Medicare Managed Care Manual 
Chapter 16-B: Special Needs Plans 
 
Table of Contents 
(Rev. 126, Issued: 03-31-23) 
 
10  Introduction 
10.1  General 
10.2  Statutory and Regulatory History 
10.3  Requirements and Payment Procedures 
20  Description of SNP Types 
20.1  Chronic Condition SNPs 
20.1.1  General 
20.1.2  List of Chronic Conditions 
20.1.3  Grouping Chronic Conditions 
20.1.3.1  CMS-Approved Group of Commonly Co-Morbid and 
Clinically-Linked Conditions 
20.1.3.2  MAO-Customized Group of Multiple Chronic Conditions 
20.1.4  Hierarchical Condition Categories Risk Adjustment for C-SNPs 
20.2  Dual Eligible SNPs 
20.2.1  General 
20.2.2  State Contract Requirements for D-SNPs 
20.2.3  Relationship to State Medicaid Agencies 
20.2.4  Special Cost Sharing Requirements for D-SNPs 
20.2.4.1  General 
20.2.4.2 - D-SNPs With or Without Medicare Zero-Dollar Cost Sharing 
20.2.4.3  Cost Sharing for Dual Eligibles Requiring an Institutional Level 
of Care 
20.2.5  Fully Integrated Dual Eligible SNPs 
20.2.5.1  Application of Frailty Adjustment for FIDE SNPs 
20.2.6  Benefit Flexibility for Certain D-SNPs 
20.2.6.1  Benefit Flexibility Eligibility Requirements 
20.2.6.2  Characteristics and Categories of Flexible Supplemental 
Benefits  20.2.6.3  Benefit Flexibility Approval Process 
20.3  Institutional SNPs 
20.3.1  General 
20.3.2  Institutional Equivalent SNPs 
20.3.3  Change of Residence Requirement for I-SNPs 
20.3.4  I-SNPs Serving Long-Term Care Facility Residents 
30  Application, Approval, and Service Area Expansion Requirements 
30.1  General 
30.2  Model of Care Approval 
30.3  Existing SNP Model of Care Re-Approval and Application Submissions 
30.4  Service Area Expansion 
40  Enrollment Requirements 
40.1  General 
40.2  Verification of Eligibility 
40.2.1  Verification of Eligibility for C-SNPs 
40.2.2  Verification of Eligibility for D-SNPs 
40.2.3  Verification of Eligibility for I-SNPs/Level of Care Assessment for 
Institutional Equivalent SNPs 
40.3  Waiver to Enroll Individuals with ESRD 
40.4  Continued Eligibility When an Enrollee Loses Special Needs Status 
40.5  Special Election Period for Enrollees Losing Special Needs Status to Disenroll 
from SNP 
40.6  Open Enrollment Period for Institutionalized Individuals 
50  Renewal Options and Crosswalks 
50.1  General 
50.2  D-SNP Non-Renewals 
50.3  SNP Crosswalks 
60  Marketing 
70  Covered Benefits 
70.1  Part D Coverage Requirement 
70.2  SNP-Specific Plan Benefit Packages 
70.3  Meaningful Difference in Plan Benefits 
80  Quality Improvement 
    10  Introduction 
 
10.1  General 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
This chapter reflects the Centers for Medicare & Medicaid Services (CMS) current 
interpretation of statute and regulation that pertains to Medicare Advantage (MA) coordinated 
care plans (CCPs) for special needs individuals, referred to hereinafter as special needs plans 
(SNPs).  This manual chapter is a subchapter of chapter 16, which categorizes guidance that 
pertains to specific types of MA plans, such as private fee-for-service (PFFS) plans.  The 
contents of this chapter are generally limited to the statutory framework set forth in title XVIII, 
sections 1851-1859 of the Social Security Act (the Act), and are governed by regulations set 
forth in chapter 42, part 422 of the Code of Federal Regulations (CFR) (42 CFR 422.1 et seq.).  
This chapter also references other chapters of the Medicare Managed Care Manual (MMCM) 
that pertain to enrollment, benefits, marketing, and payment guidance related to special needs 
individuals. 
 
To assist MA organizations (MAOs) in distinguishing the requirements that apply to SNPs, 
Table 1 below provides information on the applicability in sections of this chapter to each 
specific type of SNP, that is, chronic condition SNP (C-SNP), dual eligible SNP (D-SNP), and 
institutional SNP (I-SNP), as described in section 20 of this chapter. 
 
Table 1:  Chapter Sections Applicable to Certain SNP Types 
 
SNP Type  Applicable Sections 
C-SNP  20.1; 40.2.1; 50.3 
D-SNP  20.2; 30.4; 40.2.2; 40.4; 50.2; 50.3  
I-SNP  20.3; 40.2.3; 40.6; 50.3 
 
10.2  Statutory and Regulatory History 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
The Medicare Modernization Act of 2003 (MMA) established an MA CCP specifically designed 
to provide targeted care to individuals with special needs.  In the MMA, Congress identified 
special needs individuals as:  1) institutionalized individuals; 2) dual eligibles; and/or 3) 
individuals with severe or disabling chronic conditions, as specified by CMS.  MA CCPs 
established to provide services to these special needs individuals are called Specialized MA 
plans for Special Needs Individuals, or SNPs. 42 CFR 422.2 defines special needs individuals 
and specialized MA plans for special needs individuals.  SNPs were first offered in 2006.  The 
MMA gave the SNP program the authority to operate until December 31, 2008. 
 
The Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Extension Act 
of 2007 subsequently extended the SNP program from December 31, 2008, to December 31, 
2009, but imposed a moratorium that prohibited CMS from approving new SNPs after January 1,  2008.  Accordingly, CMS did not accept SNP applications in 2008 for contract year (CY) 2009. 
 
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) lifted the 
Medicare, Medicaid, and SCHIP Extension Act of 2007 moratorium on approving new SNPs. 
MIPPA further extended the SNP program through December 31, 2010, thereby allowing CMS 
to accept MA applications for new SNPs and SNP service area expansions until CY 2010.  CMS 
accepted SNP applications from MA applicants for creating new SNPs and expanding existing 
CMS-approved SNPs for all three types of specialized SNPs in accordance with additional SNP 
program requirements specified in MIPPA.  CMS regulations that implement and further detail 
MIPPA application requirements for SNPs are located at 42 CFR 422.501-504. 
 
Effective immediately upon its enactment in 2011, section 3205 of the Patient Protection and 
Affordable Care Act (ACA) extended the SNP program through December 31, 2013, and 
mandated further SNP program changes as outlined below.  Section 607 of the American 
Taxpayer Relief Act of 2012 (ATRA) extended the SNP program through December 31, 2014.  
Section 1107 of the Bipartisan Budget Act of 2013 (Pub. L. 113-67) extended the SNP program 
through December 31, 2015.  Section 107 of the Protecting Access to Medicare Act of 2014 
extended the SNP program through December 31, 2016.  Most recently, section 206 of the 
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the SNP program 
through December 31, 2018. 
 
Section 3205 of the ACA amended sections 1859(f)(7), 1853(a)(1)(B)(iv), and 1853(a)(1)(C)(iii) 
of the Act to: 
 
  Require all SNPs to be approved by the National Committee for Quality Assurance 
(NCQA) (based on standards established by the Secretary) (see section 30.2 of this 
chapter);  
 
  Authorize CMS to apply a frailty adjustment payment for Fully Integrated Dual Eligible 
(FIDE) SNPs (see section 20.2.5.1 of this chapter); and 
 
  Improve risk adjustment for special needs individuals with chronic health conditions (see 
section 20.1.4 of this chapter). 
 
10.3  Requirements and Payment Procedures 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
SNPs are expected to follow existing MA program rules, including MA regulations at 42 CFR 
422, as interpreted by guidance, with regard to Medicare-covered services and Prescription Drug 
Benefit program rules.  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 (see 42 CFR 422.2).  SNPs should assume that existing Part C and D 
rules apply unless there is a specific exception in the regulation/statutory text or other guidance 
to CMS interpreting the rule as not applicable to SNPs.  Additional requirements for SNP plans 
can be found in the Prescription Drug Benefit Manual at:  
https://www.cms.gov/medicare/prescription-drug- coverage/prescriptiondrugcovcontra/partdmanuals.html. 
 
Payment procedures for SNPs mirror the procedures that CMS uses to make payments to non-
SNP MA plans.  SNPs must prepare and submit bids like other MA plans, and are paid in the 
same manner as other MA plans based on the plans enrollment and the risk adjustment payment 
methodology.  Guidance on payment to MAOs is available in chapter 8 of the MMCM.  CMS 
posts current MA payment rates online in the Ratebooks & Supporting Data section at: 
http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/. 
 
Current CMS guidance on cost sharing requirements, including guidance provided by the CMS 
model marketing materials at: https://www.cms.gov/Medicare/Health-
Plans/ManagedCareMarketing/MarketngModelsStandardDocumentsandEducationalMaterial.htm
l, is applicable to all SNPs. 
 
20  Description of SNP Types 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
SNPs may be any type of MA CCP, including either a local or regional preferred provider 
organization (i.e., LPPO or RPPO) plan, a health maintenance organization (HMO) plan, or an 
HMO Point-of-Service (HMO-POS) plan, as described in chapter 1 of the MMCM.  This section 
describes the three types of SNPs (i.e., C-SNPs, D-SNPs, and I-SNPs) in further detail. 
 
20.1  Chronic Condition SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
20.1.1  General 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
C-SNPs are SNPs that restrict enrollment to special needs individuals with specific severe or 
disabling chronic conditions, defined in 42 CFR 422.2.  Approximately two-thirds of Medicare 
enrollees have multiple chronic conditions requiring coordination of care among primary 
providers, medical and mental health specialists, inpatient and outpatient facilities, and extensive 
ancillary services related to diagnostic testing and therapeutic management.  
 
A C-SNP must have specific attributes that go beyond the provision of basic Medicare Parts A 
and B services and care coordination that is required of all CCPs, in order to receive the special 
designation and marketing and enrollment accommodations provided to C-SNPs.  (See section 
60 below and the Medicare Marketing Guidelines at:  https://www.cms.gov/Medicare/Health-
Plans/ManagedCareMarketing/FinalPartCMarketingGuidelines.html, for more information on 
SNP-specific marketing). 
 
20.1.2  List of Chronic Conditions 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
Section 1859(b)(6)(B)(iii) of the Act and 42 CFR 422.2 define special needs individuals with 
severe or disabling chronic conditions as special needs individuals who have one or more co- morbid and medically complex chronic conditions that are substantially disabling or life 
threatening; have a high risk of hospitalization or other significant adverse health outcomes; and 
require specialized delivery systems across domains of care.  CMS solicited public comments 
on chronic conditions meeting the clarified definition and convened the SNP Chronic Condition 
Panel in the fall of 2008.  Panelists included six clinical experts on chronic condition 
management from three federal agenciesthe Agency for Healthcare Research and Quality 
(AHRQ), the Centers for Disease Control and Prevention (CDC), and CMS.  After discussing 
public comments on a proposed list of SNP-specific chronic conditions, the panelists 
recommended, and CMS subsequently approved, the following 15 SNP-specific chronic 
conditions: 
 
1.  Chronic alcohol and other drug dependence; 
 
2.  Autoimmune disorders limited to: 
 
  Polyarteritis nodosa, 
  Polymyalgia rheumatica, 
  Polymyositis, 
  Rheumatoid arthritis, and 
  Systemic lupus erythematosus; 
 
3.  Cancer, excluding pre-cancer conditions or 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-stage liver disease; 
 
9.  End-stage renal disease (ESRD) requiring dialysis; 
 
10. Severe hematologic disorders limited to: 
 
  Aplastic anemia, 
  Hemophilia, 
  Immune thrombocytopenic purpura, 
  Myelodysplatic syndrome,    Sickle-cell disease (excluding sickle-cell trait), and 
  Chronic venous thromboembolic disorder; 
 
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 (i.e., hemiplegia, quadriplegia, paraplegia, monoplegia), 
  Huntingtons disease, 
  Multiple sclerosis, 
  Parkinsons disease, 
  Polyneuropathy, 
  Spinal stenosis, and 
  Stroke-related neurologic deficit; and 
 
15. Stroke. 
 
The list of SNP-specific chronic conditions is not intended for purposes other than clarifying 
eligibility for the C-SNP CCP benefit package.  CMS may periodically re-evaluate the fifteen 
chronic conditions as it gathers evidence on the effectiveness of care coordination through the 
SNP product, and as health care research demonstrates advancements in chronic condition 
management. 
 
20.1.3  Grouping Chronic Conditions 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
When completing the SNP application, MAOs may apply to offer a C-SNP that targets any one  of the following: 
 
1.  A single CMS-approved chronic condition (selected from the list in section 20.1.2 
above), 
 
2.  A CMS-approved group of commonly co-morbid and clinically-linked conditions 
(described in section 20.1.3.1 below), or 
 
3.  An MAO-customized group of multiple chronic conditions (described in section 20.1.3.2 
below). 
 
20.1.3.1  CMS-Approved Group of Commonly Co-Morbid and Clinically-
Linked Conditions 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
A C-SNP may not be structured around multiple commonly co-morbid conditions that are not 
clinically linked in their treatment because such an arrangement results in a general market 
product rather than one that is tailored for a particular population.  C-SNPs are permitted to 
target a group of commonly co-morbid and clinically linked chronic conditions.  Based on 
CMSs data analysis and recognized national guidelines, CMS identified five combinations of 
commonly co-existing chronic conditions that may be the focus of a C-SNP. 
 
CMS accepts applications for C-SNPs that focus on the following five multi-condition 
groupings: 
 
Group 1:  Diabetes mellitus and chronic heart failure; 
 
Group 2:  Chronic heart failure and cardiovascular disorders; 
 
Group 3:  Diabetes mellitus and cardiovascular disorders; 
 
Group 4:  Diabetes mellitus, chronic heart failure, and cardiovascular disorders; and 
 
Group 5:  Stroke and cardiovascular disorders. 
 
For MAOs that are approved to offer a C-SNP targeting one of the above-listed groups, enrollees 
need to have only one of the qualifying conditions for enrollment.  CMS will review the Model 
of Care (MOC) and benefits package for the multi-condition C-SNP to determine adequacy in 
terms of creating a specialized product for the chronic conditions it serves. 
 
20.1.3.2  MAO-Customized Group of Multiple Chronic Conditions 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
MAOs may develop their own multi-condition C-SNPs for enrollees who have all of the 
qualifying commonly co-morbid and clinically linked chronic conditions in the MAOs specific 
combination.  MAOs that pursue this customized option must verify that enrollees have all of the  qualifying conditions in the combination.  MAOs interested in pursuing this option for multi-
condition C-SNPs are limited to groupings of the same 15 conditions selected by the panel of 
clinical advisors that other C-SNPs must select.  As with SNPs pursuing the Commonly Co-
Morbid and Clinically-Linked Option described in section 20.1.3.1, CMS will carefully assess 
the prospective multi-condition SNP application to determine the adequacy of its care 
management system for each condition in the combination and will review the MOC and benefits 
package. 
 
20.1.4  Hierarchical Condition Categories Risk Adjustment for C-SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
CMS uses a risk score that reflects the known underlying risk profile and chronic health status of 
similar individuals for purposes of hierarchical condition categories (HCC) risk adjustment 
described under section 1853(a)(1)(C) of the Act.  The Act requires CMS to use such risk score 
in place of the default risk score that is otherwise used to determine payment for new enrollees in 
MA plans.  For a description of any evaluation conducted during the preceding year and any 
revisions made under section 1853(b) of the Act, refer to CMSs annual Announcement of 
Calendar Year Medicare Advantage Capitation Rates and Medicare Advantage and Part D 
Payment Policies and Final Call Letter (Announcement), located at:  
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-
and-Documents.html. 
 
20.2  Dual Eligible SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
20.2.1  General 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
D-SNPs enroll individuals who are entitled to both Medicare (title XVIII) and medical assistance 
from a state plan under Medicaid (title XIX).  States cover some Medicare costs, depending on 
the state and the individuals eligibility.  The Medicaid eligibility categories encompass all 
categories of Medicaid eligibility including: 
 
  Full Medicaid (only); 
  Qualified Medicare Beneficiary without other Medicaid (QMB Only); 
  QMB Plus; 
  Specified Low-Income Medicare Beneficiary without other Medicaid (SLMB Only); 
  SLMB Plus; 
  Qualifying Individual (QI); and 
  Qualified Disabled and Working Individual (QDWI).  States may vary in determining their eligibility categories; therefore, there may be state-specific 
differences in the eligibility levels in comparison to those listed here.  For specific information 
regarding Medicaid eligibility categories, refer to:  http://www.medicaid.gov/Medicaid-CHIP-
Program-Information/By-Population/Medicare-Medicaid-Enrollees-Dual-Eligibles/Seniors-and-
Medicare-and-Medicaid-Enrollees.html. 
 
CMS no longer categorizes D-SNPs by subtype (see the December 7, 2015, HPMS memo 
Discontinuation of Dual Eligible Special Needs Plans Sub-type Categories).  However, Table 2 
below summarizes the dual eligible Medicaid programs (Dual Eligible Beneficiaries Under the 
Medicare and Medicaid Programs, Medicare Learning Network, February 2016). 
 
Table 2: Dual Eligible Medicaid Programs 
 
Program  Income  Resources  Medicare  Other  Benefits 
Criteria*  Criteria*  Part A and  Criteria 
Part B 
Enrollment 
Full  Determined  Determined  Not  In some   Full Medicaid 
Medicaid  by State  by State  applicable  cases,  coverage either 
(only)  (N/A)  institutional  categorically or 
status or  through optional 
clinical  coverage groups 
need may  based on Medically 
factor into  Needy status, 
eligibility  special income 
levels for 
institutionalized 
individuals, or 
home- and 
community- based 
waivers 
 Medicaid may pay 
for Part A (if any) 
and Part B 
premiums and cost 
sharing for 
Medicare services 
furnished by 
Medicare providers 
to the extent 
consistent with the 
Medicaid State Plan 
QMB  100% of  3 times  Part A***  N/A   Medicaid pays for 
Only  Federal  Supplemental  Part A (if any) and 
Poverty  Security  Part B premiums, 
Line (FPL)  Income (SSI)  and may pay for  Program  Income  Resources  Medicare  Other  Benefits 
Criteria*  Criteria*  Part A and  Criteria 
Part B 
Enrollment 
resource  deductibles, 
limit,  coinsurance, and 
adjusted  copayments for 
annually in  Medicare services 
accordance  furnished by 
with  Medicare providers 
increases in  to the extent 
Consumer  consistent with the 
Price Index  Medicaid State Plan 
(CPI)  (even if payment is 
not available under 
the State plan for 
these charges, 
QMBs are not liable 
for them) 
QMB  100% of  Determined  Part A***  Meets   Full Medicaid 
Plus  FPL  by State  financial  coverage 
and other   Medicaid pays for 
criteria for  Part A (if any) and 
full  Part B premiums, 
Medicaid  and may pay for 
benefits  deductibles, 
coinsurance, and 
copayments to the 
extent consistent 
with the Medicaid 
State Plan (even if 
payment is not 
available under the 
State plan for these 
charges, QMBs are 
not liable for them) 
SLMB  >100% of  3 times SSI  Part A  N/A   Medicaid pays for 
Only  FPL but  resource  Part B premiums 
<120% of  limit, 
FPL  adjusted 
annually in 
accordance 
with 
increases in 
CPI 
SLMB  >100% of  Determined  Part A***  Meets   Full Medicaid  Program  Income  Resources  Medicare  Other  Benefits 
Criteria*  Criteria*  Part A and  Criteria 
Part B 
Enrollment 
Plus  FPL but  by State  financial  coverage 
<120% of  and other   Medicaid pays for 
FPL  criteria for  Part B premiums 
full 
Medicaid 
benefits 
QI**  120% of  3 times SSI  Part A  N/A   Medicaid pays for 
FPL but  resource  Part B premiums 
<135% of  limit, 
FPL  adjusted 
annually in 
accordance 
with 
increases in 
CPI 
QDWI  200% of  2 times SSI  Part A  N/A   Medicaid pays for 
FPL  resource  benefits lost  Part A premiums 
limit  due to 
individuals 
return to 
work; 
eligible to 
enroll in and 
purchase 
Part A 
coverage 
* States can effectively raise these Federal income and resources criteria under Section 1902(r)(2) of the 
Social Security Act (the Act). 
** Beneficiaries under this program are not otherwise eligible for full Medicaid coverage through the 
State. 
*** To qualify as a QMB or a QMB plus, individuals must be enrolled in Part A (or if uninsured for Part 
A, have filed for premium-Part A on a conditional basis).  For more information on this process, refer 
to Section HI 00801.140 of the Social Security Administration (SSA) Program Operations Manual 
System at http://policy.ssa.gov/poms.nsf/lnx/0600801140 on the SSA website.  To qualify as a SLMB, 
SLMB plus, or QI, individuals must be enrolled in Part A.  Part A coverage is not a factor for full 
Medicaid eligibility. 
 
20.2.2  State Contract Requirements for D-SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
As provided under section 164(c)(2) of MIPPA, and as amended by section 3205(d) of the ACA, 
as of January 1, 2013, all D-SNPs are required to have an executed contract with applicable State 
Medicaid Agencies.  See section 1859(f)(3)(D) of the Act.   
The SNP application, which is available through HPMS, provides further information on how 
and when D-SNPs must submit their State Medicaid Agency Contracts (SMACs) and related 
information to CMS.  Plans should refer to the State Medicaid Agency Contract Upload 
Document and other documents included in the online application page in HPMS. 
 
The SMAC must document each entitys roles and responsibilities with regard to dual eligibles, 
and must cover the minimum regulatory requirements below: 
 
1.  The MAOs responsibilities, including financial obligations, to provide or arrange 
for Medicaid benefits. 
 
This contractual element requires the process by which the D-SNP agency provides 
and/or arranges for Medicaid benefits be clearly outlined in the contract between the 
State Medicaid Agency and the entity.  All contracts must specify how the Medicare and 
Medicaid benefits are integrated and/or coordinated. 
 
2.  The categories of eligibility for dual eligibles to be enrolled under the D-SNP, 
including the targeting of specific subsets. 
 
This contractual element requires the contract to clearly identify the dual-eligible 
population that is eligible to enroll in the D-SNP.  A D-SNP may only enroll dual 
eligibles as specified in the SMAC.  For example, if a State Medicaid Agency contracts 
with a plan for a Medicaid wraparound package for certain dual eligibles (e.g., those 
aged 65 and above), the MAO may establish a D-SNP that limits enrollment to that 
same subset of dual eligibles.  For MAOs whose contract with the state is for Medicaid 
managed care, enrollment in a D-SNP offered by the organization must be limited to 
the same category of Medicaid dual eligibles as are permitted to enroll in that 
organizations Medicaid managed care contract. 
 
3.  The Medicaid benefits covered under the D-SNP. 
 
This contractual element requires information be included on plan benefit design, 
benefit administration, and assignment of responsibility for providing, or arranging for, 
the covered benefits.  The contract must specify the benefits offered in the Medicaid 
State Plan, including any benefits that are not covered by original Medicare that the SNP 
will offer.  If the list of services is an attachment to the contract, the SNP must 
reference the list in the body of the contract. 
 
4.  The cost sharing protections covered under the D-SNP. 
 
This contractual element requires that D-SNPs not impose cost sharing on specified dual 
eligibles (i.e., Full Medicaid individuals, QMBs, or any other population designated by 
the state) that exceed the amounts permitted under the State Medicaid plan if the 
individual were not enrolled in the D-SNP.  In addition, the D-SNP must meet all MA 
maximum out-of-pocket (MOOP) requirements.   
5.  The identification and sharing of information about Medicaid provider 
participation. 
 
This contractual element requires that a process be enumerated regarding how the state 
will identify and share information about providers contracted with the State Medicaid 
Agency so that they may be included in the SNP provider directory.  Although CMS 
does not require all providers to accept both Medicare and Medicaid, the D-SNPs 
network must meet the needs of the dual-eligible population served. 
 
6.  The verification process of an enrollees eligibility for both Medicare and 
Medicaid. 
 
This contractual element requires that MAOs receive access to real-time information 
verifying eligibility of dual-eligible enrollees from the State Medicaid Agency.  The 
agreed-upon eligibility verification process between the D-SNP and the state must be 
described in detail. 
 
7.  The service area covered under the SNP. 
 
This contractual element requires that the covered service area(s) in which the state has 
agreed the MAO may market and enroll, be clearly identified.  The D-SNP service 
area(s) must be consistent with the SMAC-approved service area(s). 
 
8.  The contracting period. 
 
This contractual element requires a period of performance between the State Medicaid 
Agency and the D-SNP of at least January 1 through December 31 of the year following 
the due date of the contract.  Contracts also may be drafted as multi-year, or evergreen 
contracts (i.e., continuously valid until a change is made in the contract), as long as the 
entire calendar year is covered. 
 
CMS requires the D-SNP to submit a SMAC for review by July 1 every year.  A D-SNP with 
an evergreen contract is still required to submit its contract to CMS by July 1 and must include 
a letter from the State Medicaid Agency stating that it intends to continue contracting with the 
MAO for the upcoming calendar year. 
 
20.2.3  Relationship to State Medicaid Agencies 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
Pursuant to section 1859 of the Act, State Medicaid Agencies are not required to enter into 
contracts with MAOs with respect to a SNP.  However, if the MAO does have such a contract, 
the MAO must still meet all CMS application requirements, to include securing a license and 
certification from the State Department of Insurance to offer an MA product in the state, among 
other requirements. 
  20.2.4  Special Cost Sharing Requirements for D-SNPs  
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
20.2.4.1  General 
(Rev. 126, Issued:03-31-23, Effective:01-01-23, Implementation: 01-01-23) 
 
MAOs offering D-SNPs must comply with and ensure that their contracted providers comply 
with limits on out-of-pocket costs for dually eligible individuals. Pursuant to section 1852(a)(7) 
of the Act and 42 CFR 422.504(g)(1)(iii), D-SNPs cannot impose cost sharing for Medicare 
Parts A or B benefits on specified dually eligible individuals (QMBs and full-benefit Medicaid 
individuals, or other Medicaid populations when the state is responsible for covering such 
amounts) that would exceed the amounts permitted under the State Medicaid Plan if the 
individual were not enrolled in the D-SNP. This category includes QMB Only and QMB Plus, 
the two categories of dual eligibility  that have all Medicare Parts A and B cost sharing covered 
by Medicaid, and may also include other dually eligible enrollees for whom the state covers Part 
A or Part B cost sharing (such as SLMB Plus). 
 
Like all other local MA plans (per 42 CFR 422.100(f)(4)), D-SNPs must establish a MOOP 
amount. For purposes of tracking out-of-pocket spending relative to its MOOP amount, a plan 
must count all costs for Medicare Parts A and B services accrued under the plan benefit 
package, including cost sharing paid by any applicable secondary or other coverage (such as 
through Medicaid, employer(s), and commercial insurance) and any cost sharing that remains 
unpaid (such as because of limits on Medicaid liability for Medicare cost sharing under the 
lesser-of policy and the cost sharing protections afforded certain dually eligible individuals). 
When these out-of-pocket costs for an enrollee reach the MOOP amount, the D-SNP is 
responsible for 100 percent of the costs of items and services covered under Parts A and B.  
 
D-SNPs (like all MA organizations) are responsible for tracking out-of-pocket spending 
accrued by each enrollee and must alert enrollees and contracted providers when the MOOP 
amount is reached (42 CFR 422.100(f)(4) and (f)(5)(iii), and 422.101(d)). Remittance advice or 
explanation of benefits notices issued per 42 CFR 422.111(k) that indicate attainment of the 
MOOP amount and the absence of any additional cost sharing charges may fulfill the notice 
requirement for providers and enrollees.  
 
20.2.4.2 - D-SNPs With or Without Medicare Zero-Dollar Cost Sharing 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
At the time of plan creation, each D-SNP must identify whether or not if offers Medicare zero-
dollar cost sharing.  In HPMS, D-SNPs will have the option of one of the following two 
indicators: 
 
1.  Medicare Zero-Dollar Cost Sharing Plan, or  
 
2.  Medicare Non-Zero Dollar Cost Sharing Plan.   
  These two indicators will be used in multiple areas within HPMS and are essential to the proper 
display of benefits in Medicare Plan Finder.  
 
20.2.4.3  Cost Sharing for Dual Eligibles Requiring an Institutional Level of 
Care 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
As provided under section 1860D-14 of the Act, full-benefit dual eligible individuals who are 
institutionalized individuals have no cost sharing for covered Part D drugs under their 
Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug (MA-PD) Plan.  As of 
January 1, 2012, section 1860D-14 of the Act also eliminates Part D cost sharing for Full 
Medicaid individuals who are receiving home and community-based services (HCBS) either 
through: 
 
  A home and community-based waiver authorized for a state under section 1115 or 
subsection (c) or (d) of section 1915 of the Act; 
 
  A Medicaid State Plan Amendment under section 1915(i) of the Act; or 
 
  A Medicaid managed care organization with a contract under section 1903(m) or section 
1932 of the Act. 
 
These services target frail, elderly individuals who, without the delivery in their home of services 
such as personal care services, would be institutionalized.  HCBS eligibility is not based on 
where an individual resides.  In other words, SNPs cannot assume that all enrollees residing in 
assisted living facilities receive HCBS and therefore qualify for the zero-dollar cost sharing.  
Thus, in order to qualify for zero-dollar cost sharing, a SNP must determine or an enrollee must 
demonstrate that s/he is a full-benefit Medicaid individual receiving HCBS as stated above.  
Below, we list acceptable documents that SNPs may use as best available evidence for 
demonstrating receipt of HCBS: 
 
  A copy of a state-issued Notice of Action, Notice of Determination, or Notice of 
Enrollment that includes the enrollees name and HCBS eligibility date during a month 
after June of the previous calendar year; 
 
  A copy of a state-approved HCBS Service Plan that includes the enrollees name and 
effective date beginning during a month after June of the previous calendar year; 
 
  A copy of a state-issued prior authorization approval letter for HCBS that includes the 
enrollees name and effective date beginning during a month after June of the previous 
calendar year; or 
 
  Other documentation provided by the state showing HCBS eligibility status during a 
month after June of the previous calendar year. 
 
20.2.5  Fully Integrated Dual Eligible SNPs  (Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
A FIDE SNP is a D-SNP that is a Medicare and Medicaid fully integrated product.  D-SNPs 
classified as FIDE are described in section 1853(a)(1)(B)(iv) of the Act and at 42 CFR 422.2.  
FIDE SNPs are CMS-approved D-SNPs that: 
 
  Enroll special needs individuals entitled to medical assistance under a Medicaid State 
Plan, as defined in section 1859(b)(6)(B)(ii) of the Act and 42 CFR 422.2; 
 
  Provide dual-eligible enrollees access to Medicare and Medicaid benefits under a 
single managed care organization; 
 
  Have a CMS-approved, MIPPA-compliant contract with a State Medicaid Agency 
that includes coverage of specified primary, acute, and long-term care benefits and 
services, consistent with state policy, under risk-based financing; 
 
  Coordinate the delivery of covered Medicare and Medicaid health and long-term 
care services, using aligned care management and specialty care network methods 
for high-risk enrollees; and 
 
  Employ policies and procedures approved by CMS and the state to coordinate or 
integrate member materials, enrollment, communications, grievance and appeals, and 
quality improvement. 
 
As stated in the April 2, 2012, Announcement of Calendar Year (CY) 2013 Medicare 
Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final 
Call Letter in determining whether a D-SNP meets the FIDE-SNP definition at 42 CFR 422.2, 
CMS will allow long-term care benefit carve-outs or exclusions only if the plan can 
demonstrate that it meets the following criteria: 
 
  The plan must be at risk for substantially all of the services under the capitated rate; 
 
  The plan must be at risk for nursing facility services for at least six months (180 days) 
of the plan year; 
 
  The enrollee must not be disenrolled from the plan as a result of exhausting the service 
covered under the capitated rate; and 
 
  The plan must remain responsible for managing all benefits, including any carved-out 
service benefits, notwithstanding the method of payment (e.g., fee-for-service, separate 
capitated rate) received by the plan. 
 
Additionally, notwithstanding any benefit carve-outs permitted under such an arrangement, D- 
SNPs in states that currently require capitation of long-term care benefits for a longer duration 
than this specified minimum must maintain this level of capitation. 
  20.2.5.1  Application of Frailty Adjustment for FIDE SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
Section 1853(a)(1)(B)(iv) of the Act gives the Secretary the authority to apply a frailty 
adjustment payment under the rules for Program of All-Inclusive Care for the Elderly (PACE) 
payment, for certain FIDE SNPs, to reflect the costs of treating high concentrations of frail 
individuals.  CMS announces its methodology for determining whether a FIDE SNP has a 
similar average level of frailty...as the PACE program in its annual Announcement, located 
at:  https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-
and-Documents.html.  Every fall, we also notify each FIDE SNP of its frailty score and of how it 
compares to PACE organizations. 
 
Frailty scores are calculated using the limitation on activities of daily living (ADL) reported by a 
plans enrollees, based on the Medicare Health Outcomes Survey (HOS) from the year previous 
to the payment year.  For example, for payment year 2017, CMS will use the 2016 HOS or 
Health Outcomes Survey-Modified (HOS-M) to determine a frailty score for FIDE SNPS.  
MAOs that believe they will be sponsoring a FIDE SNP in 2017 and want to be considered for a 
frailty payment must participate in the 2016 HOS or HOS-M to allow for CMS to calculate their 
frailty score.  For more information, please see the annual fall HPMS memo, Participation in 
HOS for MA Organizations Planning to Sponsor FIDE SNPs. 
 
Therefore, in order for a SNP to be eligible to receive frailty payments pursuant to section 1853 
of the Act, the SNP must: (1) satisfy the FIDE SNP definition under 42 CFR 422.2(3); (2) 
participate in the HOS; and (3) have similar average levels of frailty as PACE organizations as 
described in the Advance Notice for the given year. 
 
20.2.6  Benefit Flexibility for Certain D-SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
Regulations at 42 CFR 422.102(e) allow D-SNPs that meet a high standard of integration 
(although not necessarily as much integration as FIDE SNPs) and specified performance and 
quality-based standards to offer supplemental benefits beyond those currently permitted for MA 
plans.  CMS has limited this benefit flexibility to qualified D-SNPs because CMS believes those 
plans are best positioned to achieve the objective of keeping dual-eligible enrollees who are at 
risk of institutionalization in the community. 
 
20.2.6.1  Benefit Flexibility Eligibility Requirements 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
In order to be eligible for benefit flexibility, the D-SNP must: 
 
  Be a specialized MA plan for dual-eligible special needs individuals described in section 
1859(b)(6)(B)(ii) of the Act. 
 
  Be operational in the upcoming CY and have operated the entire previous CY. 
    Possess a valid contract arrangement with the state, in accordance with CMS policy and 
the requirements at 42 CFR 422.107, that: 
 
  Includes coverage of specified primary, acute, and long-term care benefits and 
-
services to the extent capitated coverage is consistent with state policy; and 
 
  Coordinates delivery of covered Medicare and Medicaid primary, acute, and long-
-
term care services throughout its entire service area, using aligned care 
management and specialty care network methods for high-risk enrollees. 
 
  Have received a three-year approval of its MOC most recently reviewed by NCQA. 
 
  Be part of a contract with a current three-star (or higher) overall rating on the Medicare 
Plan Finder website.  Please note:  If the D-SNP is part of a contract that does not have 
sufficient enrollment to generate a star rating, CMS will base the ratings on the most 
recent SNP plan-level Healthcare Effectiveness Data and Information Set (HEDIS) 
measures.  The plan must receive 75 percent or greater on at least five of the following 
measures: 
 
  Controlling Blood Pressure; 
-
  Appropriate Monitoring of Patients Taking Long-Term Medications; 
-
  Board-Certified Physicians (Geriatricians), Care for Older Adults - Medication 
-
Review; 
  Care for Older Adults - Functional Status Assessment; 
-
  Care for Older Adults - Pain Screening; and 
-
  Medication Reconciliation Post-Discharge. 
-
 
  Not be part of a contract with a score of two (negative) points or more on either the Part 
C or the Part D portion of the previous application cycle past performance review 
methodology.  The past performance methodology currently analyzes the performance 
of MA and Part D contracts in 11 distinct performance categories, assigning negative 
points to contracts with poor performance in each category.  The analysis uses a 14-
month look-back period. 
 
20.2.6.2  Characteristics and Categories of Flexible Supplemental Benefits 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
CMS expects D-SNPs to use the flexibility to design their benefits in a way that adds value for 
the enrollee by augmenting and/or bridging a gap between Medicare and Medicaid covered 
services.  CMS may approve flexible supplemental benefits that have the following 
characteristics: 
 
  Are most appropriate for individuals who need assistance with  ADLs, such as: 
  Eating, drinking, dressing, bathing, grooming, toileting, transferring, and 
-
mobility.    
  Are most appropriate for individuals who need assistance with instrumental activities 
of daily living (IADLs), such as:  
  Transportation, grocery shopping, preparing food, financial management, and 
-
medication management.  
 
  Must be provided to the enrollee at zero cost. 
 
  Must not be duplicative of Medicaid, including the State Medicaid or local benefits for 
enrollees who are eligible to receive identical Medicaid services. 
 
  Must not be duplicative of Medicare, including Medicare supplemental benefits 
(described in chapter 4 of the MMCM). 
 
  Must be uniformly offered and available to all enrollees. 
 
Table 3 below sets forth guidance on specific categories of flexible supplemental benefits that 
qualified D-SNPs may consider offering to those enrollees who do not already qualify for them 
under Medicaid. 
     
Table 3: Flexible Supplemental Benefits for Consideration 
 
Proposed  Benefit Description  Acceptable  PBP Description 
Benefit  Means of 
Category  Delivery 
Non-Skilled  Non-skilled services and  Services would  Describe the criteria 
In-Home  support services performed by  be performed by  the plan intends to use 
Support  a personal care attendant or  individuals  (e.g., level of care 
Services  by another individual that is  licensed by the  need, ADL limitations, 
providing these services  state to provide  etc.) to determine 
consistent with state  personal care  which enrollees are 
requirements in order to assist  services, or in a  eligible for personal 
individuals with disabilities  manner that is  care services. 
and/or chronic conditions  otherwise 
with performing ADLs and  consistent with 
IADLs as necessary to  state 
support recovery, to prevent  requirements. 
decline following an acute 
illness, prevent exacerbation 
of a chronic condition, and/or 
to aid with functional 
limitations.  This benefit 
category also includes non-
medical transportation that 
assists in the performance of 
IADLs, but that goes beyond 
the transportation services 
supplemental benefit 
described in section 30.3 of 
chapter 4 of the MMCM.  Proposed  Benefit Description  Acceptable  PBP Description 
Benefit  Means of 
Category  Delivery 
In-Home Food  Meal delivery service (beyond  Meals would be  Describe the Medicare 
Delivery  the limited coverage described  provided  meal benefit 
in chapter 4 of the MMCM)  consistent with  comprehensively, and 
for individuals who cannot  plan policies for  clearly distinguish 
prepare their own food (IADL  ensuring  meal benefits for 
limitation) due to functional  nutritional  individuals who would 
limitations with ADLs or  content (i.e.,  already qualify under 
short-term functional  minimum  current meal benefit 
disability, or for individuals  recommended  guidance from meal 
who, based on a physicians  daily nutritional  benefits under an 
recommendation, require  requirements).  expanded definition. 
nutritional supplementation  Describe any limits 
following an acute illness or  imposed on meal 
resulting from a chronic  benefits (e.g., 
condition.  duration, criteria for 
eligibility, number of 
meals/day). 
Supports for  Provision of respite care Specific  Describe how benefits 
Caregivers of  either through a personal care  caregiver  relate to plan-covered 
Enrollees  attendant or through provision  support benefits  benefits, as well as 
of short-term institutional- must directly  any limitations (e.g., 
based care for caregivers of  relate to the  number of 
enrollees.  Coverage may  provision of  counseling/support 
include benefits such as  plan-covered  sessions covered per 
counseling and training  benefits.  year, number of 
courses (related to the  hours/days of respite 
provision of plan-covered  care covered per year 
benefits) for caregivers of  and/or episode). 
enrollees.  Proposed  Benefit Description  Acceptable  PBP Description 
Benefit  Means of 
Category  Delivery 
Home  Coverage of home  Home  Describe benefit 
Assessments,  safety/assistive devices and  assessments  comprehensively, and 
Modifications,  home assessments and  would be  clearly distinguish 
and Assistive  modifications beyond those  performed by  safety assessments 
Devices for  permitted in chapter 4 of the  trained  and devices already 
Home Safety  MMCM.  personnel (e.g.,  covered under chapter 
Coverage may include  occupational  4 of the MMCM from 
items/services such as rails  therapists), or  additional benefits 
in settings beyond the  by persons with  qualified SNPs could 
enrollees bathroom.  qualifications  provide.  Describe 
  required by the  enrollee criteria for 
state, if  receiving these 
applicable.  additional benefits 
(e.g., enrollee at risk 
of falls, etc.) 
Adult Day Care  Services such as  Provided by  Describe the criteria 
Services  recreational/social activities,  staff whose  imposed for receipt of 
meals, assistance with  qualifications  adult day care services 
ADLs/IADLs, education to  and/or  (e.g., prior 
support performance of  supervision  authorization by a 
ADLs/IADLs, physical  meet state  medical practitioner, 
maintenance/rehabilitation  licensing  institutional level of 
activities, and social work  requirements.  care requirement, etc.) 
services. 
 
20.2.6.3  Benefit Flexibility Approval Process 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
In order for a D-SNP to offer the flexible supplemental benefits outlined above, D-SNPs shall: 
 
1.  Submit notification to CMS of their intent to offer flexible supplemental benefits; 
 
2.  Receive a CMS determination that the D-SNP is eligible; 
 
3.  Submit a bid that incorporates the flexible supplemental benefits the D-SNP intends to 
offer; and 
 
4.  Receive CMS approval of the D-SNPs bid. 
  In order for a D-SNP to offer the flexible supplemental benefits, CMS must first determine the 
D-SNP meets CMSs eligibility requirements.  Each year, CMS issues guidance in HPMS 
informing D-SNPs of the deadline to request a CMS review of its contract to determine if the D-
SNP may offer flexible supplemental benefits as part of their bid for the respective contract year.  
D-SNPs are required to submit this notification on plan letterhead to CMSs mailbox located at:  
https://dmao.lmi.org.  This request should also include the following identifying information: 
 
  Contract Number/ID; 
 
  Contract Name; 
 
  Plan Number/ID; 
 
  Plan Type; and 
 
  Contract Year for which the D-SNP intends to offer flexible supplemental benefits. 
 
Once CMS is notified of an existing D-SNPs intent to offer these flexible supplemental benefits, 
CMS will review the following elements for each requesting D-SNP: 
 
  SMAC; 
  Past performance data, inclusive of star ratings and/or HEDIS measures; and 
  CMSs MOC approval period. 
CMS reviews these elements to render its decision on whether or not the D-SNP meets CMS 
eligibility requirements.  CMS issues a decision on the D-SNPs eligibility through HPMS in 
advance of the bid submission deadline in order to provide eligible D-SNPs sufficient time to 
establish any provider contracts that may be necessary in order to offer flexible supplemental 
benefits. 
 
If CMS deems that a D-SNP is eligible, then the D-SNP may incorporate the flexible 
supplemental benefits into its bid submission.  If CMS deems that a D-SNP is not eligible, then 
the D-SNP may not incorporate the flexible supplemental benefits into its bid submission. 
 
Eligible D-SNPs that choose to offer flexible supplemental benefits shall include the proposed 
benefit(s) as a part of their PBPs during bid submission.  The plan must attest, at the time of bid 
submission, that the flexible supplemental benefit(s) described in the PBP does not 
inappropriately duplicate an existing service(s) that enrollees are eligible to receive under a 
waiver, the State Medicaid Plan, Medicare Part A or B, or through the local jurisdiction in which 
they reside.  CMS will review the flexible supplemental benefit(s) submitted with the PBPs and 
determine whether these benefits comply with the requirements. 
 
20.3  Institutional SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16)   
20.3.1  General 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
I-SNPs are SNPs that restrict enrollment to MA eligible individuals who, for 90 days or longer, 
have had or are expected to need the level of services provided in a long-term care (LTC) skilled 
nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for 
individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility.  A 
complete list of acceptable types of institutions can be found in the Medicare Advantage 
Enrollment and Disenrollment Guidance at https://www.cms.gov/Medicare/Eligibility-and-
Enrollment/MedicareMangCareEligEnrol/index.html. 
 
For information regarding the assessment of an enrollees level of care (LOC) needs, see section 
40.2.3 of this chapter. 
 
CMS may allow an I-SNP that operates either single or multiple facilities to establish a county-
based service area as long as it has at least one long-term care facility that can accept enrollment 
and is accessible to the county residents.  As with all MA plans, CMS will monitor the plans 
marketing/enrollment practices and long-term care facility contracts to confirm that there is no 
discriminatory impact. 
 
20.3.2  Institutional Equivalent SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
For an I-SNP to enroll MA eligible individuals living in the community, but requiring an 
institutional LOC, the following two conditions must be met: 
 
1.  A determination of institutional LOC that is based on the use of a state assessment tool.  
The assessment tool used for persons living in the community must be the same as that 
used for individuals residing in an institution.  In states and territories without a specific 
tool, I-SNPs must use the same LOC determination methodology used in the respective 
state or territory in which the I-SNP is authorized to enroll eligible individuals. 
 
2.  The I-SNP must arrange to have the LOC assessment administered by an independent, 
impartial party (i.e., an entity other than the respective I-SNP) with the requisite 
professional knowledge to identify accurately the institutional LOC needs.  Importantly, 
the I-SNP cannot own or control the entity. 
 
20.3.3  Change of Residence Requirement for I-SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
If an I-SNP enrollee changes residence, the I-SNP must document that it is prepared to 
implement a CMS-approved MOC at the enrollees new residence, or in another I-SNP 
contracted LTC setting that provides an institutional level of care. 
 
  20.3.4  I-SNPs Serving Long-Term Care Facility Residents 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
I-SNPs that serve residents of LTC facilities must own, operate, or have a contractual 
arrangement with the LTC facility.  The LTC facility must adhere to the I-SNPs approved 
MOC.  CMS requires that the contract between the I-SNP and the LTC facility include the 
following: 
 
1.  Facilities in a chain organization must be contracted to adhere to the I-SNP MOC. 
 
If the I-SNPs contract is with a chain organization, the chain organization and the 
applicant agree that the facilities listed will adhere to the approved I-SNP MOC. 
 
2.  Facilities must provide I-SNP clinical staff access to the I-SNP enrollees. 
  
The contracted facility must agree to provide I-SNP clinical staff appropriate access to 
the I-SNP enrollees residing in the facility.  The I-SNP clinical staff includes physicians, 
nurses, nurse practitioners, and care coordinators, in accordance with the I-SNP protocols 
for operation. 
 
3.  The I-SNP must provide protocols in accordance with the approved I-SNP MOC. 
 
The I-SNP must agree to provide protocols to the facility for serving the I-SNP enrollees 
in accordance with the approved I-SNP MOC.  The I-SNPs contract with the facility 
must reference these protocols. 
 
4.  Delineation of services provided by the I-SNP staff and the LTC facility staff must 
be specified. 
 
The I-SNP staff and the facility staff must provide a delineation of the specific services to 
the I-SNP enrollees, in accordance with the protocols and payment for the services 
provided by the facility. 
 
5.  A training plan for LTC facility staff to understand the MOC must be included. 
 
A training plan must be in place to ensure that LTC facility staff understands their 
responsibilities in accordance with the approved I-SNP MOC, protocols, and contract.  If 
the training plan is a separate document, the contract should reference it. 
 
6.  Procedures must be developed and in place for facilities to maintain a list of 
credentialed I-SNP clinical staff. 
 
Procedures should ensure cooperation between the I-SNP and the facility in maintaining a 
list of credentialed I-SNP clinical staff in accordance with the facilitys responsibilities 
under Medicare conditions of participation. 
  7.  A contract year for I-SNP must be specified. 
 
The contract must include the full CMS contract cycle, which begins on January 1 and 
ends on December 31.  The I-SNP may also contract with additional LTC facilities 
throughout the CMS contract cycle. 
 
8.  Grounds for early termination and a transition plan for I-SNP enrollees must be 
specified. 
 
The termination clause must clearly state any grounds for early termination of the 
contract between the I-SNP and the LTC facility.  The contract must include a clear plan 
for transitioning the enrollee should the I-SNPs contract with the LTC facility terminate. 
 
30  Application, Approval, and Service Area Expansion Requirements 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
30.1  General 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
Every applicant that proposes to offer a SNP must obtain additional CMS approval as an MA-PD 
plan.  A CMS MA-PD contract that is offering a new SNP, or that is expanding the service area 
of a CMS-approved SNP, needs to complete only the SNP application portion of the MA 
application if CMS has already approved the service area for the MA contract.  Otherwise, if the 
MAO is planning to expand its contract service area, it must complete both a SNP application 
and an MA Service Area Expansion (SAE) application for the approval of the MA service area.  
Further guidance on SAE procedures is provided in section 30.4 of this chapter. 
 
The SNP application contains a list of questions and attestations requiring a yes or no 
response and requires the applicant to upload documentation in support of responses to the 
questions and attestations.  This is generally similar to the format of the MA application.  The 
timeline for submitting the SNP application is the same as the MA application timeline.  All SNP 
applications must be submitted electronically through the Health Plan Management System 
(HPMS) to CMS by the SNP application due date.  The MA application and the SNP application 
for the current contract year are available at http://www.cms.hhs.gov/MedicareAdvantageApps/.  
The SNP application is located in appendix I of the MA application. 
 
30.2  Model of Care Approval 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
As provided under section 1859(f)(7) of the Act, every SNP must have an NCQA-approved 
MOC.  The MOC provides the basic framework under which the SNP will meet the needs of 
each of its enrollees.  The MOC is a vital quality improvement tool and integral component for 
ensuring that the unique needs of each enrollee are identified by the SNP and addressed through 
the plans care management practices.  The MOC provides the foundation for promoting SNP 
quality, care management, and care coordination processes.  Please note that detailed information 
regarding the SNP MOC elements and scoring criteria are located in chapter 5 of the MMCM.   
The statute gives the Secretary the authority to establish standards for the MOC approval 
process.  The NCQA MOC approval process scores each of the clinical and non-clinical 
elements of the MOC.  SNPs are approved for one, two, or three year periods. 
 
SNPs that have a failing score (less than 70 percent) for their initial MOC submission will have 
one cure opportunity to achieve a passing score (greater than 70 percent).  Regardless of the 
score following that cure opportunity (provided the score is at least 70 percent), those SNPs will 
receive a one-year approval.  Table 4 below summarizes the MOC review and cure process. 
 
Table 4:  Overview of MOC Review and Cure Processes 
 
Score for Initial  Cure  Post 1st Cure  Final Approval Status 
MOC  Options 
Submission (%) 
85% to 100%  No cure  N/A  3-year approval 
options 
75% to 84%  No cure  N/A  2-year approval 
options 
70% to 74%  No cure  N/A  1-year approval 
options 
69% or below  One cure  70% or higher  1-year approval 
option 
69% or below  One cure  69% or below  No approval 
option 
 
This policy provides added incentive for SNPs to develop and submit comprehensive and 
carefully considered MOCs for initial NCQA approval and rewards those SNPs that have 
demonstrated ability to develop quality MOCs. 
 
30.3  Existing SNP Model of Care Re-Approval and Application Submissions 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
An MAO must submit a MOC if one of the following scenarios applies: 
 
  The MAO seeks to offer a new SNP; 
 
  The MAOs SNPs MOC approval period ends; or 
 
  CMS deems it necessary to ensure compliance with the applicable regulation(s).  
Examples include: 
 
  During an audit, if it appears that the MOC is not meeting CMS standards, then 
-
CMS may ask the SNP to correct and resubmit the MOC; or    During a regulation change involving the MOC, CMS may ask SNPs to resubmit 
-
their MOCs to ensure that they meet the new regulatory requirements. 
 
30.4  Service Area Expansion 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
An MAO may only operate a SNP in its MA-PD approved service area.  An MAO may seek to 
expand its SNP service area either (1) into its existing MA-PD service area, or (2) into a service 
area(s) where it does not currently operate.  Please see table 5 below for application information 
pertaining to these two different scenarios. 
 
Table 5: SNP SAE Scenarios 
 
  Complete SNP  Complete MA-PD 
SAE Application?  SAE Application? 
1.  MAO seeks to expand its SNP  Yes  No 
service area into its existing MA-
PD service area. 
2.  MAO seeks to expand its SNP  Yes  Yes 
service area into a service area(s) 
where it does not currently operate.  
 
The proposed SAE may not exceed the existing or pending service area for the MA contract.  
Please note that every D-SNP must have a SMAC for each state in which the D-SNP operates, 
and the CMS-approved service area must match the service area delineated in the SMAC.  In 
addition, beginning for CY 2017, MAOs are not required to submit a new MOC when requesting 
an SAE for a SNP (see the January 14, 2016, HPMS memo Changes to Special Needs Plan and 
Medicare-Medicaid Plan Model of Care Submissions and Updates in the Health Plan 
Management System).  
 
40  Enrollment Requirements 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
40.1  General 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
As specified in section 1859(f) of the Act, SNPs may only enroll individuals who meet the plans 
specific eligibility criteria and enrollment requirements.  For example, a D-SNP that is    
approved to serve only a Full Medicaid population may not enroll an individual who is not 
qualified as a Full Medicaid individual even though the individual may qualify for a different 
category of Medicaid.  Similarly, an individual who has no Medicaid entitlement may not enroll 
in a D-SNP of any type.  A C-SNP approved to serve a population with diabetes may not enroll 
individuals who do not have the diabetic condition.  However, enrollees who are dual eligible 
and who qualify for a C-SNP can choose to enroll in either a D-SNP or a C-SNP.  An individual 
who loses eligibility and is disenrolled from a SNP may re-enroll in the same SNP if that 
individual once again meets the specific eligibility criteria of the SNP.  In general, limits on  enrollment, whether specific to persons with Medicare or for any individual eligible to enroll in 
the SNP, are not permissible.  MAOs, including those offering SNPs, must accept, without 
restriction, all eligible individuals whose enrollment elections are received during a valid 
election period.  See 42 CFR 422.60 and section 1851(g)(1) of the Act. 
 
42 CFR 422.52(f) stipulates that a SNP must employ a process approved by CMS to verify the 
eligibility of each individual enrolling in the SNP.  SNPs must include elements on the 
enrollment request that correspond to the special needs criteria of the particular SNP.  Refer to 
policy regarding enrollment request mechanisms, including special guidance for C-SNPs, in the 
Medicare Advantage Enrollment and Disenrollment Guidance. 
 
SNPs that choose whether to opt in to the Online Enrollment Center (OEC) are held to the same 
accountability as other MAOs.  MAOs must accept enrollments through the OEC.  Additional 
guidance on enrollment processes is available in the Medicare Advantage Enrollment and 
Disenrollment Guidance.  Refer to section 40.2.1 of this chapter and the Medicare Advantage 
Enrollment and Disenrollment Guidance for more information about C-SNP eligibility 
verification processes.  The Medicare Advantage Enrollment and Disenrollment Guidance also 
includes information about special election periods (SEPs) for dual-eligible enrollees or enrollees 
who lose their dual eligibility. 
 
40.2  Verification of Eligibility 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
40.2.1  Verification of Eligibility for C-SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
As required of all SNPs, C-SNPs must verify the applicants special needs status.  Prior to 
enrollment, the C-SNP must contact the applicants existing provider to verify that the individual 
has the qualifying condition(s).  Not only does contact with the existing provider permit 
confirmation of the condition(s), but it also affords the opportunity to initiate the exchange of 
health information and facilitate the smooth transition of care to the C-SNP. 
 
The C-SNP may use, in its effort to obtain eligibility verification from the existing provider, a 
fax or other dated document that allows the existing provider to select the enrollees diagnosed 
chronic condition(s) from the C-SNP list of qualified conditions.  The C-SNP should attempt to 
obtain eligibility verification information from an enrollees existing provider using methods 
other than telephone contact.  (Note that ESRD C-SNPs may use a physician-signed CMS Form 
2728 ESRD Evidence Report as verification of the chronic condition.) 
 
An MAO may request CMS approval to use a Pre-enrollment Qualification Assessment Tool in 
its process for verifying an individuals eligibility for C-SNP enrollment.  (Details regarding the 
components of this tool and requirements for its use are provided below.)  This CMS-approved 
tool collects information about the chronic condition(s) targeted by the C-SNP directly from the 
individual and includes a signature line for a physician or other qualified provider to confirm the 
individuals eligibility for C-SNP enrollment.  MAOs approved to use this tool, but unable to 
obtain verification of the condition from the provider prior to enrollment, may enroll the  individual, but the C-SNP must obtain confirmation of the qualifying chronic condition(s) from 
the existing provider or a plan provider qualified to confirm the condition no later than the end of 
the first month of enrollment.  The organization must advise the enrollee that he/she will be 
disenrolled from the plan at the end of the second month if his/her eligibility cannot be verified 
during the first month of enrollment.  In that situation, the C-SNP must notify the enrollee within 
the first seven calendar days of the second month of enrollment that he/she will be disenrolled at 
the end of that second month. 
 
CMS will approve the use of a Pre-enrollment Qualification Assessment Tool under the 
following conditions: 
 
  The Pre-enrollment Qualification Assessment Tool includes a set of clinically 
appropriate questions relevant to the qualifying chronic condition(s) and covers the 
applicants past medical history, current signs and/or symptoms, and current 
medications to provide reliable evidence that the applicant has the applicable 
condition(s). 
 
  The MAO maintains a record of the results of the Pre-enrollment Qualification 
Assessment Tool, which includes the date and time of the assessment if completed 
during a face-to-face interview with the applicant, or the receipt date, if received by 
mail. 
 
  The MAO conducts a post-enrollment confirmation of each enrollees information and 
eligibility using medical information (medical history, current signs and/or symptoms, 
diagnostic testing, and current medications) provided by the enrollees existing 
provider or a plan provider. 
 
  The MAO ensures that any payment or compensation associated with enrollments 
will be forfeited if the qualifying chronic condition(s) cannot be confirmed. 
 
  A C-SNP, using a Pre-enrollment Qualification Assessment Tool, that is unable to 
obtain confirmation of the chronic condition(s) required for C-SNP eligibility from 
either the enrollees existing provider or a plan provider during the first month of 
enrollment must notify the enrollee within the first seven calendar days of the 
following month that s/he will be disenrolled at the end of that second month of 
enrollment. 
 
  All information gathered in the Pre-enrollment Qualification Assessment Tool will be 
held confidential and in accordance with Health Insurance Portability and 
Accountability Act (HIPAA) privacy provisions. 
 
  The MAO tracks the total number of enrollees and the number and percent by 
condition whose post enrollment verification matches the pre-enrollment verification.  
Data and supporting documentation is available upon request by CMS. 
 
MAOs must submit an online request for CMS approval to use a Pre-enrollment Qualification  Assessment Tool.  To request approval, go to https://dmao.lmi.org/ and enter Pre-enrollment 
Qualification Assessment Tool in the subject line, along with the applicable contract (H) 
number.  Whenever a plan changes or adds conditions to the Pre-enrollment Qualification 
Assessment Tool, CMS requires a new approval. 
 
40.2.2  Verification of Eligibility for D-SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
A D-SNP must confirm an individuals Medicare and Medicaid eligibility prior to enrollment 
into the D- SNP.  Acceptable proof of Medicaid eligibility may include, for example:  a current 
Medicaid card; a letter from the state agency that confirms entitlement to Medical Assistance; or 
verification through a systems query to a state eligibility data system.  Additional enrollment 
guidance is located in the Medicare Advantage Enrollment and Disenrollment Guidance. 
 
40.2.3  Verification of Eligibility for I-SNPs/Level of Care Assessment for 
Institutional Equivalent SNPs 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
When an individual elects to enroll in an I-SNP before she/he has received at least 90 days of 
institutional LOC, the I-SNP may use a number of sources of information to show that the 
individuals condition makes it likely that either the length of stay or the need for an institutional 
LOC will be at least 90 days.  Examples of sources of information that CMS considers 
appropriate for this purpose include:  a state LOC assessment tool; current Minimum Data Set 
(MDS) data; or a letter from the nursing facility on the organizations letterhead stating that the 
nursing facility expects the enrollee to require a stay in excess of 90 days. 
 
Pursuant to section 1859(f)(2) of the Act, individuals living in the community may enroll in an I-
SNP only if they have been determined to need an institutional LOC.  CMS permits I-SNPs 
serving individuals living in the community who require an institutional LOC to restrict 
enrollment to those individuals that reside in, or agree to reside in, a contracted assisted living 
facility (ALF) or continuing care community, as this may be necessary to ensure uniform 
delivery of specialized care. 
 
Use of an ALF or continuing care community is optional.  If a community-based I-SNP limits 
enrollment to individuals who reside in a specific ALF or continuing care community, a potential 
enrollee must agree to reside in the MAOs contracted ALF or continuing care community in 
order to enroll in the SNP.  The SNP must demonstrate the need for the limitation on enrollment, 
and must describe how community resources will be organized and provided. 
 
MAOs requesting to offer a new, or expand an existing, I-SNP to individuals living in the 
community and requiring an institutional LOC must submit to CMS information via HPMS that 
pertains to: 
 
  The state LOC assessment tool; and 
 
  The entity performing the LOC assessments.   
An entity unrelated to the MAO must perform the assessments.  This independent entity may not 
be an employee of the MAO or its parent organization, and must be an independent contractor or 
grantee.  In addition, the independent entity may not receive any kind of bonus or differential 
payment for qualifying members for the SNP. 
 
MAOs must submit this required information as a part of their SNP application.  Applications for 
this type of I-SNP are reviewed on a case-by-case basis for approval during the annual MA 
application cycle.  Refer to section 30 of this chapter for further information regarding the SNP 
application submission. 
 
40.3  Waiver to Enroll Individuals with ESRD 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
Pursuant to section 1851(a)(3)(B) of the Act, MAOs are not permitted to enroll individuals with 
ESRD.  However, a SNP may enroll individuals with ESRD if it has obtained a waiver from 
CMS to be open for enrollment to individuals with ESRD under 42 CFR 422.52(c).  MAOs 
should request this waiver as part of the SNP application.  The ESRD waiver is available to all 
types of SNPs.  CMSs decision to grant an ESRD waiver is conditional upon the SNP arranging 
access to services specifically targeted to individuals living with ESRD (e.g., nephrologists, 
hemodialysis centers, and renal transplant centers). 
 
SNP applicants requesting an ESRD waiver must complete an upload document as part of the 
SNP application.  This document must include: 
 
  A description of how the applicant intends to monitor and serve the unique needs of 
the ESRD enrollees, including their care coordination. 
 
  A list of any additional service(s) provided to enrollees with ESRD, including a 
description of how/why these services are relevant to ESRD enrollees.  
Additional benefits may include, but are not limited to: 
 
  Transportation; 
-
  Support groups (e.g., enrollee, family, caregiver); and 
-
  Self-care education (e.g., nutrition, wound care). 
-
 
  A description of the interdisciplinary care teams role in the assessment and delivery of 
services needed by enrollees with ESRD. 
 
  A list of the contracted nephrologist(s) that meets the current CMS-required health 
services delivery (HSD) access criteria. 
 
  A list of the contracted dialysis facility(ies) that meets the current CMS-required HSD 
access criteria. 
 
  A description of the dialysis options available to enrollees (e.g., home dialysis,  nocturnal dialysis). 
 
  A list of the contracted kidney transplant facility(ies). 
 
  A description of enrollee access to contracted kidney transplant facility(ies), including 
the average distance enrollees in each county served by the SNP must travel to reach a 
contracted kidney transplant facility. 
 
SNPs that did not initially elect to enroll ESRD individuals at the time of application must 
submit a new SNP application if they wish to begin enrolling individuals with ESRD.  Refer to 
section 30 of this chapter for further guidance on the SNP application process.  Once CMS 
approves the ESRD waiver, the SNP must allow all eligible ESRD individuals to enroll, in 
accordance with the Medicare Advantage Enrollment and Disenrollment Guidance. 
 
40.4  Continued Eligibility When an Enrollee Loses Special Needs Status 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
A SNP enrollee may become ineligible for the plan following his/her enrollment due to the loss 
of his/her special needs status.  Please refer to the Medicare Advantage Enrollment and 
Disenrollment Guidance for information on deemed continued eligibility, the length of the grace 
period, the implications of not regaining eligibility, the potential for involuntary disenrollment, 
and related enrollment/disenrollment policy issues. 
 
During the period of deemed continued eligibility for a D-SNP specifically, the D-SNP must 
continue to provide all MA plan-covered Medicare benefits.  During this period, the D-SNP is 
not responsible for continued coverage of Medicaid benefits that are included under the 
applicable Medicaid State Plan, nor is the D-SNP responsible for Medicare premiums or cost 
sharing for which the state would be liable had the enrollee not lost his/her Medicaid eligibility.  
However, cost sharing amounts for Medicare basic and supplemental benefits do not change 
during this period. 
 
During the period of deemed continued eligibility, MAOs are responsible for knowing: 
 
  The benefits covered for the enrollee; 
 
  The state requirements; and 
 
  The enrollee notification requirements. 
 
40.5  Special Election Period for Enrollees Losing Special Needs Status to 
Disenroll from SNP 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
CMS provides a SEP for individuals enrolled in a SNP who are no longer eligible for the SNP 
because they no longer meet the required special needs status for enrollment.  SNPs must send 
the appropriate notice to the enrollee explaining the disenrollment.  Refer to the Medicare  Advantage Enrollment and Disenrollment Guidance for additional guidance on SEPs for these 
individuals. 
 
40.6  Open Enrollment Period for Institutionalized Individuals 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
An open enrollment period for institutionalized individuals (OEPI) is available for individuals 
who meet the definition of an institutionalized individual to enroll in or disenroll from an I-
SNP.  Refer to the Medicare Advantage Enrollment and Disenrollment Guidance for further 
information about the OEPI. 
 
50  Renewal Options and Crosswalks 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
50.1  General 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
The guidance in this section specifically applies to SNP renewal options and crosswalks.  Table 6 
below provides an overview of the SNP crosswalk policy.  For general crosswalk guidance, 
please refer to the Bid Submission User Manual, located under the Plan Bids tab in HPMS.  For 
crosswalk exception guidance, please refer to CMSs annual spring HPMS memo, Process for 
Requesting an HPMS Crosswalk Exception. 
 
50.2  D-SNP Non-Renewals 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
Note that all MAOs that offer D-SNPs must have contracts with State Medicaid Agencies in the 
states in which they operate.  In the event that an MAO is not able to secure such a contract (or 
subcontract) for one or more of its D-SNPs, the MAO must terminate those D-SNPs in 
accordance with CMSs non-renewal instructions outlined in chapter 11 of the MMCM.  
Enrollees in those plans will be disenrolled from their D-SNP and may elect to receive services 
under original Medicare or another MA plan into which they wish to enroll.  Enrollees who are 
dual-eligible have an ongoing SEP andin the event of a D-SNP non-renewalwill be 
disenrolled to original Medicare and automatically enrolled in a benchmark stand-alone PDP. 
 
50.3  SNP Crosswalks 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
MAOs may not crosswalk enrollees from one SNP type to a different SNP type.  Please refer to 
chapter 11 of the MMCM for the standard crosswalk rules applicable to all MA plans, which 
include all SNPS.  The table below outlines the crosswalk scenarios for D-SNPs, C-SNPs, and I-
SNPs.  
     
Table 6: SNP Crosswalk Scenarios 
 
D-SNP Crosswalks 
Activity  Guidelines  HPMS Plan  Systems  Enrollment  Enrollee 
Crosswalk  Enrollment  Procedures  Notifications 
Activities 
(1) Renewing  An MAO  Crosswalk  The  No  Enrollees 
D-SNP that  renews a D- Exception  renewal D- enrollment  transitioned 
transitions  SNP PBP for  Request:  SNP PBP  request is  into the other 
eligible  the upcoming  MAOs  ID must  required for  D-SNP 
enrollees into  CY and also  cannot  remain the  current  PBPreceive a 
another D-SNP  has another  complete the  same so  enrollees to  standard 
(Please note:   available D- transition of  that the  remain  ANOC. 
This scenario  SNP PBP for  current  HPMS Plan  enrolled in   
requires a  the upcoming  eligible  Crosswalk  the renewing 
crosswalk  CY.  These  enrollees to  will  D-SNP PBP 
exception.   two D-SNP  the other D- indicate  in the 
MAOs seeking  PBPs are  SNP PBP via  that  upcoming 
this crosswalk  offered to  the HPMS  enrollees  CY. 
must obtain  different  Plan  remain in   
prior approval  populations.   Crosswalk.  the same D- New 
from CMS by  MAOs must  SNP PBP.  enrollees 
submitting a  submit a    must 
crosswalk  Crosswalk  The MAO  complete an 
exception  Exception  must  enrollment 
request.)  Request via  submit  request. 
HPMS.  If  enrollment 
approved,  transactions 
the MAO  to transition 
will be  current 
permitted to  eligible 
submit  enrollees 
enrollment  into the 
transactions.  other D-
  SNP PBP. 
HPMS Plan  Enrollees 
Crosswalk  not 
Definition:  transitioned 
An MAO is  by the 
offering  submission 
more than  of 
one D-SNP  enrollment 
PBP and  transactions 
wishes to  will remain 
move  enrolled in  enrollees  the 
between  renewing 
them and  D-SNP 
keep the D- PBP. 
SNP PBPs. 
(2) Renewing  An MAO  Crosswalk  The  No  Current 
D-SNP in a  reduces the  Exception  renewal D- enrollment  enrollees in 
multi-state  service area  Request:  SNP PBP  request is  the renewal 
service area  of a previous  MAOs  ID must  required for  portion of the 
with a SAR to  CY D-SNP  cannot  remain the  current  service area 
accommodate  PBP to  complete the  same so  enrollees in  receive a 
state  accommodate  transition of  that the  the  standard 
contracting  state  current  HPMS Plan  remaining  ANOC. 
efforts in  contracting  eligible  Crosswalk  portion of the   
portions of that  efforts in a  enrollees to  will  service area  Current 
service area  multi-state  one or more  indicate  to remain  enrollees in 
(Please note:   service area.    new or  that  enrolled in  the reduced 
This scenario  renewing  enrollees  the renewing  portion of the 
requires a  upcoming  remain in  D-SNP PBP  service area 
crosswalk  CY D-SNP  the same D- in the  who are 
exception.   PBPs via the  SNP PBP.    upcoming  transitioned 
MAOs seeking  HPMS Plan    CY.    to a new or 
this crosswalk  Crosswalk.  The MAO    renewing D- 
must obtain  MAOs must  must  New  SNP PBP 
prior approval  submit a  submit  enrollees  receive a 
from CMS by  Crosswalk  enrollment  must  standard 
submitting a  Exception  transactions  complete  ANOC. 
crosswalk  Request via  to transition  enrollment 
exception  HPMS.  If  current  request. 
request.)  approved,  eligible 
the MAO  enrollees in 
will be  the reduced 
permitted to  portion of 
submit  the service 
enrollment  area of the 
transactions.  previous 
  CY D-SNP 
HPMS Plan  PBP into 
Crosswalk  the new or 
Definition:  renewing 
An  upcoming 
upcoming  CY D-SNP 
CY D-SNP  PBP(s).  
PBP that  Enrollees 
links to a  not 
previous CY  transitioned  D-SNP PBP  by the 
and only  submission 
retains a  of 
portion of its  enrollment 
plan service  transactions 
area.  The  will remain 
upcoming  enrolled in 
CY D-SNP  the 
PBP must  renewing 
retain the  D-SNP 
same D-SNP  PBP. 
PBP ID as 
the previous 
CY D-SNP 
PBP.  In 
addition, a 
new D-SNP 
PBP is added 
for the 
upcoming 
CY that is 
not linked to 
a previous 
CY. 
 
HPMS Plan 
Crosswalk 
Designation: 
Renewal 
Plan with a 
SAR 
AND/OR 
New Plan 
AND/OR 
Renewal 
Plan 
C-SNP Crosswalks 
Activity  Guidelines  HPMS Plan  Systems  Enrollment  Enrollee 
Crosswalk  Enrollment  Procedures  Notifications 
Activities 
(1) Renewing  An MAO  HPMS Plan  The  No  Current 
C-SNP with  combines one  Crosswalk  renewal C- enrollment  enrollees 
one chronic  or more  Definition:  SNP PBP  request is  receive a 
condition that  whole MA  One or more  ID must  required for  standard 
transitions  PBPs of the  previous CY  remain the  current  ANOC. 
eligible  same type  plans that  same so  eligible    enrollees into  offered in the  consolidate  that CMS  enrollees to 
another C-SNP  previous CY  into one plan  may  remain 
with a CMS- into a single  for the  consolidate  enrolled in 
approved  renewal PBP  upcoming  enrollees  the renewing 
grouping which  so that all  CY.  The  into the  C-SNP PBP 
contains that  current  plan ID for  renewal C- in the 
same chronic  eligible  the  SNP PBP  upcoming 
condition  enrollees in  upcoming  ID in  CY.   
the combined  CY must be  HPMS.     
PBP are  the same as    New 
offered the  one of the  The MAO  enrollees 
same benefits  consolidating  does not  must 
in the  previous CY  submit  complete an 
upcoming  plan IDs.   enrollment  enrollment 
CY.  The    transactions  request.  
MAO must  HPMS Plan  for current   
(2) Renewing  designate  Crosswalk  eligible  Submit  Current 
C-SNP with a  which of the  Designation:  enrollees.    MARx  enrollees 
CMS-approved  renewal PBP  Consolidated    disenrollment  receive a 
grouping that  IDs will be  Renewal  The MAO  transactions  standard 
transitions  retained in the  Plan  may have to  to disenroll  ANOC. 
eligible  CY after  submit 4Rx  ineligible   
enrollees into  consolidation.   data for  enrollees. 
another C-SNP  CMS will not  enrollees 
with one of the  allow for  whose PBP 
chronic  consolidations  ID changed. 
conditions from  across 
that grouping  contracts 
(Please note:   (with limited 
This scenario  exceptions for 
requires a  some renewal 
crosswalk  options, as 
exception.   described 
MAOs seeking  elsewhere in 
this crosswalk  chapter 4).  
must obtain  Only whole 
prior approval  PBPs may be 
from CMS by  consolidated; 
submitting a  a previous CY 
crosswalk  PBP may not 
exception  be split 
request.)  among 
(3) Non- different  Submit  Current 
renewing C- PBPs in the  MARx  enrollees 
SNP in a CMS- upcoming  disenrollment  receive a 
approved  CY.  Note: If  transactions  standard  grouping that  an MAO  to disenroll  ANOC. 
transitions  reduces a  ineligible   
eligible  service area  enrollees. 
enrollees to a  when 
different CMS- consolidating 
approved  PBPs, it must 
grouping C- follow the 
SNP if the new  rules for a 
grouping  plan renewal 
contains at least  with SAR 
one condition  described 
that the prior  elsewhere in 
plan contained  chapter 4. 
I-SNP Crosswalks 
Activity  Guidelines  HPMS Plan  Systems  Enrollment  Enrollee 
Crosswalk  Enrollment  Procedures  Notifications 
Activities 
(1) Renewing  An MAO  HPMS Plan  The  No  Current 
Institutional  combines one  Crosswalk  renewal I- enrollment  enrollees 
SNP that  or more  Definition:  SNP PBP  request is  receive a 
transitions  whole MA  One or more  ID must  required for  standard 
enrollees to an  PBPs of the  previous CY  remain the  current  ANOC. 
Institutional/  same type  plans that  same so  eligible   
Institutional  offered in the  consolidate  that CMS  enrollees to 
Equivalent SNP  previous CY  into one plan  may  remain 
(2) Renewing  into a single  for the  consolidate  enrolled in  Current 
Institutional  renewal PBP  upcoming  enrollees  the renewing  enrollees 
Equivalent SNP  so that all  CY.  The  into the  I-SNP PBP  receive a 
that transitions  current  plan ID for  renewal I- in the  standard 
enrollees to an  eligible  the  SNP PBP  upcoming  ANOC. 
Institutional/  enrollees in  upcoming  ID in  CY.     
Institutional  the combined  CY must be  HPMS.     
Equivalent SNP  PBP are  the same as    New 
(3) Renewing  offered the  one of the  The MAO  enrollees  Current 
Institutional/  same benefits  consolidating  does not  must  enrollees 
Institutional  in the  previous CY  submit  complete an  receive a 
Equivalent SNP  upcoming  plan IDs.   enrollment  enrollment  standard 
that transitions  CY.  The    transactions  request.   ANOC. 
eligible  MAO must  HPMS Plan  for current     
enrollees to an  designate  Crosswalk  eligible 
Institutional  which of the  Designation:  enrollees.   
SNP  renewal PBP  Consolidated   
(4) Renewing  IDs will be  Renewal  The MAO  Submit  Current 
Institutional/  retained in the  Plan   may have to  MARx  enrollees 
Institutional  CY after    submit 4Rx  disenrollment  receive a 
Equivalent SNP  consolidation.   data for  transactions  standard  that transitions  CMS will not  enrollees  to disenroll  ANOC. 
eligible  allow for  whose PBP  ineligible   
enrollees to an  consolidations  ID changed.   enrollees. 
Institutional  across   
Equivalent SNP  contracts 
(5) Non- (with limited    Current 
renewing  exceptions for  enrollees 
Institutional/  some renewal  receive a 
Institutional  options, as  standard 
Equivalent SNP  described  ANOC. 
that transitions  elsewhere in   
eligible  chapter 4).  
enrollees to  Only whole 
another  PBPs may be 
Institutional/  consolidated; 
Institutional  a previous CY 
Equivalent SNP  PBP may not 
be split 
among 
different 
PBPs in the 
upcoming 
CY.  Note: If 
an MAO 
reduces a 
service area 
when 
consolidating 
PBPs, it must 
follow the 
rules for a 
plan renewal 
with SAR 
described 
elsewhere in 
chapter 4. 
 
60  Marketing 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
As with any MA plan, SNPs must market to all individuals eligible to enroll.  For example, if a 
SNP is offered for institutionalized enrollees at select LTC facilities, the SNP must market to all 
Medicare Part A and/or Part B enrollees residing in those facilities.  D-SNPs may wish to work 
with their respective states to identify an acceptable method of marketing towards dual-eligible 
enrollees.  Refer to the Medicare Marketing Guidelines for further information on marketing 
requirements for SNPs.   
70  Covered Benefits 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
70.1  Part D Coverage Requirement 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
All SNPs must offer Part D prescription drug coverage, regardless of whether or not the MAO 
offers a CCP with Part D benefits in the same service area.  Refer to 42 CFR 422.2 and chapter 4 
of the MMCM for more information about this requirement. 
 
70.2  SNP-Specific Plan Benefit Packages 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
CMS expects MAOs offering SNPs to have a well-developed MOC, to structure their health care 
service delivery system to support this model, and to design their PBP to address the specialized 
needs of the targeted enrollees.  All SNPs should have specially designed PBPs that go beyond 
the provision of basic Medicare Parts A and B services and care coordination that is required of 
all CCPs.  These SNP-specific PBPs should include, but not be limited to: 
 
  Supplemental health benefits specific to the needs of the unique SNP population; 
 
  Specialized provider networks (e.g., physicians, home health, hospitals, etc.) specific to 
the unique SNP population; and 
 
  Appropriate enrollee cost sharing structured around the unique SNP populations health 
conditions and co-morbidities for all Medicare-covered and supplemental benefits. 
 
The following are examples of SNP benefits that exceed basic Medicare Parts A and B benefits: 
 
  No or lower cost sharing; 
 
  Longer benefit coverage periods for inpatient services; 
 
  Longer benefit coverage periods for specialty medical services; 
 
  Parity (equity) between medical and mental health benefits and services; 
 
  Additional preventive health benefits (e.g., dental screening, vision screening, hearing 
screening, age-appropriate cancer screening, risk-based cardiac screening); 
 
  Social services (e.g., connection to community resources for economic assistance) and 
transportation services; and 
 
  Wellness programs to prevent the progression of chronic conditions.   
All social-support services must be approved supplemental benefits consistent with the guidance 
in chapter 4 of the MMCM. 
 
70.3  Meaningful Difference in Plan Benefits 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
To determine whether SNPs satisfy the meaningful difference requirement outlined in chapter 4 
of the MMCM, SNPs are evaluated by groups or subgroups, as appropriate, of SNP types, as 
follows: 
 
  C-SNPs:  Separated by the chronic disease served. 
 
  I-SNPs:  Separated into the categories of either Institutional (Facility), Institutional 
Equivalent (Living in the Community), or a combination of Institutional and 
Institutional Equivalent. 
 
  D-SNPs:  Excluded from the meaningful difference evaluation. 
 
For more information on CMSs meaningful difference requirements for SNPs, please refer to 
the annual Announcement, located at:  https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.html. 
 
80  Quality Improvement 
(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16) 
 
The quality improvement requirements applied to non-SNP MA plans are also applied to SNPs.  
Pursuant to 42 CFR 422.152(c)-(g), each SNP must conduct both a Chronic Care Improvement 
Program (CCIP) and a Quality Improvement Project (QIP) targeting the special needs population 
that it serves.  Refer to chapter 5 of the MMCM for further guidance on SNP quality 
improvement and reporting requirements.