Special Needs Plan/OHP

A Special Needs Plan is a type of Medicare Advantage plan. Medicare Advantage plans combine Medicare Part A and Part B coverage, in addition to other services such as prescription drug, dental, and vision coverage.

Special Needs Plans are meant for people with chronic health conditions with special healthcare needs. To enroll in a Special Needs Plan (SNP), you must be enrolled in Original Medicare and must be eligible for one of the following plans offered by SNPs:

  • Chronic Condition Special Needs Plans
  • Institutional Special Needs Plans
  • Dual Eligible Special Needs Plans

Chronic Condition Special Needs Plans

Chronic Condition Special Needs Plans (C-SNPs) are meant for Medicare beneficiaries with chronic or severe health issues. Through this plan, people in this category can get the special healthcare they need. This plan is open to individuals with certain conditions such as type 2 diabetes, cancer, chronic heart failure, HIV, and stroke. C-SNPs also provide coverage for people with varying conditions that fall under certain groups such as cardiovascular disease, lung disease, mental health disorders, and neurological disorders.

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Institutional Special Needs Plans

Institutional Special Needs Plans (I-SNPs) are suitable for Part C enrollees who need to be admitted in a medical institution for 90 days or more. I-SNPs cover care expenses such as skilled nursing facility care, long-term care facilities, and immediate healthcare for beneficiaries with psychiatric needs or intellectual disabilities.

Dual Eligible Special Needs Plans

Dual Eligible Special Needs Plans (D-SNPs) provide coverage to Part C enrollees who are also eligible for Medicaid, i.e. dual eligible enrollees. D-SNPs are suitable for enrollees with special healthcare needs who cannot afford their healthcare expenses due to low income or other reasons.

Oregon Healthcare Program (OHP)

On the topic of Medicaid, in the state of Oregon, there is a program called the Oregon Healthcare Program which is a Medicaid package that provides coverage for those with a low-income. It also provides coverage for working families, pregnant women, children, adults, and seniors living in Oregon, and offers coverage for medical, dental, and mental care and treatment for substance abuse.

Here’s a breakdown of the coverage offered by the Oregon Healthcare Program:

  • Physical health coverage that includes doctor visits, diagnostic tests, treatment costs, 24-hour emergency care, ambulance services, family planning services, pregnancy, and newborn care
  • Behavioral health coverage including mental health counseling and help with addiction to tobacco, alcohol, and drugs
  • Dental health services such as preventive treatments, cleaning, checkups, X-rays, fillings, tooth removal, and 24-hour emergency care
  • Prescription drugs coverage for drugs not covered by Medicare Part D
  • Eye care coverage including glasses to treat a medical condition such as aphakia, keratoconus, and after cataract surgery
  • Vision care services such as tests and glasses only for pregnant women and children under the age of 21
  • Other coverage elements include costs of hearing aids, medical equipment, home health care, therapy, hospital care, and transportation to doctor appointments

Although there’s no specific time to qualify for the Oregon Health Plan, you need to check your income eligibility when applying. As a Medicaid program, this plan aims to provide free health care coverage to individuals and families living on a low income.

To become eligible for OHP, you need to fulfill the income and residency requirements. Other factors that make up the eligibility criteria include age, health care resources, and disability status.

Eligibility and Enrollment

To be eligible for a Special Needs Plan, you must be enrolled in Medicare Part A and Part B, and live within the plan’s service area. Also, you must meet the eligibility requirements for either of the three Special Needs Plan types. Let’s review these requirements just once more:

  • To qualify for a Dual Eligible Special Needs Plan, you must be eligible or enrolled in both Medicare and Medicaid.
  • To qualify for a Chronic Condition Special Needs Plan, you must provide a valid diagnosis from a physician that proves you have a chronic or severe health issue and need specialized care. 
  • To enroll in an I-SNP, you must meet the requirements for high-level care or need to stay in a facility for 90 days or longer.

For additional information or assistance with Special Needs Plans or the Oregon Healthcare Program, contact Scott Sims Insurance at (541) 915-0939.