100-16 Medicare Managed Care Manual: Chapter 16b - Subchapter B - Special Needs Plans

Medicare Managed Care Manual
Chapter 16-B: Special Needs Plans
Table of Contents
(Rev. 131; Issued: 11-22-24)
Transmittals for Chapter 16-B
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 Definitions
20.2.1.1– Eligibility Definitions
20.2.1.2– D-SNP Definitions
20.2.1.1.1– Definition of a D-SNP
20.2.1.1.2– Definition of FIDE SNP
20.2.1.1.3– Definition of HIDE SNP
20.2.1.1.4– Coordination-only D-SNP
20.2.1.1.5– Applicable Integrated Plan
20.2.2 – State Contract Requirements for D-SNPs
20.2.2.1 – Establishing Integration Status
20.2.2.2 – Changes in State Medicaid Agency Contracts
20.2.2.2.1 – Changes in Integration Status

20.2.3 – Relationship to State Medicaid Agencies (42 CFR 422.107(b))
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
20.2.4.2.1 Definition of Medicare Zero-Dollar Cost Sharing Dual
Eligible Special Needs Plans
20.2.4.2.2 Special Considerations for PPO D-SNPs
20.2.4.2.3 Medicare Zero-Dollar Cost Sharing D-SNPs and Enrollee
Lapse in Medicaid Eligibility
20.2.4.3 – Cost Sharing for Dual Eligibles Requiring an Institutional Level
of Care
20.2.5 – Additional Requirements for Certain D-SNPs
20.2.5.1 – Application of Frailty Adjustment for FIDE SNPs
20.2.6 – Medicaid Carve-Outs and FIDE SNP and HIDE SNP Status
20.2.7– State D-SNP-only Contracts
20.2.7.1 – Limiting Certain MA Contracts to D-SNPs
20.2.7.2 – State Notification to CMS
20.2.7.3 – Integrated Materials
20.2.7.4 – Joint State/CMS Oversight
20.2.8– Benefit Flexibility for Certain D-SNPs
20.2.8.1 – Benefit Flexibility Eligibility Requirements
20.2.8.2 – Characteristics and Categories of Flexible Supplemental
Benefits
20.2.8.3 – Benefit Flexibility Approval Process
20.2.9 – D-SNP Enrollee Advisory Committees
20.2.9.1— Flexibility in EAC Operations
20.2.9.2 – Other Information and Technical Assistance
20.2.10 – Additional Responsibilities for D-SNPs
20.2.10.1 	– Responsibilities Related to Assisting with Access
to Benefits, Appeals, and Grievances
20.2.10.1.1- When 42CFR 422.562(a)(5) Requires D-
SNP to Provide Assistance
20.2.10.1.2- When 42CFR 422.562(a)(5) Does Not
Require D-SNP to Provide Assistance
20.2.10.1.3- Other considerations
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 Terminations and Non-Renewals for lack of a State Medicaid Agency
Contract
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
90 – SNP Health Risk Assessment Screening Requirement
90.1 – General
90.2 - Instruments for Screening for Housing Stability, Food Security, and Access to
Transportation

90.2.1 - Additional Considerations
90.3 – List of Social Needs Screening Instruments

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 Children’s 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 plan’s 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 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:
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),
• 	Huntington’s disease,
• 	Multiple sclerosis,
• 	Parkinson’s 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
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 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 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 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 CMS’s 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 Definitions
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
20.2.1.1– Eligibility Definitions
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
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 individual’s eligibility. Individuals in the following Medicaid
eligibility categories may be eligible to enroll in D-SNPs, to the extent permitted in the state
Medicaid agency contract (see section 20.2.2 of this chapter):
• 	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:
https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-
coordination/medicare-medicaid-coordination-
office/downloads/medicaremedicaidenrolleecategories.pdf.
20.2.1.2 D-SNP Definitions
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
20.2.1.2.1 Definition of a D-SNP
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
Dual eligible special needs plans (D-SNPs) are SNPs that exclusively serve Medicare
beneficiaries who are also entitled to Medicaid.
Per 42 CFR 422.2, a D-SNP:
(1) Coordinates the delivery of Medicare and Medicaid services for individuals who are
eligible for such services;
(2) May provide coverage of Medicaid services, including long-term services and
supports and behavioral health services for individuals eligible for such services; and
(3) Has a contract with the state Medicaid agency that meets the minimum requirements
in paragraph 42 CFR 422.107(c) (further described in section 20.2.2 of this chapter.)
Additionally, each D-SNP must satisfy one or more of the following criteria for the integration of
Medicare and Medicaid benefits:
(1) Meet the additional requirement specified in 42 CFR 422.107(d) in its contract with
the state Medicaid agency, or in other words, meet the criteria for a coordination-only D-
SNP;
(2) Meet the definition of a highly integrated dual eligible special needs plan (HIDE
SNP); or
(3) Meet the definition of a fully integrated dual eligible special needs plan (FIDE SNP).
These concepts and definitions are described in more detail below.

20.2.1.2.2 Definition of FIDE SNP
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
A FIDE SNP is defined in 42 CFR 422.2 as a D-SNP—
• 	That provides dually eligible individuals access to Medicare and Medicaid benefits under
a single entity that holds both an MA contract with CMS and a Medicaid managed care
organization contract under section 1903(m) of the Act with the applicable state;
• 	Whose capitated contract with the state Medicaid agency requires coverage of the
following elements to the extent Medicaid coverage of such benefits is available to
individuals eligible to enroll in a FIDE SNP in the state, except as approved by CMS
under 42 CFR 422.107(g) and (h):
o 	Primary care and acute care, and for plan year 2025 and subsequent years
including Medicare cost-sharing as defined in section 1905(p)(3)(B), (C), and (D)
of the Act, without regard to the limitation of that definition to QMBs;1
o 	Long-term services and supports (LTSS), including coverage of nursing facility
services for a period of at least 180 days during the plan year;
o 	For plan year 2025 and subsequent years, behavioral health services;
o 	For plan year 2025 and subsequent years, home health services as defined in 42
CFR 440.70; and
o 	For plan year 2025 and subsequent years, medical supplies, equipment, and
appliances, as described in 42 CFR 440.70(b)(3);
• 	That coordinates the delivery of covered Medicare and Medicaid services using aligned
care management and specialty care network methods for high-risk beneficiaries;
• 	That employs policies and procedures approved by CMS and the State to coordinate or
integrate beneficiary communication materials, enrollment, communications, grievance
and appeals, and quality improvement;
• 	For plan year 2025 and subsequent years, that has exclusively aligned enrollment;2 and
• 	For plan year 2025 and subsequent years, whose capitated contract with the state
Medicaid agency covers the entire service area for the D-SNP.
Beginning in 2025, all FIDE SNPs also qualify as applicable integrated plans, as defined in 42
CFR 422.561 and section 20.2.1.2.5 of this chapter, but not all applicable integrated plans qualify
as FIDE SNPs.
20.2.1.2.3 Definition of HIDE SNP
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
1 Under 42 CFR 422.107(g) and (h), CMS allows limited carve-outs from the scope of Medicaid LTSS and Medicaid
behavioral health services that must be covered by FIDE SNPs and HIDE SNPs. More information on carve-outs
can be found in section 20.2.6 of this chapter.

A HIDE SNP, as defined in 42 CFR 422.2, is a D-SNP that provides coverage of Medicaid
benefits under a capitated contract that meets the following requirements:
• 	The capitated contract is between the state Medicaid agency and—
o 	The MA organization; or
o 	The MA organization's parent organization, or another entity that is owned and
controlled by its parent organization.
• 	The Medicaid capitated contract requires coverage of the following benefits, to the extent
Medicaid coverage of such benefits is available to individuals eligible to enroll in a HIDE
SNP in the state, except as approved by CMS under 42 CFR 422.107(g) or (h) (see
section 20.2.2.4 of this chapter):
o 	LTSS, including community-based LTSS and some days of coverage of nursing
facility services during the plan year; or
o 	Behavioral health services.
• 	For plan year 2025 and subsequent years, the capitated contract covers the entire service
area for the D-SNP.
HIDE SNPs may also qualify as applicable integrated plans, as defined in 42 CFR 422.561 and
section 20.2.1.2.5 of this chapter, but not all applicable integrated plans are HIDE SNPs.
20.2.1.2.4 Coordination-only D-SNPs
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
If a D-SNP is not a FIDE SNP or a HIDE SNP, it is a coordination-only (CO) D-SNP and is
subject to the contracting requirement specified at 42 CFR 422.107(d)(1). CO D-SNPs must have
a CMS-approved contract with a state Medicaid agency that stipulates that, for the purpose of
coordinating Medicare and Medicaid-covered services between settings of care, the D-SNP
notifies, or arranges for another entity or entities to notify, the state Medicaid agency, individuals
or entities designated by the state Medicaid agency, or both, of hospital and skilled nursing
facility admissions for at least one group of high-risk full-benefit dual eligible individuals,
identified by the state Medicaid agency. The state Medicaid agency must establish the
timeframe(s) and method(s) by which notice is provided. In the event that a D-SNP authorizes
another entity or entities to perform this notification, the D-SNP must retain responsibility for
complying with this notification requirement.
There are no federal requirements for FIDE SNPs or HIDE SNPs to comply with the requirement
at 42 CFR 422.107(d)(1). However, some states choose to apply similar notifications
requirements in their state Medicaid agency contracts for FIDE and/or HIDE SNPs.
For a CO D-SNP that, under the terms of its contract with the state Medicaid agency, only
enrolls partial-benefit dually eligible individuals, the data notification requirements at 42 CFR
422.107(d)(1) do not apply if the D-SNP operates under the same parent organization and in the
same service area as a D-SNP limited to full-benefit dually eligible enrollees that meets the
requirements at 42 CFR 422.107(d)(1) and outlined above in this section. Said another way,
partial-benefit-only D-SNPs are not required to meet the notification requirement in 42 CFR
422.107(d)(1) when the MA organization also offers a D-SNP with enrollment limited to full-

benefit dually eligible individuals that meets the integration criteria at 42 CFR 422.2 and is in the
same state and service area and under the same parent organization.
2 Aligned enrollment, as defined in 42 CFR 422.2, refers to the enrollment in a D-SNP of full-benefit dually eligible individuals whose Medicaid
benefits are covered under a Medicaid managed care organization contract (i.e., Medicaid MCO contract under section 1903(m)(2)(A) of the Act)
between (A) the applicable state and (B) the D-SNP’s MA organization, the D–SNP’s parent organization, or another entity that is owned and
controlled by the D–SNP's parent organization. When state policy limits a D-SNP's membership to individuals with aligned enrollment, this
condition is referred to as exclusively aligned enrollment.

Table 2: Features of D-SNP Types
Plan Type 	Single
entity holds
both MA
and
Medicaid
contracts
State 	option 	to
carve 	out 	certain
Medicaid benefits
Integrated
materials
Exclusively
aligned
enrollment
Applicable
integrated
plan
Medicaid plans
cover entire
service area of
the D-SNP
Data notification
requirements for
enrollee use of
hospital or SNF
admission
FIDE SNP 	Required 	No, except as
approved by CMS
under 42 CFR
422.107(g) or (h)
Required 	Required in
plan year
2025 and
later
For 2025 and
later, all FIDE
SNPs are AIPs
Required in plan
year 2025 and
later
Not federally
required
HIDE SNP 	Not
federally
required
May carve out LTSS
or behavioral health
but not both. Any
carve-out of services
in the category must
be approved by
CMS under 42 CFR
422.107(g) or (h)
Not
federally
required
Not federally
required
Can qualify as
AIPs, but not
AIPs by
default
Required in plan
year 2025 and
later
Not federally
required
CO D-SNP 	Not
federally
required
No requirements on
Medicaid benefits
provided
Not
federally
required
Not federally
required
Can qualify as
AIPs in
certain
contexts
Not federally
required
Required, except in
specific instances
for D-SNPs that
only enroll partial-
benefit dually
eligible individuals
Note: States may apply requirements beyond the federal minimum requirements shown in the table above.

20.2.1.2.5 Applicable Integrated Plan
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
Applicable integrated plans (AIPs) are defined in 42 CFR 422.561 as either of the following
arrangements:
• 	A FIDE SNP or HIDE SNP and a Medicaid managed care organization where—
o 	The FIDE SNP or HIDE SNP has exclusively aligned enrollment; and
o 	The Medicaid managed care organization (as defined in section 1903(m) of the Act
and which has a contract under section 1903(m)(2)(A) of the Act) through which such
D-SNP, its parent organization, or another entity that is owned and controlled by its
parent organization covers Medicaid services for dually eligible individuals enrolled
in such D-SNP and such Medicaid managed care organization; or
• 	A D-SNP and affiliated Medicaid managed care plan where—
o 	The D-SNP, by state policy, has enrollment limited to those beneficiaries enrolled in a
Medicaid managed care organization;
o 	There is a capitated contract between the MA organization, the MA organization's
parent organization, or another entity that is owned and controlled by its parent
organization and
 	A Medicaid agency, or
 	A Medicaid managed care organization that contracts with the Medicaid
agency; and
o 	Through the capitated contract, Medicaid benefits including primary care and acute
care, including Medicare cost-sharing without regard to the limitation of that
definition to QMBs, and at a minimum, one of the following: home health services as
defined in 42 CFR 440.70, medical supplies, equipment, and appliances as described
in 42 CFR 440.70(b)(3), or nursing facility services are covered for the enrollees.
AIPs must offer integrated appeals and grievances at the plan level in accordance with 42 CFR
422.629 through 422.634. More information on integrated appeals and grievances can be found in the
Addendum to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and
Appeals Guidance for Applicable Integrated Plans, located here:
https://www.cms.gov/files/document/dsnpartscdgrievancesdeterminationsappealsguidanceaddendum.
pdf
Beginning in 2025, all FIDE SNPs are AIPs. Currently, most AIPs are FIDE SNPs or HIDE SNPs.
CO D-SNPs may qualify as AIPs under certain circumstances. As an example, the following
arrangements would be AIPs under current regulations, where both plans include enrollment that is
exclusively aligned between the CO D-SNP and the affiliated Medicaid MCO:
• 	A CO D-SNP and affiliated Medicaid MCO where the CO D-SNP holds a contract with a
separate Medicaid MCO to cover all capitated managed care benefits in the state and the
separate Medicaid MCO holds the contract with the state for those benefits; and
• 	A CO D–SNP and affiliated Medicaid MCO where the affiliated Medicaid MCO holds a
contract with the state for the capitated Medicaid benefits.
20.2.2 – State Contract Requirements for D-SNPs
(Rev.129, Issued: 08-11-23, Effective: 08- 11- 23; Implementation: 08- 11- 23)

Section 164(c)(2) of MIPPA, and as amended by section 3205(d) of the ACA, requires that all D-
SNPs have an executed contract with applicable state Medicaid agencies beginning January 1,
2013. See section 1859(f)(3)(D) of the Act and implementing regulations at 42 CFR 422.107.
The Medicare Advantage Dual Eligible Special Need Plans Application, which is available through
HPMS and on the CMS website, provides further information on how and when D-SNPs must
submit their state Medicaid agency contracts (SMACs) and related information to CMS.
CMS requires each D-SNP to submit a SMAC for review by the first Monday in July every year for
each state in which it seeks to operate for the upcoming contract year. A D-SNP with an evergreen
SMAC is still required to submit its contract to CMS by the first Monday in July.
The SMAC must document each entity’s roles and responsibilities with regard to dually eligible
individuals, and must cover the minimum regulatory requirements below:
1. 	The MAO’s responsibility to coordinate the delivery of, and if applicable, provide
coverage of Medicaid services. (42 CFR 422.107(c)(1))
The SMAC must document the MAO’s responsibility to coordinate the delivery of Medicaid
benefits for individuals who are eligible for such services and, if applicable, provide
coverage of Medicaid benefits, including long-term services and supports and behavioral
health services, for individuals eligible for such services.
2. 	The categories of eligibility for dually eligible individuals to be enrolled
under the D-SNP. (42 CFR 422.107(c)(2))
The SMAC must clearly identify the dually eligible populations that are eligible to enroll
in the D-SNP. A D-SNP may only enroll dually eligible individuals as specified in the
SMAC. If a SMAC states that a D-SNP can only enroll certain dually eligible individuals
(e.g., full-benefit dually eligible individuals, those aged 65 and above), the MAO must
limit its D-SNP enrollment accordingly.
3. 	The Medicaid benefits covered under the D-SNP. (42 CFR 422.107(c)(3))
The SMAC must include information on plan benefit design, benefit administration, and
assignment of responsibility for providing, or arranging for, the covered benefits. The
contract must document the Medicaid benefits covered under a capitated contract, as
applicable, between the state Medicaid agency and the MAO offering the D-SNP, the D-
SNP’s parent organization, or another entity that is owned and controlled by the D-SNP’s
parent organization. 	If the list of services is an attachment to the contract, the D-SNP
must reference the list in the body of the contract.
4. 	The cost sharing protections covered under the D-SNP. (42 CFR 422.107(c)(4))
The SMAC must require that D-SNPs not impose cost sharing on specified dually eligible
individuals (i.e., full-benefit dually eligible individuals, QMBs, or any other population
designated by the state) that exceeds the amount that would be 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, as described in section
20.2.4.1 of this chapter.

5. 	The identification and sharing of information on Medicaid provider participation. (42
CFR 422.107(c)(5))
The SMAC must enumerate a process for how the state will identify and share
information about providers contracted with the state Medicaid agency so that they may
be included in the D-SNP’s provider directory. Although CMS does not require all
providers to accept both Medicare and Medicaid, the D-SNP’s network must meet the
needs of the dually eligible population served.
6. 	The verification process of an enrollee’s eligibility for Medicaid. (42 CFR 422.107(c)(6))
The SMAC must require that MAOs receive access to information verifying
eligibility of dually eligible enrollees from the state Medicaid agency. The SMAC
must describe how the D-SNP and the state exchange information to verify each
enrollee’s Medicaid eligibility.
7. 	The service area covered under the SNP. (42 CFR 422.107(c)(7))
The SMAC must identify the service areas for which the state has agreed the MAO may offer
(i.e., market and enroll beneficiaries in) one or more D-SNPs. The D-SNP service area(s)
must be consistent with the SMAC-approved service area(s).
8. 	The contract period. (42 CFR 422.107(c)(8))
The SMAC must require 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.
9. 	Unified appeals and grievances. (42 CFR 422.107(c)(9))
For D-SNPs that meet the definition of an applicable integrated plan as defined in 42 CFR
422.561, the SMAC must require documentation of the use of unified appeals and
grievance procedures under 42 CFR 422.629 through 422.634, 438.210, 438.400, and
438.402.
10. Minimum integration requirement. (42 CFR 422.107(d))
10a. Hospital and skilled nursing facility data notification requirements. (42 CFR
422.107(d)(1))
The SMAC requires any D-SNP that is not a fully integrated or highly integrated D-SNP
(as defined in 422.2), except as specified at 42 CFR 422.107(d)(2) (which is described in
section 10b below), to notify, or arrange for another entity or entities to notify, the state
Medicaid agency, individuals or entities designated by the state Medicaid agency, or both,
of hospital and skilled nursing facility admissions for at least one group of high-risk full-
benefit dual eligible individuals, identified by the state Medicaid agency. The SMAC must

establish the timeframe(s) and method(s) by which notice is provided. In the event that a
D-SNP authorizes another entity or entities to perform this notification, the D-SNP must
retain responsibility for complying with the requirement in 42 CFR 422.107(d)(1).
10b. Exception to hospital and SNF data notification requirements for certain D-SNPs
(42 CFR 422.107(d)(2))
The SMAC requirement at 42 CFR 422.107(d)(1) (which is described in section 10a) does
not apply to a D-SNP that meets two conditions:
(1) Under the terms of its SMAC, the D-SNP only enrolls beneficiaries who are not
entitled to full medical assistance under a state plan under title XIX of the Act (i.e.,
partial-benefit dually eligible individuals); and
(2) The D-SNP operates under the same parent organization and in the same service area
as a D-SNP limited to beneficiaries with full medical assistance under a state plan
under title XIX of the Act (i.e., full-benefit dually eligible individuals) that meets the
requirements under 42 CFR 422.107(d)(1).
20.2.2.1 Establishing Integration Status
(Rev.131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
The process outlined in section 20.2.2.1 relies on CMS regulation at 42 CFR 422.2, which was
codified in the CY 2020 and 2021 MA and Part D Final Rule (CMS-4185-F), which was published on
April 16, 2019.
CMS determines a D-SNP’s status as CO, HIDE, FIDE, and/or AIP based on language in the SMAC.
The matrices that D-SNPs complete inform (but do not dictate) the outcome of the CMS assessment.
We notify MA organizations during the SMAC review of our determination of integration status for
each D-SNP. MA organizations can request a review of that determination during the annual SMAC
review process.
20.2.2.2 Changes in State Medicaid Agency Contracts
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
We recognize that states and MA organizations offering D-SNPs may amend the SMAC throughout
the contract year. CMS seeks to maintain the most current version of the executed SMAC within
HPMS as the system of record for MA organizations. While not all changes made in the SMAC
impact provisions set forth in 42 CFR 422.2 and 422.107 specifically, we request the MA
organization submit all amendments made to the SMAC through HPMS.
20.2.2.2.1 Changes in Integration Status
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
There are limited circumstances when revisions to the SMAC may affect the integration level of the
D-SNP. These limited circumstances are typically a result of a Medicaid managed care program
procurement or other state contracting process. In many instances the outcome of these procurements
may be protested by losing organizations or disputed through the judicial system. In other instances,

a state Medicaid program may start a new contract period in a month other than January. When
there are changes to the state contracting with the Medicaid managed care plan that impacts the D-
SNP’s integration status, the MA organization should submit the revised SMAC to CMS for CMS to
make a redetermination of the integration status. Examples of when CMS expects to review a revised
SMAC and may make a redetermination of the integration level include when:
• 	The Medicaid managed care contract with the D-SNP, the D-SNP’s parent organization, or
another entity that is owned and controlled by the parent organization adds LTSS and/or
behavioral health covered services that may change the D-SNP from coordination-only to
FIDE or HIDE
• 	The Medicaid managed care plan affiliated with the D-SNP, the D-SNP’s parent organization
or another entity that is owned and controlled by the parent organization loses its Medicaid
managed care contract with the state mid-year, thus changing the D-SNP from FIDE or
HIDE to coordination-only
• 	The state makes changes that create enrollment limitations
MA organizations can submit a SMAC revision request directly through the D-SNP Management
Module in HPMS. CMS requests the SMAC revision requests be submitted no later than 30 days prior
to the proposed integration status change. This should allow CMS sufficient time to review the
updated SMAC prior to implementation of the Medicaid managed care program change. We note,
however, that in no instances will an off-cycle redetermination of D-SNP integration status allow for
a mid-year crosswalk of enrollees between D-SNP benefit packages.
20.2.3 – Relationship to State Medicaid Agencies (42 CFR 422.107(b))
(Rev. 129, Issued: 08-11-23, Effective: 08- 11- 23; Implementation: 08- 11- 23)
Pursuant to section 164(c)(4) of MIPPA, state Medicaid agencies are not required to enter into
contracts with MAOs with respect to D-SNPs. In addition to the SMAC, the MAO must still meet
all CMS application requirements, including that the organization be organized and licensed under
state law as a risk-bearing entity eligible to offer health insurance or health benefits coverage in the
state, to have an MA contract and to offer a D-SNP.
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. 128; Issued:06-30-23; Effective: 06-30-23; Implementation: 06- 30-23)
When MA organizations submit bids for the upcoming contract year, each D-SNP must identify
whether or not the D-SNP has Medicare zero-dollar cost sharing. In HPMS, D-SNPs 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 are used in multiple areas within HPMS, and use of the accurate indicator is
essential to the proper display of benefits in Medicare Plan Finder.
We strongly encourage states and D-SNPs to finalize D-SNP eligibility criteria in their State
Medicaid Agency Contracts well in advance of D-SNP bid submissions. However, if a state changes
the Medicaid eligibility criteria it requires the D-SNP to use through the State Medicaid Agency
Contract after bid submission and before contract approval, the MA organization will have the ability
to change the D-SNP’s (or D-SNPs’) Medicare Zero-Dollar Cost Sharing D-SNP designation(s) in
HPMS.
20.2.4.2.1 Definition of Medicare Zero-Dollar Cost Sharing Dual Eligible Special
Needs Plans
(Rev.128; Issued:06-30-23; Effective: 06-30-23; Implementation: 06- 30-23)
A Medicare Zero-Dollar Cost Sharing D-SNP is a D-SNP under which all Medicare Part A and B
services are provided with no Medicare cost sharing to all enrollees who remain dually enrolled in
both Medicare and Medicaid. This term encompasses the following types of plan designs:
1. 	Where cost sharing for enrollees is $0 as part of the plan design (i.e., cost sharing for all Part
A and B benefits has been reduced to $0 as part of the supplemental benefits provided by the
D-SNP); and

2. 	Where there is cost sharing in the plan design, but all individuals who are eligible to enroll in
the D-SNP are protected by sections 1848(g)(3)(A) and 1866(a)(1)(A) of the Act from cost
sharing, or otherwise qualify for Medicaid coverage of cost sharing (see section 1852(a)(7) of
the Act and 42 CFR 422.504(g)(1)(iii) for cost sharing protections afforded non-QMB full-
benefit dually eligible individuals).
CMS uses the designation of a Medicare Zero-Dollar Cost Sharing D-SNP to ensure that information
provided to beneficiaries is accurate, clear, and consistent with the requirements on MA organizations
at 42 CFR 422.111 and 422.2260-422.2267.
For a Medicare Zero-Dollar Cost Sharing D-SNP, information on Medicare Plan Finder on
Medicare.gov describe all Part A and B services under the D-SNP, such as inpatient hospital stays
and doctor visits, as available at no cost to the enrollee. Plan materials may also describe the D-SNP
benefits that way. Such descriptions are accurate – even if the D-SNP plan benefit in the MA
organization’s bid to CMS includes cost sharing for Medicare Part A and B services – if all
individuals who are eligible to enroll in the D-SNP are protected from cost sharing (see number 2
above). An MA plan, including a D-SNP, that has no cost sharing for services under Medicare Part A
and B in its plan bid will also have such benefits described as available with no cost sharing, both in
plan materials and on Medicare Plan Finder. This information helps dually eligible enrollees
understand what costs they will have when choosing a plan and allows D-SNP materials to clearly
show that costs are not a barrier to accessing covered services. When the “Medicare Zero-Dollar Cost
Sharing D-SNP” designation is not available, plan materials and Medicare Plan Finder will indicate
that cost sharing for Medicare varies depending on the enrollee’s category of Medicaid eligibility.
Like all MA plans, both Medicare Zero-Dollar Cost Sharing D-SNPs and other D-SNPs can reduce
Medicare Part A and B cost sharing as a supplemental benefit. CMS bid review applies the same
standards for all D-SNPs.
A D-SNP that includes cost sharing in its plan design may designate itself as a Medicare Zero-Dollar
Cost Sharing D-SNP provided that it meets all of the following criteria:
1. 	The D-SNP plan benefit package limits enrollment, under the terms of its State Medicaid
Agency Contract, to dual eligibility categories with Medicare cost sharing protections:
o 	QMB Only;
o 	QMB Plus;
o 	SLMB Plus and;
o 	Other Full Benefit Dual Eligibles (FBDE).
If the D-SNP enrolls members of dual eligibility categories that do not have Medicare cost
sharing payable by Medicaid (i.e., SLMB-only, QI, or QDWI), the D-SNP cannot (and
must not) be designated as a Medicare Zero-Dollar Cost Sharing D-SNP.
2. 	The D-SNP provider contracts (1) require that providers accept the D-SNP’s payment and any
Medicaid payment of Medicare cost sharing (whether paid by the Medicaid agency, the D-
SNP itself, or a Medicaid managed care plan) as payment in full and (2) prohibit providers
from collecting from a dually eligible enrollee any Medicare cost sharing that is payable under
Medicaid (42 CFR 422.504(g)(1)(iii) and 74 FR 1494-1499 (January 12, 2009)).
Per 42 CFR 422.504(g)(1)(iii), such D-SNP provider contract provisions must also apply to
SLMB Plus and FBDE enrollees for whom Medicare cost sharing protections are more
limited, if those groups are eligible to enroll in the D-SNP. SLMB Plus and FBDE enrollees
cannot be charged Medicare cost sharing above any Medicaid copay applicable to the same

service under the Medicaid state plan or a waiver. In the rare instance that a Part A or B
service is not covered under the Medicaid state plan or a Medicaid waiver, the cost sharing for
a SLMB Plus or FBDE enrollee is the Medicare cost sharing under the MA plan benefit
because of the limits in Medicaid coverage. (This is because 42 CFR 422.504(g)(1)(iii) applies
when the State is responsible for coverage or payment of the Medicare cost sharing.)
However, States may elect in their Medicaid State Plan to pay all Medicare cost sharing for all
FBDE individuals (including SLMB Plus individuals), even for Medicare services not covered
by Medicaid under the State Plan. To comply with § 422.504(g)(1)(iii), Medicare Advantage
plans in those states must ensure that their network providers in those states do not charge a
SLMB Plus or FBDE enrollee Medicare cost sharing for any Medicare Part A or B service
above the Medicaid copay for the same service as covered under the Medicaid State Plan (see
2020 Medicaid Section E of the Coordination of Benefits and Third Party Liability
Handbook, Available online at: https://www.medicaid.gov/medicaid/eligibility/coordination-
of-benefits-third-party-liability/index.html). MA organizations can determine if states have
made such an election by checking the Medicaid State Plan. We encourage states and D-SNPs
to include this information in their State Medicaid Agency Contracts.
Providers can never charge a QMB Only or QMB Plus enrollee Medicare cost sharing for any
Medicare Part A or B service above any applicable Medicaid copay per section 1902(p)(3) of
the Act.
3. 	The providers contracted with the D-SNP do not charge Medicaid copays, deductibles, or
coinsurance for any Medicaid service that is also a Medicare Part A or B service. If a D-SNP
operates in a state that imposes Medicaid copays on dually eligible enrollees for specific
services, then the D-SNP must list those Medicaid copays in its plan materials for those
services and may not be designated as a Medicare Zero-Dollar Cost Sharing D-SNP, unless:
o 	The D-SNP or Medicaid managed care plan responsible for Medicaid payment of
Medicare cost sharing does not impose Medicaid copayments for enrollees (i.e., the
plan pays the provider the copay in lieu of payment by the dually eligible enrollee); or
o 	The state limits its payment of Medicare cost sharing to the Medicaid rate for the
service, and the amount the D-SNP pays the provider for the service is equal to or
greater than the Medicaid rate, including in any deductible phase of the benefit. (In this
circumstance, no Medicaid payment is made so there is no Medicaid copay.)
20.2.4.2.2 Special Considerations for PPO D-SNPs
(Rev.128; Issued:06-30-23; Effective: 06-30-23; Implementation: 06- 30-23)
D-SNP PPOs that that are designated as a Zero-Dollar Cost Share D-SNP may not describe out-of-
network services in plan materials as available at “zero cost” because non-contracted providers that
are not enrolled in Medicaid may charge the Medicare cost sharing under the plan benefit to non-
QMBs. QMB Plus and QMB Only beneficiaries would pay $0; other full-benefit dually eligible
individuals would pay the plan benefit cost sharing rate (see sections 1848(g)(3) and 1866(a)(1)(A) of
the Act for provisions protecting QMBs regardless whether the MA organization has a contract with
the provider that prohibits the collection of cost sharing per 42 CFR 422.504(g)(1)(iii)). For example,
an out-of-network service with 30 percent coinsurance under the plan benefit would be described as
“$0 or 30 percent.” For D-SNPs designated as Zero-Dollar Cost Share, Medicare Plan Finder will
continue to show the cost sharing in the plan benefit for out-of-network services, and in-network cost
sharing will show $0.
20.2.4.2.3 Medicare Zero-Dollar Cost Sharing D-SNPs and Enrollee Lapse in

Medicaid Eligibility
(Rev.128; Issued:06-30-23; Effective: 06-30-23; Implementation: 06- 30-23)
D-SNPs can provide up to six months of deemed continued eligibility for enrollees who have lost, but
are expected to regain, Medicaid eligibility, per 42 CFR 422.52(d). The Medicare cost sharing
protections for enrollees in a Medicare Zero-Dollar Cost Sharing D-SNP lapse if an enrollee no
longer has Medicaid eligibility for any of the dual eligibility categories with cost sharing protections.
During periods when Medicaid eligibility for Medicaid coverage of cost sharing for Medicare Part A
and B benefits has lapsed and the individual remains enrolled in the D-SNP, plan providers may
collect Medicare cost sharing under the MA plan benefit for the service. Enrollee materials from
Medicare Zero-Dollar Cost Sharing D-SNPs, including any required plan notice related to the loss of
Medicaid eligibility, must explain that the enrollee may be billed cost sharing for Medicare Part A
and Part B benefits if the enrollee loses Medicaid eligibility. This ensures that the materials are
accurate as required by 42 CFR 422.111(b)(2)(iii) and 422.2262(a)(1)).
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 enrollee’s 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 enrollee’s 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

enrollee’s 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 – Additional Requirements for Certain D-SNPs
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
20.2.5.1 – Application of Frailty Adjustment for FIDE SNPs
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
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 the annual Announcement of Calendar Year (CY) Medicare
Advantage (MA) Capitation Rates and Part C and Part D Payment Policies located at:
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-
Documents.html. Policy changes and changes in the assumptions and methodologies for MA
payment and the calculation of the frailty adjustment are discussed each year in the Advance
Notice of Methodological Changes for Calendar Year (CY) for Medicare Advantage (MA)
Capitation Rates and Part C and Part D Payment Policies, which is issued at least 60 days before
the first Monday in April of the year preceding the calendar year for which the rates and frailty
adjustment are applicable. Each year, we also notify each FIDE SNP of its frailty score and of
how it compares to PACE organizations.
CMS calculates frailty scores at the PBP level using the limitation on activities of daily living
(ADL) reported by a plan’s enrollees, based on the Medicare Health Outcomes Survey (HOS) or
Health Outcomes Survey-Modified (HOS-M) from the year previous to the payment year. For
example, for payment year 2024, CMS will use the 2023 HOS or HOS-M to determine a frailty
score for FIDE SNPs. MA organizations that believe they will be sponsoring a FIDE SNP in 2024
and want to be considered for a frailty payment must participate in the 2023 HOS or HOS-M to
allow for CMS to calculate their frailty score. For more information, please see the annual HPMS
memo, “Participation in HOS/HOS-M 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; (2) participate in
the HOS/HOS-M; and (3) have similar average levels of frailty as PACE organizations as
described in the Advance Notice for the given year.
20.2.6 – Medicaid Carve-Outs and FIDE SNP and HIDE SNP Status
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
CMS determines the integration status for MA organizations offering D-SNPs through our annual
SMAC review. As part of the review, CMS assesses the scope of existing or proposed carve-outs
against regulatory requirements and determines whether a D-SNP meets the FIDE SNP or HIDE
SNP designation. This policy is designed to accommodate differences in state Medicaid policy.

Under 42 CFR 422.107(g) and (h), CMS allows limited carve-outs from the scope of Medicaid
LTSS and Medicaid behavioral health services that must be covered by FIDE SNPs and HIDE
SNPs.
CMS currently grants FIDE SNP and HIDE SNP status despite limited carve-out of Medicaid LTSS
if such carve-outs:
1. 	Apply primarily to a minority of the dually eligible LTSS users eligible to enroll in a FIDE
SNP or HIDE SNP who use long-term services and supports; or
2. 	Constitute a small part of the total scope of Medicaid LTSS provided to the majority of dually
eligible individuals eligible to enroll in a FIDE SNP or HIDE SNP who use Medicaid LTSS.
CMS did not establish a uniform set of carve-out limits or a numerical limit on carve-outs due to the
variation across states.3
Examples of permissible LTSS carve-outs for FIDE SNPs and HIDE SNPs that apply to a minority of
dually eligible LTSS users may include services specifically limited to individuals with intellectual or
developmental disabilities, individuals with traumatic brain injury, or children.
Carve-outs of specific Medicaid LTSS are permissible if the carved-out services would typically only
be a small component of the broad array of LTSS provided to the majority of Medicaid LTSS users
eligible to enroll in the FIDE SNP or HIDE SNP. CMS would not, however, approve carve-outs for
LTSS services for a specific population – for example, individuals with intellectual or developmental
disabilities – if enrollment in the FIDE SNP or HIDE SNP was limited to individuals with those
disabilities. For example, personal emergency response systems or home modifications may be
important supports for participants in a Medicaid home and community-based waiver program, but
those specific services would rarely constitute the preponderance of an enrolled dually eligible
individual’s care plan because most individuals receiving such services also receive other types of in-
home supports, such as personal care services. Therefore, approving a carve-out of coverage of
personal emergency response systems or home modifications may be permissible under §
422.107(g)(2) where those constitute a small part of the total scope of LTSS provided to the majority
of beneficiaries eligible to enroll in the D-SNP. In contrast, CMS would not expect to approve carve-
outs of in-home personal care or related support services provided to older adults or people with
disabilities even if such services were limited to individuals meeting a nursing home level of care.
CMS defines Medicaid behavioral health carve-outs to be of limited scope if such carve-outs:
1. 	Apply primarily to a minority of the dually eligible users of behavioral health services eligible
to enroll in the D-SNP who use behavioral health services; or
2. 	Constitute a small part of the total scope of behavioral health services provided to the majority
of beneficiaries eligible to enroll in the D-SNP.
Only a small part of the Medicaid behavioral health services may be carved out to ensure the
innovative services that many Medicaid programs provide to individuals with severe and moderate
mental illness are covered through the affiliated Medicaid managed care plan (or the D-SNP if it
holds the Medicaid managed care contract directly).
Examples of permissible carve-outs that apply to primarily a minority of dually eligible users of such
services who are eligible to enroll in the FIDE SNP or HIDE SNP include school-based services for
3 For further discussion, see 87 FR 27757

individuals under 21 years of age and court-mandated services where the D-SNP is not limited to
individuals under 21 years of age.
Examples of permissible carve-outs that constitute a small part of the total scope of Medicaid
behavioral health services include inpatient psychiatric facilities and other residential services,
specifically payment of Medicare cost-sharing or coverage of days not covered by Medicare;
substance abuse treatment, such as payment of Medicare cost-sharing or coverage of services not
covered by Medicare; services provided by a Federal Qualified Health Center or Rural Health Clinic;
and Medicaid-covered prescription drugs for treatment of behavioral health conditions.4
20.2.7 State D-SNP-only Contracts
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
20.2.7.1 Limiting Certain MA Contracts to D-SNPs
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
Through the SMAC, a state can require MA organizations to (a) apply for and seek CMS approval of
MA contracts that only include one or more D-SNPs with exclusively aligned enrollment within a
state and (b) require those D-SNPs to utilize certain integrated materials and notices for enrollees.
CMS will facilitate such requirements in accordance with the procedures and requirements at 42 CFR
422.107(e). CMS will approve D-SNP-only contracts when a state, through the SMAC, requires
exclusively alignment enrollment, requires the D–SNPs to request MA contracts that only include one
or more state-specific D–SNPs, and requires the D-SNP to use (and the D-SNP uses) certain
minimum integrated member materials. However, implementation of such D-SNP-only contracts
requires prior notification and administrative activities to begin well in advance of the applicable
contract year.
20.2.7.2 State Notification to CMS
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
Implementation of a D-SNP-only contract and development of integrated plan materials generally
requires administrative steps that cannot be completed between reviewing the contract (after bid
submission) and the start of the plan year. CMS will begin good faith work following receipt of a
letter from the state Medicaid agency indicating intent to include the requirements for a D-SNP-only
contract and use of integrated materials in a future contract year and collaborate with CMS on
implementation. To begin the process to establish state D-SNP-only contracts under 42 CFR
422.107(e)(2), CMS requests the respective state Medicaid agency submit a letter to CMS regarding
its intention to pursue the further integration opportunities available under 42 CFR 422.107(e)(1) by
August of two years prior (e.g., August 2023 in anticipation of implementation in plan year 2025) to
enable the MA organization and CMS to start the necessary steps. More information on this process
4 As discussed in the CMS-4185-F rule, CMS had historically determined D-SNPs to be FIDE or HIDE SNPs when they
meet the necessary requirements but included limited carve-outs of certain services from the Medicaid coverage provided
by the Medicaid managed care plan. The CMS HPMS memorandum entitled, “Additional Guidance on CY 2021
Medicare-Medicaid Integration Requirements for Dual Eligible Special Needs Plans,” January 17, 2020 (retrieved from:
https://www.cms.gov/files/document/cy2021dsnpsmedicaremedicaidintegrationrequirements.pdf) discussed the policy
later finalized at 422 CFR 422.107(g) and (h) and discussed in section 20.2.6 of this chapter. The requirements at 422
CFR 422.107(g) and (h) and discussed in section 20.2.6 of this chapter supersede the January 17, 2020 HPMS
memorandum.

can be found in previous guidance at the following link:
https://www.cms.gov/files/document/stateoppsintegratedcareprogs.pdf
20.2.7.3 Integrated Materials
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
To meet the requirements of 42 CFR 422.107(e)(1)(ii), the SMAC must require the D-SNP(s) to use
required materials that integrate Medicare and Medicaid content, including at a minimum the
Summary of Benefits, Formulary, and combined Provider and Pharmacy Directory. The state may
require use of additional integrated materials. Integrated materials must meet Medicare and Medicaid
managed care requirements consistent with applicable regulations in 42 CFR 422, 423, and 438. CMS
coordinates with states that choose to require, through their SMACs, that a D-SNP with exclusively
aligned enrollment integrate its Medicare and Medicaid member materials to ensure these integrated
materials comply with regulatory requirements.
20.2.7.4 Joint State/CMS Oversight
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
To enhance coordination between states, D-SNPs, and CMS, states that establish D-SNP-only
contracts have the opportunity to collaborate with CMS on oversight activities through access to the
Health Plan Management System (HPMS) and coordination on program audits. The state must
request access to HPMS and comply with applicable rules and policies related to such access (e.g.,
agree to protect the proprietary nature of information to which the state Medicaid agency may not
otherwise have direct access). More information on these activities can be found at 42 CFR
422.107(e)(3) and in the CY 2023 MA and Part D final rule published on May 9, 2022 (87 FR
27773).
20.2.8– Benefit Flexibility for Certain D-SNPs
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
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.
20.2.8.1 – Benefit Flexibility Eligibility Requirements
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
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.

20.2.8.2 – Characteristics and Categories of Flexible Supplemental Benefits
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
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
Category
Benefit Description 	Acceptable
Means of
Delivery
PBP Description
Non-Skilled
In-Home
Support
Services
Non-skilled services and
support services performed by
a personal care attendant or by
another individual that is
providing these services
consistent with state
requirements in order to assist
individuals with disabilities
and/or chronic conditions with
performing ADLs and IADLs
as necessary to support
recovery, to prevent 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.
Services would
be performed by
individuals
licensed by the
state to provide
personal care
services, or in a
manner that is
otherwise
consistent with
state
requirements.
Describe the criteria the
plan intends to use (e.g.,
level of care need, ADL
limitations, etc.) to
determine which
enrollees are eligible for
personal care services.

Proposed
Benefit
Category
Benefit Description 	Acceptable
Means of
Delivery
PBP Description
In-Home Food
Delivery
Meal delivery service (beyond
the limited coverage described
in chapter 4 of the MMCM) for
individuals who cannot prepare
their own food (IADL
limitation) due to functional
limitations with ADLs or short-
term functional disability, or
for individuals who, based on a
physician’s recommendation,
require nutritional
supplementation following an
acute illness or resulting from a
chronic condition.
Meals would be
provided
consistent with
plan policies for
ensuring
nutritional
content (i.e.,
minimum
recommended
daily nutritional
requirements).
Describe the Medicare
meal benefit
comprehensively, and
clearly distinguish meal
benefits for individuals
who would already
qualify under current
meal benefit guidance
from meal benefits
under an expanded
definition.
Describe any limits
imposed on meal
benefits (e.g.,
duration, criteria for
eligibility, number of
meals/day).
Supports for
Caregivers of
Enrollees
Provision of respite care—
either through a personal care
attendant or through provision
of short-term institutional-
based care— for caregivers of
enrollees. Coverage may
include benefits such as
counseling and training courses
(related to the provision of
plan-covered benefits) for
caregivers of enrollees.
Specific
caregiver support
benefits must
directly relate to
the provision of
plan-covered
benefits.
Describe how benefits
relate to plan-covered
benefits, as well as any
limitations (e.g.,
number of
counseling/support
sessions covered per
year, number of
hours/days of respite
care covered per year
and/or episode).

Proposed
Benefit
Category
Benefit Description 	Acceptable
Means of
Delivery
PBP Description
Home
Assessments,
Modifications,
and Assistive
Devices for
Home Safety
Coverage of home
safety/assistive devices and
home assessments and
modifications beyond those
permitted in chapter 4 of the
MMCM.
Coverage may include
items/services such as rails
in settings beyond the
enrollee’s bathroom.
Home
assessments
would be
performed by
trained
personnel (e.g.,
occupational
therapists), or
by persons with
qualifications
required by the
state, if
applicable.
Describe benefit
comprehensively, and
clearly distinguish
safety assessments and
devices already
covered under chapter
4 of the MMCM from
additional benefits
qualified SNPs could
provide. Describe
enrollee criteria for
receiving these
additional benefits
(e.g., enrollee at risk of
falls, etc.)
Adult Day Care
Services
Services such as
recreational/social activities,
meals, assistance with
ADLs/IADLs, education to
support performance of
ADLs/IADLs, physical
maintenance/rehabilitation
activities, and social work
services.
Provided by
staff whose
qualifications
and/or
supervision
meet state
licensing
requirements.
Describe the criteria
imposed for receipt of
adult day care services
(e.g., prior
authorization by a
medical practitioner,
institutional level of
care requirement, etc.)
20.2.8.3 – Benefit Flexibility Approval Process
(Rev. 130; Issued: 01-12-24; Effective: 01-12-24; Implementation: 01-12-24)
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-SNP’s bid.
In order for a D-SNP to offer the flexible supplemental benefits, CMS must first determine the D-

SNP meets CMS’s 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 CMS’s 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-SNP’s 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
• 	CMS’s 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-SNP’s 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.
20.2.9 – D-SNP Enrollee Advisory Committees
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
The policies outlined in section 20.2.9 rely on CMS regulation at 42 CFR 422.107(f), which was
codified in CY 2023 MA and Part D Final Rule (CMS-4192-F), which was published on May 9, 2022.
Enrollee advisory committees provide a means to engage enrollees in discussions and to provide
information and viewpoints on ways to improve access to covered services and coordination of

services. For dually eligible individuals, these considerations are especially important. By soliciting
and responding to enrollee input, D-SNPs, like all managed care plans, can better ensure that
policies and procedures are responsive to the needs, preferences, and values of enrollees and their
families and caregivers. One of the ways D-SNPs can engage dually eligible individuals is by
including enrollees in plan governance, such as establishing enrollee advisory committees and
placing enrollees on governing boards. Engaging enrollees in these ways seeks to keep enrollee and
caregiver voices front and center in plan operations and can help plans achieve high-quality,
comprehensive, and coordinated care.5
42 CFR 422.107(f) requires that an MA organization offering one or more D-SNPs in a state establish
and maintain one or more enrollee advisory committees (EACs) that serve D-SNPs offered by the MA
organization in that state. The EAC must:
1. 	Include at least a reasonably representative sample of the population enrolled in the 	D-
SNP(s), or other individuals representing those enrollees; and
2. 	Solicit input on, among other topics, ways to improve access to covered services, coordination
of services, and health equity for underserved populations.
Some D-SNPs, or their Medicaid managed care plans offered by the same parent organization as the
MA organization offering the D-SNP, covering long term services and supports, may also operate
similar advisory committees to meet state or federal Medicaid requirements. An MA organization that
operates a D-SNP that is affiliated with a Medicaid managed care plan can use one EAC to meet both
the requirement under 42 CFR 438.110 and 42 CFR 422.107(f), when all the criteria in both
requirements are met.
20.2.9.1 – Flexibility in EAC Operations
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
We encourage MA organizations to work with D-SNP enrollees and their representatives to establish
the most effective and efficient processes for enrollee engagement. The requirements at 42 CFR
422.107(f) are nonprescriptive on meeting frequency, location, format, enrollee recruitment and
training methods, use and adoption of telecommunications technology, or other parameters for
operation of the EACs.
This flexibility extends to the geographic scope of the EAC(s) within each state. For example, the
EAC could include enrollees from a D-SNP offered in a single county, or it could consist of enrollees
from D-SNPs offered in multiple counties. For instance, a MA organization that offers separate D-
SNPs in Broward, Hillsborough, and Orange counties in Florida could establish one EAC that
convenes enrollees representative of each of these distinct regions via virtual communication
methods. Alternatively, the MA organization could establish separate EACs in each county or use a
combination of these approaches. Similarly, an MA organization that offers separate D-SNPs serving
full-benefit dually eligible individuals and partial-benefit dually eligible individuals in the same state
could solicit enrollee input through one or more EACs where separate committees might represent
specific eligibility groups.
5 Resources for Integrated Care and Community Catalyst, ‘‘Listening to the Voices of Dually Eligible Beneficiaries:
Successful Member Advisory Councils’’, 2019. Retrieved from:
https://www.resourcesforintegratedcare.com/Member_Engagement/Video/Listening_to_Voices_of_Dually_Eligible_Bene
ficiaries

20.2.9.2 – Other Information and Technical Assistance
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
We sponsored technical assistance for MA organizations on establishing meaningful EACs through
the Resources for Integrated Care.6 Nothing in these technical assistance materials supersedes the
applicable regulation or guidance in this manual. However, we encourage D-SNPs to consider those
materials to maximize the success of the EAC.
We issued a Health Plan Management System (HPMS) memorandum on June 18, 2024, entitled
“Lessons Learned from Dual Eligible Special Needs Plans Enrollee Advisory Committee Strategic
Conversation.”7 The memorandum outlines lessons learned from a series of strategic conversations
CMS held with MA organizations to understand first year implementation of D-SNP EACs. Lessons
learned focus on EAC:
• 	Participant recruitment and retention
• 	Participant preparation and engagement
• 	Meeting structure
• 	Follow up
We also issued an HPMS memo on November 28, 2022, “Cash, Cash Equivalent, Voucher, Gift Card,
and In-Kind Benefits for Enrollees Who Are Enrollee Advisory Committee Participants.”8 This
memorandum describes considerations for D-SNPs regarding cash, cash equivalent, voucher, gift
card, and in-kind benefits for individuals who participate in enrollee advisory committees.
20.2.10 – Additional Responsibilities for D-SNPs
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
The policies outlined in section 20.2.10 rely on CMS regulation at 42 CFR 422.562(a)(5), which was
codified in CY 2020 and 2021 MA and Part D Final Rule (CMS-4185-F), which was published on
April 16, 2019.
20.2.10.1 – Responsibilities Related to Assisting with Access to Benefits, Appeals, and
Grievances
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
6 Resources for Integrated Care, “Best Practices for Implementing Enrollee Advisory Committees”, video recording,
webinar slides, and other resources retrieved from:
https://www.resourcesforintegratedcare.com/2022_ric_webinar_best_practices_for_implementing_enrollee_advisory_com
mittees/. Resources for Integrated Care, “Launching an Enrollee Advisory Committee”, Tip Sheet
https://www.resourcesforintegratedcare.com/wp-content/uploads/2024/01/TA-Duals_Tip-Sheet-Launching-an-
EAC_final.pdf. Resources for Integrated Care, “Enrollee Advisory Committees: Navigating the Feedback Process”, Tip
Sheet https://www.resourcesforintegratedcare.com/wp-content/uploads/2023/07/TA-Duals_-TipSheet-Feedback-for-
Improvement_final.pdf.
7 CMS, Lessons Learned from Dual Eligible Special Needs Plans Enrollee Advisory Committee Strategic Conversation,”
June 18, 2024 retrieved from: https://www.cms.gov/about-cms/information-systems/hpms/hpms-memos-archive-
weekly/hpms-memos-wk-3-june-17-21
8 CMS, “Cash, Cash Equivalent, Voucher, Gift Card, and In-Kind Benefits for Enrollees Who Are Enrollee Advisory
Committee Participants,” November 28, 2022 retrieved from: https://www.cms.gov/httpseditcmsgovresearch-statistics-
data-and-systemscomputer-data-and-systemshpmshpms-memos-archive/hpms-memos-wk-5-november-28-30

Per 42 CFR 422.562(a)(5), D-SNPs must offer to assist an enrollee with obtaining Medicaid-covered
services and resolving grievances, including requesting authorization of Medicaid services, as
applicable, and navigating Medicaid appeals and grievances in connection with the enrollee's own
Medicaid coverage, regardless of whether such coverage is in Medicaid fee-for-service or a Medicaid
managed care plan, such as a Medicaid MCO, prepaid inpatient health plan (PIHP), or prepaid
ambulatory health plan (PAHP), as defined in 42 CFR 438.2. If the enrollee accepts the offer of
assistance, the plan must provide the assistance.
Examples of such assistance include the following:
(A) Explaining to an enrollee how to make a request for Medicaid authorization of a service
and how to file an appeal following an adverse benefit determination, such as—
(1) Assisting the enrollee in identifying the enrollee's specific Medicaid managed care
plan or fee-for-service point of contact;
(2) Providing specific instructions for contacting the appropriate agency in a fee-for-
service setting or for contacting the enrollee's Medicaid managed care plan,
regardless of whether the Medicaid managed care plan is affiliated with the enrollee's
D-SNP; and
(3) Assisting the enrollee in making contact with the enrollee's fee-for-service contact
or Medicaid managed care plan.
(B) Assisting a beneficiary in filing a Medicaid grievance or a Medicaid appeal.
(C) Assisting an enrollee in obtaining documentation to support a request for authorization of
Medicaid services or a Medicaid appeal.
D-SNPs can provide assistance in many ways, also including advising enrollees to call providers and
questions to ask, identifying necessary forms to file, and referring enrollees to an organization with
more expertise (such as a state ombudsman, State Health Insurance Assistance Programs, and other
relevant assistance programs). We recognize that state Medicaid systems vary substantially, and that
the specific forms of assistance will also vary from market to market. We do not seek to be overly
prescriptive in the types of assistance a D–SNP must provide, and the examples provided above and
in regulation are not intended to be exhaustive.
20.2.10.1.1 – When 42 CFR 422.562(a)(5) Requires D-SNPs to Provide Assistance
(Rev.131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
The D-SNP must offer to provide the assistance described above and in 42 CFR 422.562(a)(5)(i)
whenever it becomes aware of an enrollee's need for a Medicaid-covered service. Offering such
assistance is not dependent on an enrollee's specific request. There are a number of ways in which a
D–SNP could become aware of the need for assistance. A non-exhaustive list includes: During a
health risk assessment when an enrollee shows a need for more LTSS than she currently receives
through Medicaid; during a request for coverage of a Medicaid-covered service made to the D–SNP;
and during a call to the D–SNP’s customer service line.
Each D-SNP must offer to provide and actually provide assistance as required by 42 CFR
422.562(a)(5)(i) using multiple methods.
(A) When an enrollee accepts the offer of assistance described in 42 CFR 422.562(a)(5)(i), the
D-SNP may coach the enrollee on how to self-advocate.

(B) The D-SNP must also provide an enrollee reasonable assistance in completing forms and
taking procedural steps related to Medicaid grievances and appeals.
We expect that D–SNPs, as plans with expertise in serving dually eligible beneficiaries, should be
able to identify a potential Medicaid coverage issue as part of their regular assessments and care
management processes. For example, a D–SNP may become aware that an enrollee is unsatisfied
with the personal care services she is receiving based on the work of a care coordinator or from a
call or email from the enrollee or enrollee’s family. We note that regulation text at 42 CFR
422.562(a)(5) does not explicitly require a D–SNP to use its care coordination or case management
programs to identify this type of issue.
Not all enrollees would need assistance in the actual filing of grievances and appeals; for many
enrollees, simply receiving information under 42 CFR 422.562(a)(5)(i) would be sufficient. However,
it would not be acceptable for a D–SNP to tell an enrollee simply to contact ‘‘Medicaid’’ in general
when the enrollee encounters a problem with his or her Medicaid coverage or is obviously in need of
assistance in figuring out how to file an appeal of a denial of Medicaid-covered benefits.
20.2.10.1.2 – When 42 CFR 422.562(a)(5) Does Not Require D-SNPs to Provide
Assistance
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
If an enrollee does not want the D–SNP’s help in resolving an issue, then the D–SNP would not be
obligated to provide assistance. The intention is not to create any affirmative obligation on the D–
SNP to assist enrollees if they decline the offer of assistance. Enrollees are free to decide for
themselves how to navigate their Medicaid coverage. The only obligation on D–SNPs is to offer
assistance, and when a request is made or an offer of assistance is accepted, to provide it.
Further, partial-benefit dually eligible enrollees do not qualify for the full range of Medicaid services,
and therefore, this requirement does not create any new obligation for D–SNPs to offer assistance for
such enrollees to access Medicaid-covered services.
20.2.10.1.3 – Other Considerations
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
Each D-SNP must, upon request from CMS, provide documentation demonstrating its compliance
with 42 CFR 422.562(a)(5).
The obligation to provide assistance under 42 CFR 422.562(a)(5)(i) does not create an obligation for
a D-SNP to represent an enrollee in a Medicaid appeal. Further, it does not include a requirement to
resolve the coverage issue.
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 enrollee’s 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 plan’s
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 enrollee’s 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-SNP’s 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-SNP’s 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-SNP’s 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 facility’s 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-SNP’s 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 plan’s 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
MOC
Submission (%)
Cure
Options
Post 1st Cure 	Final Approval Status
85% to 100% 	No cure
options
N/A 	3-year approval
75% to 84% 	No cure
options
N/A 	2-year approval

70% to 74% 	No cure
options
N/A 	1-year approval
69% or below 	One cure
option
70% or higher 	1-year approval
69% or below 	One cure
option
69% or below 	No approval
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 MAO’s SNP’s 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
SAE Application?
Complete MA-PD
SAE Application?
1. 	MAO seeks to expand its SNP service
area into its existing MA-PD service
area.
Yes 	No
2. 	MAO seeks to expand its SNP service
area into a service area(s) where it
does not currently operate.
Yes 	Yes
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. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
As specified in section 1859(f) of the Act, SNPs may only enroll individuals who meet the plan’s
specific eligibility criteria and enrollment requirements. For example, a D-SNP that is approved to
serve only full-benefit Medicaid beneficiaries may not enroll an individual who is not qualified for
full-benefit Medicaid 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 dually 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. MA organizations, including
those offering SNPs, must accept, without restriction, all eligible individuals whose enrollment
elections are received during a valid election period, expect where a state limits or freezes
enrollment through a D-SNP’s SMAC. See 42 CFR 422.52, 42 CFR 422.60 and section 1851(g)(1)
of the Act.
42 CFR 422.52 establishes eligibility rules for SNPs. 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 MA organizations. MA organizations must accept enrollments through the
OEC except when limited by CMS or when a D-SNP is limited by provisions in its SMAC. 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 dually 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 applicant’s special needs status. Prior to enrollment,
the C-SNP must contact the applicant’s 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 enrollee’s diagnosed chronic
condition(s) from the C-SNP list of qualified conditions. The C-SNP should attempt to obtain
eligibility verification information from an enrollee’s 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 individual’s 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 individual’s
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 applicant’s 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 enrollee’s information and
eligibility using medical information (medical history, current signs and/or symptoms,
diagnostic testing, and current medications) provided by the enrollee’s 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
enrollee’s 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 individual’s 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
individual’s 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 organization’s 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 MAO’s 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.
CMS’s 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 team’s 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. 127, Issued: 06-02-23, Effective: 01-01-23, Implementation: 01-01-23)
The guidance in this section specifically applies to SNP renewal options and crosswalks as codified at
42 CFR 422.530.9 The regulation at 42 CFR 422.530 was adopted in 2021 to codify longstanding
guidance with some modifications. Tables 6 through 8 below provides an overview of the SNP
crosswalk policy. For general crosswalk guidance for all MA plans (as well as MA special needs
plans), please refer to the Bid Submission User Manual, located under the Plan Bids tab in HPMS.
50.2 – D-SNP Terminations and Non-Renewals for lack of a State Medicaid Agency
Contract
(Rev. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
All MA organizations that offer D-SNPs must have contracts with state Medicaid agencies in the
states in which they operate per section 1859(f)(3)(D) of the Act and 42 CFR 422.107. In the event
that an MA organization is not able to secure such a contract (or subcontract) with the state
Medicaid agency(ies) for one or more of its D-SNPs, the MA organization must non-renew or
terminate those D-SNPs in accordance with 42 CFR 422.506 through 422.510. Enrollees in those
plans will be disenrolled from their D-SNP and may elect to receive Part A and Part B benefits
under original Medicare or another MA plan into which they wish to enroll.
Several SEPs are available to individuals affected by such an action, including:
• 	Enrollees have a SEP at 42 CFR 422.62(b)(1) available when an MA plan (including a D-
SNP) is terminating.
• 	Enrollees who are dually eligible individuals or LIS-eligible individuals have a SEP at 42
CFR 423.38(c)(4) that may be used in any month to enroll into original Medicare and a
standalone Part D prescription drug plan.
• 	Full-benefit dually eligible individuals also have a SEP at 42 CFR 423.38(c)(35) that may
be used in any month to enroll into a FIDE SNP, HIDE SNP, or AIP to facilitate aligned
enrollment in the affiliated Medicaid MCO.
1 See also the final rules at 86 FR 5864, 5963 - 5969 (Jan. 19, 2021) (available online here:
https://www.govinfo.gov/content/pkg/FR-2021-01-19/pdf/2021-00538.pdf) and 87 FR 27704, 27743 – 27768 (May 9, 0222) (available online here:
https://www.govinfo.gov/content/pkg/FR-2022-05-09/pdf/2022-09375.pdf) for discussion of § 422.530.
.

In the event of a D-SNP termination or non-renewal, the D-SNP enrollees who do not make an
enrollment request will be enrolled into original Medicare and automatically enrolled in a
benchmark stand-alone PDP after the termination of the D-SNP. For more information about SEPs
and enrollment periods available to dually eligible individuals, refer to Chapter 2 of the MMCM,
which is also posted as the MA Enrollment and Disenrollment Guidance here:
https://www.cms.gov/medicare/eligibility-andenrollment/medicaremangcareeligenrol.
50.3 – SNP Crosswalks
(Rev.131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
A crosswalk is the movement of enrollees from one plan (or plan benefit package (PBP)) to another
plan (or PBP) under a contract between the MA organization and CMS. To crosswalk enrollee from
one PBP to another is to change the enrollment from the first PBP to the second. Except as specified
in 42 CFR 422.530(c)(2), (3), and (4)(ii), MA organizations may not crosswalk enrollees from one
contract to another contract. MA organizations may not crosswalk enrollees from one SNP type to a
different SNP type.
In addition, MA organizations must comply with renewal and nonrenewal rules in 42 CFR §§
422.505 and 422.506 in order to complete plan or PBP crosswalks. Please refer to 42 CFR §
422.530 for the standard crosswalk rules applicable to all MA plans, including all SNPs. Please also
refer to the annual End-of-Year Enrollment and Payment Systems Processing Information memo
released each year for details related to the Medicare Advantage and Prescription Drug (MARx)
System Transaction Processing and Rollover and Terminating Plan MARx Transaction Processing
instructions. The tables below outline the crosswalk scenarios for D-SNPs, C-SNPs, and I-SNPs.
Table 6: C-SNP Crosswalk Scenarios
Activity 	Regulatory Authority 	Requires
Crosswalk
Exception
Allows Movement
across Contracts
HPMS Plan
Crosswalk
Renewing C-SNP
with one chronic
condition that
transitions eligible
enrollees into
another C-SNP with
a grouping that
contains that same
chronic condition.
Non-renewing C-
SNP with one
chronic condition
that transitions
eligible
enrollees into
another C-SNP with
a grouping that
contains the same
chronic condition.
42 CFR
422.530(b)(2)(i)(A)
42 CFR
422.530(b)(2)(i)(B)
42 CFR
422.530(b)(2)(i)(C)
No 	No. Except as
provided by §
422.530(c), crosswalks
are prohibited between
different contracts or
different plan types
(for example,
HMO to PPO or from
one type of SNP to a
different type of SNP).
Several types of
exceptions are
addressed elsewhere in
Tables 6 through 8.
During Bid
Submission
window, select Plan
Crosswalk
Designation:
Consolidated Plan
Renewal

Non-renewing C-
SNP with a
grouping that is
transitioning
eligible enrollees
into a different C-
SNP if the new
grouping contains
at least one
condition that the
prior plan
contained.
Renewing C-SNP
with a grouping of
multiple conditions
that is transitioning
eligible enrollees
into another C-SNP
with one of the
chronic conditions
from that grouping.
42 CFR 422.530(c)(5) 	Yes 	No. This is not one of
the exceptions
permitting a crosswalk
across contracts.
During Bid
Submission
window, select
Consolidated
Renewal Plan
Table 7: D-SNP Crosswalk Scenarios
Activity 	Regulatory
Authority
Requires
Crosswalk
Exception
Allows
Movement
across
Contracts
Guidelines 	HPMS Plan
Crosswalk
Renewing D-
SNP with a
multi-state
service area that
reduces its
service area and
moves
enrollees who
are no longer in
the service
area of the
renewing D-
SNP to one or
more renewing
D-SNPs (for
42 CFR
422.530(c)(3)
Yes 	Yes 	Movement is
permitted if the
enrollees are eligible
for the
receiving D-SNPs
and CMS
determines the
crosswalk is
necessary to
accommodate
changes to the
contracts between the
state and D-SNP
under 42 CFR
422.107.
During
Crosswalk
Exception
Submission
window,
select
Crosswalk
Exception
Request
Type 2 –
Renewing
D-SNP with
service area
change,
includes

Activity 	Regulatory
Authority
Requires
Crosswalk
Exception
Allows
Movement
across
Contracts
Guidelines 	HPMS Plan
Crosswalk
which the
enrollees are
eligible) offered
under the same
parent
organization.
RPPO to
LPPO
A D-SNP in a
RPPO that non-
renews to create
state-specific
local PPOs in
its
place to
accommodate
state contacting
efforts in the
service area and
moves
enrollees who
are no
longer in the
service area to
one or more
renewing D-
SNPs offered
under the same
parent
organization.
42 CFR
422.530(c)(3)
Yes 	Yes 	Movement is
permitted if the
enrollees are eligible
for the
receiving D-SNPs
and CMS
determines the
crosswalk is
necessary to
accommodate
changes to the
contracts between the
state and D-SNP
under 42 CFR
422.107.
During
Crosswalk
Exception
Submission
window,
select
Crosswalk
Exception
Request
Type 2 –
Renewing
D-SNP with
service area
change,
includes
RPPO to
LPPO
Renewing D-
SNP has
another new or
renewing
D-SNP and the
two D-
SNPs are
offered to
different
populations, and
moves enrollees
who are
42 CFR
422.530(c)(4)(i)
Yes 	No 	Movement is
permitted if the
enrollees meet the
eligibility criteria for
the new or renewing
D-SNP and
CMS determines it is
in the best interest of
the enrollees to move
to
the new or renewing
D-SNP in order to
During
Crosswalk
Exception
Submission
window,
select
Crosswalk
Exception
Request
Type 3 –
Change in

Activity 	Regulatory
Authority
Requires
Crosswalk
Exception
Allows
Movement
across
Contracts
Guidelines 	HPMS Plan
Crosswalk
no longer
eligible for their
current D-SNP
into the
promote access and
continuity of
D-SNP
populations
other new or
renewing D-
SNP offered by
the same MA
organization.
care for enrollees
relative to the absence
of a crosswalk
exception.
MA
organization
creates a new
D-
SNP-only MA
contract when
required by a
state as
described in 42
CFR
422.107(e),
eligible
enrollees may
be moved
from the
existing D-SNP
(that is non-
renewing or
having its
eligible
population
newly restricted
by a state to
achieve
exclusively
aligned
enrollment) to a
D-SNP
offered under
the D-SNP-only
contract.
42 CFR
422.530(c)(4)(ii)
Yes 	Yes 	The new D-SNP-only
contract is approved
and permitted by
CMS
under § 422.107(e)
and movement must
be to the same plan
type operated by the
same parent
organization.
During
Crosswalk
Exception
Submission
window,
select
Crosswalk
Exception
Request
Type 9 –
MA-PD
with a D-
SNP
transition to
D-SNP only
contract

Activity 	Regulatory
Authority
Requires
Crosswalk
Exception
Allows
Movement
across
Contracts
Guidelines 	HPMS Plan
Crosswalk
When one or
more MA
organizations
that share a
parent
organization
seek to
consolidate D-
SNPs in the
same service
area down to a
single PBP
under one MA-
PD contract to
comply with the
requirements at
42 CFR
422.514(h) and
422.504(a)(20).
42 CFR
422.530(c)(4)(iii)
Yes 	Yes 	Available beginning
in 2026 for CY 2027.
Movement must be to
the same plan type
and operated under
by the same parent
organization
During
Crosswalk
Exception
Submission
window,
select
relevant
Crosswalk
Exception
Request
Table 8: I-SNP Crosswalk Scenarios
Activity 	Regulatory
Authority
Requires
Crosswalk
Exception
Allows
Movement
across
Contracts
HPMS Plan
Crosswalk
Renewing 	Institutional
SNP 	that 	transitions
enrollees 	to 	an
Institutional/Institutional
Equivalent SNP
42 CFR
422.530(b)(2)(ii)(A)
No 	No 	During Bid
Submission
window, select
Consolidated
Renewal Plan
Renewing Institutional
Equivalent SNP that transitions
enrollees to an Institutional/
Institutional
42 CFR
422.530(b)(2)(ii)(B)
No 	No 	During Bid
Submission
window, select
Equivalent SNP 	Consolidated
Renewal Plan
Renewing Institutional/
Institutional Equivalent SNP
that transitions eligible
42 CFR
422.530(b)(2)(ii)(C)
No 	No 	During Bid
Submission
window, select

Activity 	Regulatory
Authority
Requires
Crosswalk
Exception
Allows
Movement
across
Contracts
HPMS Plan
Crosswalk
enrollees to an Institutional
SNP
Consolidated
Renewal Plan
Renewing Institutional/
Institutional Equivalent SNP
that transitions eligible
enrollees to an Institutional
Equivalent SNP
42 CFR
422.530(b)(2)(ii)(D)
No 	No 	During Bid
Submission
window, select
Consolidated
Renewal Plan
Nonrenewing
Institutional/Institutional
Equivalent SNP that transitions
eligible enrollees to another
Institutional/Institutional
Equivalent SNP
42 CFR
422.530(b)(2)(ii)(E)
No 	No 	During Bid
Submission
window, select
Consolidated
Renewal Plan

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 population’s 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 CMS’s 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. 131; Issued: 11-22-24; Effective: 11-22-24; Implementation: 11-22-24)
The quality improvement requirements applied to non-SNP MA plans are also applied to SNPs.
Pursuant to 42 CFR 422.152(c), each SNP must conduct a Chronic Care Improvement Program
(CCIP) 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.
90 – SNP Health Risk Assessment Screening Requirement
(Rev. 129; Issued: 08-11-23; Effective: 01-01-24; Implementation: 01-01-24)
90.1 – General

(Rev. 129; Issued: 08-11-23; Effective: 01-01-24; Implementation: 01-01-24)
Regulations at 42 CFR 422.101(f)(1)(i)10 require that all MA SNP health risk assessments
(HRAs) must include at least one question from a list of screening instruments specified by CMS
in sub-regulatory guidance on each of three domains (housing stability, food security, and access
to transportation) beginning in contract year (CY) 2024. This requirement helps to better identify
the risk factors that may inhibit enrollees from accessing care and achieving optimal health
outcomes and independence and enable SNPs to take these risk factors into account in enrollee
individualized care plans. This section provides the list of CMS-specified screening instruments
available for SNPs to meet the requirement.
90.2 - Instruments for Screening for Housing Stability, Food Security, and
Access to Transportation
(Rev. 129; Issued: 08-11-23; Effective: 01-01-24; Implementation: 01-01-24)
SNPs can meet the requirement at 42 CFR 422.101(f)(1)(i) in one of two ways:
1. 	Use a state-required screening instrument that includes questions on the required
domains.
As discussed in the CY 2023 MA and Part D Final Rule (87 FR 27734), SNPs can use state-
required Medicaid screening instruments that include questions on housing stability, food
security, and access to transportation to satisfy the HRA content requirement in 42 CFR
422.101(f)(1)(i). By allowing SNPs to use the questions in state-required screening
instruments, we aim to prevent duplication of screening efforts. For the purposes of this
requirement, SNPs that are required by a state to use a certain screening instrument in the
same contract year may use that state-required instrument to meet this requirement. For
example, a SNP required by a state to use an assessment instrument in CY 2024 that includes
questions on these domains could use that instrument to meet the requirement at 42 CFR
422.101(f)(1)(i) for CY 2024.
In addition, CMS recognizes that SNPs operating in a particular state that are not subject to
state assessment requirements (e.g., chronic condition special needs plans [C-SNPs] and
institutional special needs plans [I-SNPs] are not required to have contracts with states) may
wish to use an assessment instrument a state requires for dual eligible special needs plans (D-
SNPs) to satisfy the requirement at 42 CFR 422.101(f)(1)(i) if that instrument includes
questions in the three required domains. C-SNPs and I-SNPs may use such a state-required
assessment instrument to meet this requirement as long as the state requires that instrument
for D-SNPs in the same state in the same contract year, as outlined above. For example, a C-
SNP operating in a state that requires D-SNPs to use a certain assessment instrument in CY
2025 may use that state-specified instrument to meet the 42 CFR 422.101(f)(1)(i)
requirement to include questions in the specified domains in CY 2025 so long as that
instrument includes the questions in the three required domains. Such SNPs may use
questions on the three required domains from a state-required assessment as part of their
10 https://www.govinfo.gov/content/pkg/FR-2022-05-09/pdf/2022-09375.pdf

HRA without using the entire state-required assessment (i.e., adding questions on the three
domains to the SNP’s own existing HRA instrument).
Finally, SNPs may use state-required screening instruments for plans whose service areas
include a state that requires a particular state-specific screening instrument. For example, a
SNP plan benefit package whose service area encompasses the Kansas City metro area could
include counties in both Missouri and Kansas. In this example, if Missouri required a certain
state-specific screening instrument and Kansas did not, the plan may use the Missouri state-
required screening instrument for all enrollees in that service area, including those who reside
in Kansas.
While many states that require screening for these three domains are using validated
screening instruments, some state-required screening instruments may be state-specific and
not meet the standards described below (e.g. not a validated, health information technology
(IT)-encoded instrument). This could create a challenge for data standardization and
interoperability. However, CMS believes the need for flexibility outweighs this potential
challenge but may revisit this position in the future. We encourage SNPs to reach out to the
states in which they operate with any questions about state-specific screening requirements.
2. 	Select questions on the required domains from validated, health information
technology (IT)-encoded screening instruments.
Alternatively, if not using a state-required screening instrument, SNPs may select questions
from other validated, health IT-encoded screening instruments. Table 7 in section 90.1.2
specifies CMS’s list of social needs screening instruments from which SNPs must select
questions on the three required domains to meet the requirement at 42 CFR 422.101(f)(1)(i)
if the SNP does not use a state-required screening instrument that includes questions on the
required topics (see Table 7 below).
CMS aimed to include validated, widely used screening instruments and considered the
availability of screening instruments, including whether they are proprietary or require a fee.
The list in Table 7 includes a number of screening instruments that are non-proprietary
and/or available at no cost. For those screening instruments that are proprietary, SNPs are
responsible for securing the necessary licenses to use the intellectual property of entities that
own these instruments and the questions as formulated in them.
In addition, use of the questions from a specific screening instrument specified by CMS must
be consistent with the instructions for the screening instrument for the SNP’s use of the
question(s) on housing, food security, and access to transportation to satisfy the SNP’s
obligations under 42 CFR 422.101(f)(1)(i). CMS’s review of the questions on the screening
instruments specified in Table 7 has taken into account instructions and permissible
variations. Therefore, when the developer of a screening instrument allows users to make
certain adaptations (e.g., translation into other languages), SNPs should make changes
consistent with the screening instrument’s specifications or consult with the relevant
screening instrument developer to determine what adaptations may be acceptable and
whether such adaptations require permission from the instrument developer. SNPs may also

want to consult with the instrument developer to understand how any adaptations to the
instrument questions might affect their validity. 42 CFR 422.2267(a)(2) requires that MA
organizations must translate required materials, including HRAs, into any non-English
language that is the primary language of at least five percent of the individuals in a plan
benefit package service area. In addition, beginning for 2024, fully integrated and highly
integrated D-SNPs (and applicable integrated plans as defined in 42 CFR 422.561) must
translate required materials into the language(s) required by the Medicaid translation
standard specified in the capitated Medicaid managed care contract held by the D-SNP or its
affiliated Medicaid managed care plan.
In selecting the screening instruments from which a SNP may select questions to comply
with 42 CFR 422.101(f)(1)(i), CMS applied the following criteria:11
• 	Screening instruments that are validated, widely used, and available. CMS
determined that the screening instruments the stakeholder-led Gravity Project has
identified as appropriate to screen for the each of the three required domains meet this
standard. The Gravity Project is a national public collaborative that convenes
stakeholders through an open and transparent collaborative process to develop and
test consensus-based standards to facilitate social determinants of health (SDOH) data
capture.12
• 	Screening instruments that maximize opportunities for SNPs to collect and
analyze standardized, quantifiable, and actionable data. CMS determined that, in
order to meet this standard, questions and responses in screening instruments should
be mapped to health IT vocabulary standards (i.e., have available LOINC® coding
terminology).
As described in the CY 2023 MA and Part D Final Rule, CMS considered the extensive work
various stakeholders have already done to research and validate screening instruments in
developing the above criteria. The above criteria align with the data elements established as
part of the United States Core Data for Interoperability, Version 2, in which LOINC ® is
identified as an applicable vocabulary standard for SDOH assessments.13 By identifying
validated screening instruments that use available health IT coding terminology as acceptable
sources for the questions required by 42 CFR 422.101(f)(1)(i), CMS aims to encourage
greater standardization of social needs screening data and facilitate interoperable exchange of
such data.
The screening instruments in Table 7 meet the above criteria at the time CMS updated this
11 Furthermore, Table 7 in section 90.1.2 also incorporates screening instruments included in the specification for the
National Committee for Quality Assurance’s (NCQA) Social Need Screening and Intervention” measure in HEDIS
Volume 2: Technical Specifications for Health Plans, 705-717.
12 The Gravity Project convenes subject matter experts to evaluate and vote on the validity and appropriateness of
available assessment instruments to screen for various domains. For the purposes of this requirement, we have
combined Gravity’s three housing-related domains (housing instability, homelessness, and inadequate housing) into
one topic (“housing stability”).
13 See the final USCDI v2 document: https://www.healthit.gov/isa/sites/isa/files/2021-07/USCDI-Version-2-July-
2021-Final.pdf.

section. However, the social needs screening field is evolving quickly, and screening
instruments that currently do not meet the criteria outlined above may meet those criteria in
the future (e.g., new LOINC ® coding terminology may be created for a screening instrument
for which it was previously not available).
Therefore, in addition to the list of screening instruments specified in Table 7, SNPs can use
questions on the three required domains from screening instruments included in the Gravity
Project’s lists linked below of screening instruments by domain, which can be found in the
National Library of Medicine Value Set Authority Center (VSAC).14 The Gravity Project
compiles these lists to include screening instruments with available LOINC ® coding that its
members have identified as appropriate to screen for each domain, and will update them if
and when new screening instruments meet these standards. CMS has determined the
assessment instruments on these lists meet the criteria described above and are permissible
for a SNP to draw from for the required questions on housing stability, food security, and
access to transportation. Please note that VSAC users must create an account and be logged
in to access the links below.
• 	Food Security: VSAC Food Insecurity Screening Assessments
• 	Housing Stability: VSAC Homelessness Screening Assessments; VSAC Housing
Instability Screening Assessments; VSAC Inadequate Housing Screening
Assessments
• 	Access to Transportation: VSAC Transportation Insecurity Screening Assessments
Currently, the screening instruments included in the VSAC are also listed in Table 7. In the
future, the VSAC lists may expand to include additional instruments that meet the above
criteria. CMS will review the VSAC resources linked above to ensure that questions on the
three domains are acceptable under 42 CFR 422.101(f)(1)(i). SNPs may use questions from
assessment instruments included in this value set as of July 2023.
CMS Post-Acute Care (PAC) Assessment Instruments
Table 7 includes several CMS PAC assessment instruments that include a question on access
to transportation that is almost identical to a transportation question included in the Protocol
for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
assessment instrument, but has a small modification to the response choices. These
assessment instruments have been thoroughly tested, have associated LOINC coding to
collect standardized data, and are already in use by providers. SNPs may use them to meet
the requirement for including one or more questions on access to transportation in their
HRAs. More details about the CMS PAC assessment instruments can be found in the CMS
Data Element Library.
90.2.1 - Additional Considerations
(Rev. 129; Issued: 08-11-23; Effective: 01-01-24; Implementation: 01-01-24)
14 VSAC is a repository for clinical coding vocabularies that define clinical concepts to support interoperable health
information exchange, and is provided by the National Library of Medicine in collaboration with the Office of the
National Coordinator for Health Information Technology and CMS.

Equity & Accessibility
CMS encourages SNPs to consider equity issues in selecting screening instruments and
questions, including the questions required by 42 CFR 422.101(f)(1)(i). In particular, SNPs
should consider whether the instrument has been validated for racial and ethnic minority
populations that the SNP serves and whether the instrument can be translated into languages
that are commonly spoken by the SNP’s enrollees. In addition, SNPs should consider
whether they can provide the questions in accessible formats using auxiliary aids and
services as required by section 1557 of the Affordable Care Act and implementing
regulations at 45 CFR Part 92. These regulations require plans to provide appropriate
auxiliary aids and services, including interpreters and information in alternate formats, to
individuals with impaired sensory, manual, or speaking skills where necessary to afford such
persons an equal opportunity to benefit from the service.
Questions from Multiple Assessment Instruments
SNPs are not required to adopt any of these screening instruments wholesale. SNPs must
adopt one or more questions related to each of the required three domains specified in 42
CFR 422.101(f)(1)(i) in their HRAs. SNPs do not need to select questions on the three
required domains from just one assessment instrument. For example, a SNP may choose one
question from a particular screening instrument on food security, and a question on housing
stability from another screening instrument. This also applies to state-required assessment
instruments. For example, if a SNP uses a state-required assessment that includes questions
about housing stability and food security, but does not include any questions about access to
transportation, the SNP must still include a question on access to transportation in its HRA
and therefore must select one or more questions on access to transportation from an
assessment instrument specified by CMS in this guidance.
Assessment Instruments with Multiple Questions on the Same Domain
There may be instances where an instrument includes multiple questions in the required
domains. For example, an assessment instrument may include a question about housing
instability as well as a question about quality of housing—both of which pertain to the
required housing stability domain. If an instrument includes more than one question for a
domain and a SNP elects to screen for that domain using that instrument, CMS strongly
encourages the SNP adopt all of the questions for that domain in their health risk assessment.
Validated assessment instruments with multiple questions on the same domain have been
validated as a panel of questions and may be less accurate at screening an enrollee for a
particular need when only one question from that panel is used. However, a SNP can comply
with 42 CFR 422.101(f)(1)(i) even if the plan does not use the full suite of questions on a
domain from a particular screening instrument.
90.3 – List of Social Needs Screening Instruments
(Rev. 129; Issued: 08-11-23; Effective: 01-01-24; Implementation: 01-01-24)
Table 7: Social Needs Screening Instruments (Version 1.0)

Note: In selecting a question in one of the required domains from the screening instruments specified
here, SNPs should use the most recent version of the screening instrument(s).
SNP Social Needs Screening Instruments
Housing
Stability
Food
Security
Access to
Transportation
Accountable Health Communities (AHC)
Health-Related Social Needs (HRSN)
Screening Tool
X 	X 	X
American Academy of Family Physicians
(AAFP) Social Needs Screening Tool
X 	X 	X
Health Leads Screening Panel® 	X 	X 	X
Protocol for Responding to and Assessing
Patients’ Assets, Risks, and Experiences
[PRAPARE]®
X 	X 	X
We Care Survey 	X 	X
WellRx Questionnaire 	X 	X 	X
Hunger Vital Sign™ (HVS) 	X
U.S. Household Food Security (SNPs can
select questions from the 18-, 10-, or 6-item
surveys)
X
Comprehensive Universal Behavior Screen
(CUBS)
X
PROMIS® 	X
CMS Post-Acute Care (PAC) Assessment
Instruments:
• 	Inpatient Rehabilitation Facilities
Patient Assessment Instrument
(IRF-PAI)
• 	Long-Term Care Hospitals
Continuity Assessment Record and
Evaluation Data Set (LCDS)
• 	Home Health Agencies Outcome
and Assessment Information Set
(OASIS)
X

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date 	CR#
R131MCM 11/22/2024 	Updates to sections 20.2.2, 20.2.9, 20.2.10, 40.1,
50.2, 50.3, and 80 of Chapter 16-B of the Medicare
Managed Care Manual.
11/22/2024 	N/A
R130MCM 01/12/2024 	Update to Section 20.2.1 and 20.2.5-20.2.7 on the
definitions of dual eligible special needs plans (D-
SNPs) and additional requirements for certain D-
SNPs
01/12/2024 	N/A
R129MCM 08/11/2023 	Amending sections 20.2.2 and 20.2.3 to update
information on the state Medicaid agency
contracts and addition of new Section 90, 90.1, 90.2,
90.2.1 and 90.3 on SNP Health Risk
Assessment Screening Requirement.
08/11/2023 	N/A
R128MCM 06/30/2023 	Update to Section 20.2.4.2 on D-SNPS With or
Without Medicare Zero-Dollar Cost Sharing
06/30/2023 	N/A
R127MCM 06/02/2023 	Update to Section 50 on Renewal Options and
Crosswalks
01/01/2023 	N/A
02/16/2023 	Update to Section 20.2.4.1 on Special Cost
Sharing Requirements for D-SNPs
03/31/2023 	N/A