Lesson 3: SNP Regulatory Framework

You must first complete Lesson 2: SNP Market Landscape before viewing this Lesson

Lesson Goal

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For you to become familiar with the regulatory framework for SNPs.


Lesson Summary

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The regulations and guidance for SNPs are part of the overall regulations for the Medicare program. SNPs have to follow most Medicare Advantage rules, and have additional SNP-specific rules. Those rules can be found in the Medicare Managed Care Manual and related CMS guidance.


The Big Topics in This Lesson

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1- Statutes governing SNP activities

The information under this topic covers the Social Security Act and Bipartisan Budget Act sections that relate to SNPs.

2- Regulations governing SNP activities

The information under this topic covers relevant sections of the Code of Federal Regulations.

3- CMS guidance governing SNP activities

The information under this topic covers the Medicare Managed Care Manual as well as additional CMS guidance related to SNPs.


Lesson Video

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Lesson Q & A

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Click on each question to learn more

Q1: What are the statutes governing SNPs?

While SNP funding authorization occurred in multiple pieces of legislation (as part of continuing authorizations, until they were permanently authorized), the main law related to SNPs is the Social Security Act. Section 1859(b)(6)(B) (iii) of the Social Security Act establishes SNPs as a special type of Medicare Advantage Plan, and sets up the federal HHS Secretary as the authority for governing SNP activities and program management.

There are also important SNP requirements found in the Bipartisan Budget Act of 2018. BBA 2018 establishes new SNP requirements around integration with Medicaid, face to face encounters with members, and broadens the types of conditions that C-SNPs can target.

 

Q2: What are the regulations governing SNPs?

Most of the regulations governing SNPs can be found in 42 CFR 422 (the Medicare Advantage Program section).

Section 422.2 establishes the definitions of special needs members and special needs plans:

  • Special needs individual means an MA eligible individualwho is institutionalized, as defined above, is entitled to medical assistance under a State plan under titleXIX, or has a severe or disabling chronic condition(s) and would benefit from enrollment in a specialized MA plan.
  • Severe or disabling chronic conditionmeans for the purpose of defining a special needs individual, an MA eligible individualwho has one or more co-morbid and medically complex chronic conditions that are substantially disabling or life-threatening, has a high risk of hospitalization or other significant adverse health outcomes, and requires specialized delivery systems across domains of care.
  • Specialized MA Plans for Special Needs Individualsmeans an MA coordinated care plan that exclusively enrolls special needs individuals as set forth in § 422.4(a)(1)(iv)and that provides Part D benefits under part 423 of this chapter to all enrollees; and which has been designated by CMS as meeting the requirements of an MA SNP as determined on a case-by-case basis using criteria that include the appropriateness of the target population, the existence of clinical programs or special expertise to serve the target population, and whether the proposal discriminates against sicker members of the target population.

Section 422.101 lays out the basic benefits SNPs must provide.

  • (f)Special needs plan model of care.
    • Specialized MA Plans for Special Needs Individualsmeans an MA coordinated care plan that exclusively enrolls special needs individuals as set forth in § 422.4(a)(1)(iv)and that provides Part D benefits under part 423 of this chapter to all enrollees; and which has been designated by CMS as meeting the requirements of an MA SNP as determined on a case-by-case basis using criteria that include the appropriateness of the target population, the existence of clinical programs or special expertise to serve the target population, and whether the proposal discriminates against sicker members of the target population.
  • (2)MA organizationsoffering SNPs must also develop and implement the following model of care components to assure an effective management structure:
    • (i)Target one of the three SNP populations defined in § 422.2of this part.
    • (ii)Have appropriate staff (employed, contracted, or non-contracted) trained on the SNP plan model of care to coordinate and/or deliver all services and benefits.
    • (iii)Coordinate the delivery of care across healthcare settings, providers, and services to assure continuity of care.
    • (iv)Coordinate the delivery of specialized benefitsand services that meet the needs of the most vulnerable beneficiaries among the three target special needs populations as defined in § 422.2 of this part, including frail/disabled beneficiaries and beneficiaries near the end of life.
    • (v)Coordinate communication among plan personnel, providers, and beneficiaries.
    • (vi)All MAOs wishing to offer or continue to offer a SNP will be required to be approved by the National Committee for Quality Assurance (NCQA) effective January 1, 2012 and subsequent years. All SNPs must submit their model of care (MOC) to CMS for NCQA evaluation and approval in accordance with CMS guidance.

Section 422.4 establishes the types of SNP plans. 

  • (iv)A specialized MA planfor special needs individuals (SNP) includes any type of coordinated care plan that meets CMS's SNP requirements and exclusively enrolls special needs individuals as defined by § 422.2 of this subpart. All MA plans wishing to offer a SNP will be required to be approved by the National Commission on Quality Assurance (NCQA) effective January 1, 2012. This approval process applies to existing SNPs as well as new SNPs joining the program. All SNPs must submit their model of care (MOC) to CMS for NCQA evaluation and approval as per CMS guidance.
Q3: What other guidance is provided by CMS related to SNPs?

The main place we can find detailed SNP guidance is the Medicare Managed Care Manual. This document covers Medicare Advantage operational requirements.

Chapter 16B is the MA-SNP chapter.

 

The table above can help you see which sections of Chapter 16b focus on each SNP type.

We will highlight a few sections that cover SNPs generally.

  • Section 30 covers the SNP application. It also includes information about the SNP Model of Care (MOC). The MOC is an extensive document that shows the plans proposed model for managing member care. The MOC has to be approved by NCQA.
  • Section 40 deals with enrollment. Processes to verify eligibility for each type of SNP are included in this section.
  • Section 60 covers marketing rules.
  • Section 70 addresses covered benefits.
  • Section 80 outlines quality improvement requirements.

 

 

 

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