healthcare providers and getting care from facilities in your network. Most of the time, your costs will be lowest when getting care from providers in your network who accept retiree insurance and Medicare. If you see out-of-network providers, you will pay full Medicare cost-sharing & your retiree coverage may not pay anything at all.

Employer-Sponsored Medicare Advantage (Part C)

There are some employers that require you to enroll in a Medicare Advantage (Part C) plan to continue getting your retiree insurance once you are eligible for Medicare. If you choose not to enroll in your employer’s Medicare Advantage (Part C) coverage, you may have difficulty getting retiree coverage back. With this in mind, you are also free to enroll in Original Medicare or another Medicare Advantage (Part C) plan of your choosing.

Employer-Sponsored Medicare Supplements

Another employer insurance plan option is employer-sponsored Medigap, or Medicare Supplement, policies. Just like employer-sponsored Medicare Advantage (Part C) plans, you do not have to enroll in employer-sponsored Medigap plans but it may be harder to get your retiree insurance back later.

Retiree Insurance and Medicare Part D Prescription Drug Plans

Retiree insurance can offer prescription drug coverage as well. If the prescription drug coverage offered with your retiree insurance is creditable drug coverage (as good or better than basic Medicare Part D) you are eligible to delay Part D enrollment. It may be beneficial to keep your retiree insurance even if it doesn’t provide creditable drug coverage. This is because some plans keep you covered when you are in the coverage gap. Remember that some plans don’t allow you to drop prescription drug coverage without losing your retiree insurance.

March 13, 2023
What Are Chronic Special Needs Plans?
What Are Chronic Special Needs Plans?

Chronic condition special needs plans, also called C-SNPS, are special types of Medicare Advantage plans that restrict enrollment to eligible members with specific chronic conditions. These plans include targeted care for these conditions such as diabetes, dementia, or heart disease and cover providers and care tailored to their unique needs. The drug formularies for these plans are also geared toward the needs of its eligible individuals.

Like other Medicare Advantage plans, C-SNPs cover at least as much as Original Medicare Parts A & B, as well as C-SNPs, are required to include prescription drug coverage. This helps ensure eligible individuals can receive all their medical needs in one plan.

C-SNPs may also assign a care coordinator that works with each beneficiary. Care coordinators help members access medications and healthcare providers that will best aid their care.

Since they are tailored to a specific need of the condition, C-SNPs may have fewer coverage limitations than other Medicare Advantage (Part C) plans and may have lower or differing costs.

Who Qualifies for a C-SNP?

Almost 67% of Medicare enrollees have at least two chronic conditions that require care from primary providers, mental health specialists, inpatient and outpatient care, and ancillary services.

Eligibility Requirements
- Be eligible for Medicare
- Live in the plan’s service area
- Diagnosed with at least one qualifying chronic condition
  - Per the CDC, a condition is chronic if
    
    It requires ongoing medical attention and/or limits the ability to perform daily living activities
    
    It lasts one or more years
What are the qualifying conditions?

Fifteen specific chronic conditions are qualifying requirements for special needs plans. These may be periodically changed or revised depending on the care coordination through the SNP product.

The 15 conditions that are C-SNP qualifying are as follows:
- Chronic alcohol and other drug dependence
- HIV/AIDS
- Cancer, excluding pre-cancer conditions
- Chronic heart failure
- Diabetes Mellitus
- Dementia
- End-stage renal disease requiring dialysis
- Stroke
- Neurologic disorders limited to:
  - Amyotrophic lateral sclerosis (ALS)
  - Epilepsy
  - Extensive paralysis
  - Huntington’s disease
  - Multiple sclerosis
  - Parkinson’s disease
  - Polyneuropathy
  - Spinal stenosis
  - Stroke-related neurologic deficit
- Chronic and disabling mental health conditions limited to:
  - Bipolar disorders
  - Major depressive disorders
  - Paranoid disorder
  - Schizophrenia
  - Schizoaffective disorder
- Chronic lung disorders limited to:
  - Asthma
  - Chronic bronchitis
  - Emphysema
  - Pulmonary fibrosis
  - Pulmonary hypertension
- Severe hematologic disorders limited to:
  - Aplastic anemia
  - Hemophilia
  - Immune thrombocytopenic purpura
  - Myelodysplastic syndrome
  - Sickle-cell disease (excluding sickle-cell trait)
- Cardiovascular disorders limited to
  - Cardiac arrhythmias
  - Coronary artery disease
  - Peripheral vascular disease
  - Chronic venous thromboembolic disorder
- Autoimmune disorders limited to
  - Polyarteritis nodosa
  - Polymyalgia rheumatica
  - Polymyositis
  - Rheumatoid arthritis
  - Systemic lupus erythematosus
If you have questions about if you or a loved one may be eligible for a C-SNP, the team at Seniorstar can help! Give us a call today for no-cost coverage consultation.
February 24, 2023