Chronic Condition Special Needs Plans (C-SNPs)
Chronic Condition Special Needs Plans (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.
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 agencies—the 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:
15 SNP-Specific Chronic Conditions:
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.
Grouping Chronic Conditions
When completing the SNP application, MAOs may apply to offer a C-SNP that targets any one of the following:
- A single CMS-approved chronic condition (selected from the list above),
- A CMS-approved group of commonly co-morbid and clinically-linked conditions (described below), or
- An MAO-customized group of multiple chronic conditions (described below).
CMS-Approved Group of Commonly Co-morbid and Clinically-Linked Conditions:
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 CMS’s 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 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.
MAO-Customized Group of Multiple Chronic Conditions:
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 MAO's 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 above, 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.
- Page last Modified: 08/10/2016 9:56 AM
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