Medicare beneficiaries who have one or more medically complex chronic conditions that are disabling or life-threatening, have a high risk of hospitalization or other adverse health outcomes, and require specialized care delivery systems. Beneficiaries must also be enrolled in Medicare Parts A and B and live in the plan's service area.

By applying for Social Security Disability. After qualifying for Social Security, the individual may be eligible for Medicare Part A and Part B. After getting Medicare A and B, the beneficiary can be eligible for a C-SNP if they have a specific qualifying chronic condition.

CMS has approved 15 specific chronic condition categories for C-SNP eligibility: chronic alcohol and other drug dependence, autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure, dementia, diabetes, end-stage liver disease, end-stage renal disease requiring dialysis, severe hematologic disorders, HIV/AIDS, chronic lung disorders, chronic and disabling mental health conditions, neurologic disorders, and stroke.

Not all of these conditions will be available in every member's area.

The plan requires the beneficiary's existing provider to verify the qualifying chronic condition within 60 days of the effective date. The plan will contact the member's primary care provider to confirm the diagnosis.

Beneficiaries can enroll during the Annual Enrollment Period (October 15–December 7), the Medicare Advantage Open Enrollment Period (January 1–March 31), or the beneficiary's Initial Enrollment Period. They can also join at any time using a Special Enrollment Period if they have a qualifying severe or disabling chronic condition and a C-SNP is available in their area.

A SEP is available for individuals with a severe or disabling chronic condition. If a beneficiary develops a qualifying condition after initial enrollment, they may use this SEP to enroll.

C-SNPs must be marketed to all eligible individuals in the service area, using Medicare Advantage marketing rules. Marketing materials targeting potential enrollees must include a disclaimer stating that enrollment is limited to individuals meeting the plan's special needs criteria.

If a beneficiary loses their special needs status, the plan must send a notice of disenrollment. The beneficiary can qualify for a SEP starting the month they lose status, allowing them to join another Medicare Advantage plan.

Yes, if the client meets the C-SNP's chronic condition eligibility and a C-SNP is available in the beneficiary's coverage area. Changes will be effective the first of the next month. Changes can also occur during AEP or OEP.

You can assist clients in completing the enrollment request, which must include verifying the C-SNP's eligibility. Agents can enroll Medicare beneficiaries into C-SNPs and receive commission on the policy.

Only if the client has a qualifying chronic condition and the C-SNP offers better benefits for their specific needs, such as specialized care for conditions like diabetes or heart failure.

Can Dual eligibles switch using their monthly SEP if they prefer a C-SNP over a D-SNP?

No. Monthly SEPs allow beneficiaries to disenroll from MA D-SNPs and switch to Original Medicare and a stand-alone Part D drug plan, or full-benefit dual eligibles can switch between certain integrated D-SNPs that align Medicare and Medicaid benefits.

All marketing materials must include a disclaimer that "This is a C-SNP. Enrollment is limited to Medicare beneficiaries with specific severe or disabling chronic conditions."

C-SNPs can be structured around a single condition or combinations from the 15 approved conditions, but cannot combine unrelated conditions to create a general product. They provide tailored benefits, specialized networks, and cost-sharing focused on the specific conditions.

C-SNPs must provide Part D prescription drug coverage and offer benefits beyond Original Medicare, such as lower cost-sharing, specialized provider networks, preventive services, wellness programs, and care coordination tailored to the chronic condition.

Loss of integration between Medicare and Medicaid. D-SNPs are designed for individuals with both Medicare and Medicaid. If a beneficiary is switched from a D-SNP to a C-SNP, they may lose Medicaid benefits, experience gaps in care coordination, and face higher out-of-pocket costs.

It means the plan you switched the member into does not align or coordinate with Medicaid. This can cause issues with the member's extra benefits, as the C-SNP does not include those Medicaid-coordinated programs.

For additional help, please contact Producer Support, which is available by chat directly from your account, by phone at (866) 568-9649, or by email at [email protected].