Medicare Chronic Conditions Coverage

All Medicare plans have some coverage for chronic health conditions. Medicare Advantage plans must generally cover all of the services covered under Original Medicare, although their costs may be different and they may offer additional benefits. Variations in benefits offered mean some plans may provide better coverage for certain chronic conditions.

Some Medicare Advantage plans offer non-medical benefits to help people with chronic conditions. According to the U.S. Government Accountability Office (GAO), as of 2022, approximately one in three Medicare Advantage plans provided at least one benefit designed to improve the health or function of chronically ill enrollees or reduce avoidable health care use. These supplemental benefits include food and meals, transportation for non-medical needs (such as a ride to the grocery store), social needs benefits (such as access to plan-sponsored programs), general support for living (such as subsidies for rent or utilities), and pest control.

Some Medicare Plans specifically cater to specific chronic conditions. These plans are called Chronic Condition Special Needs Plans (C-SNPs). Each C-SNP focuses on a different chronic condition. You can only enroll in a plan if you suffer from the condition. For example, if a C-SNP in your area serves enrollees with diabetes, you can only enroll if you have diabetes.

Medicare SNPs cover all the services Medicare Advantage plans are required to cover. They may also provide additional benefits to meet the needs of the groups they serve. All SNPs provide prescription drug coverage; some also have care coordinators who help enrollees manage their health. For example, in a C-SNP that serves people with diabetes, Medicare.gov says a care coordinator could help enrollees monitor their blood sugar, follow their diet, stick to a suitable exercise regime, schedule preventative services, and receive the right prescriptions to prevent complications.

The Medicare chronic conditions list consists of 15 chronic conditions. If you have one of these conditions, there may be a C-SNP in your area that caters to it.

The 15 SNP-Specific chronic conditions are:

1. Chronic alcohol and other drug dependence
2. Autoimmune disorders – limited to polyarteritis nodosa, polymyalgia rheumatic, polymyositis, rheumatoid arthritis, and systemic lupus erythematosus
3. Cancer – excluding pre-cancer conditions and in-situ status
4. Cardiovascular disorders – limited to cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder
5. Chronic heart failure
6. Dementia
7. Diabetes mellitus
8. End-state liver disease
9. End-stage renal disease requiring dialysis
10. Severe hematologic disorders – limited to sickle-cell disease (excluding sickle-cell trait), aplastic anemia, hemophilia, immune thrombocytopenic purpura, and myelodysplastic syndrome
11. HIV/AIDS
12. Chronic lung disorders – limited to asthma, chronic bronchitis, emphysema, pulmonary fibrosis, and pulmonary hypertension
13. Chronic and disabling mental health conditions – limited to bipolar disorders, major depressive disorders, paranoid disorder, schizophrenia, and schizoaffective disorder
14. Neurologic disorders – limited to amyotrophic lateral sclerosis (ALS), epilepsy, extensive paralysis (such as hemiplegia, quadriplegia, paraplegia, or monoplegia), Huntington’s disease, multiple sclerosis, Parkinson’s disease, polyneuropathy, spinal stenosis, and stroke-related neurologic deficit
15. Stroke

You may be able to enroll in a C-SNP at any time.

Medicare plan selection is normally limited to certain periods, such as the Medicare annual election period. However, if you have been diagnosed with a chronic condition and there is a C-SNP for that chronic condition in your area, you may qualify for a Special Enrollment Period to enroll in the plan.

Unfortunately, if there are no C-SNPs that cater to people with your chronic condition in your area, you won’t be able to enroll in a C-SNP. However, you should stay alert for new C-SNPs during the next annual election period – there is always a chance a new plan will offer coverage in your area.

In the meantime, you can look for a regular Medicare Advantage plan that meets your needs. Although the plan won’t cater to your condition specifically, it may still offer the coverage you need. If you need to see specialist doctors to manage your condition, check whether these providers are in the plan’s network and find out how much it will cost you out of pocket to make an appointment. In addition, check the cost and coverage for any prescriptions you need to manage your condition. If you need other treatments or services, check the costs and coverage for them, too. You might also like to consider plans that offer non-medical supplemental benefits to help with your general wellbeing, such as transportation and food delivery services.

That’s fantastic news! However, if you no longer have the chronic condition your C-SNP serves, you are no longer eligible to be enrolled in that plan. You will be disenrolled and will have a Special Enrollment Period to select a new plan that meets your needs.