6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans

AHIP Medicare Certification Exam

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1 Introduction

1.1 About the AHIP Medicare Certification Exam 1.2 How to Use This Study Guide

2 Chapter 2: Medicare Program Fundamentals

2.1 What Medicare Is: Program Structure & How Parts A–D Fit Together 2.2 Medicare Part A — Hospital Insurance 2.3 Medicare Part B — Medical Insurance 2.4 Medicare Eligibility Rules (Age 65, Disability, ESRD, ALS)

3 Chapter 3: Medicare Enrollment Periods

3.1 Initial Enrollment Period (IEP) 3.2 Annual Enrollment Period (AEP): October 15 – December 7 3.3 Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31 3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events 3.5 Late Enrollment Penalties (Part A, Part B, Part D)

4 Chapter 4: Medigap & Coordination of Coverage

4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights 4.2 Dual Eligibility & Medicare Savings Programs 4.3 How Original Medicare, MA, Part D & Medigap Interact

5 Chapter 5: Medicare Advantage Plan Types

5.1 Medicare Advantage (Part C) Overview: How MA Differs from Original Medicare 5.2 HMO & HMO-POS Plans 5.3 PPO Plans 5.4 PFFS Plans (Private Fee-for-Service) 5.5 MSA Plans (Medicare Medical Savings Accounts) 5.6 Cost Plans & Employer Group Waiver Plans (EGWPs)

6 Chapter 6: Special Needs Plans & MA Plan Design

6.1 Special Needs Plans (SNPs) Overview 6.2 D-SNP — Dual-Eligible Special Needs Plans 6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans 6.4 MA Benefits, MOOP & Supplemental Benefits 6.5 MA Star Ratings & Plan Quality

7 Chapter 7: Part D Structure & the 2026 Redesign

7.1 Part D Overview & Eligibility 7.2 Formularies & Drug Tiers 7.3 The 2026 Part D Benefit Redesign ($2,100 OOP Cap, $615 Max Deductible, Catastrophic Phase) 7.4 Medicare Prescription Payment Plan (Drug-Cost Smoothing)

8 Chapter 8: Part D Costs, Assistance & Appeals

8.1 Low-Income Subsidy (LIS) / Extra Help 8.2 Part D Late Enrollment Penalty & Creditable Coverage 8.3 Coverage Determinations, Exceptions & Appeals

9 Chapter 9: CMS Marketing Rules & Scope of Appointment

9.1 CMS Medicare Communications & Marketing Guidelines (MCMG) Overview 9.2 Scope of Appointment (SOA): the 48-Hour Rule & Exceptions 9.3 Permitted vs. Prohibited Marketing & Sales Activities 9.4 Marketing Events vs. Educational Events

10 Chapter 10: Enrollment & Disclosure Requirements

10.1 The Pre-Enrollment Checklist (PEC) 10.2 Enrollment Procedures & Application Requirements 10.3 Call Recording & Third-Party Marketing Organization (TPMO) Disclaimers 10.4 Agent & Broker Compensation Rules

11 Chapter 11: Marketing Conduct & Oversight

11.1 Cross-Selling Restrictions & Nominal Gift Value Rules 11.2 Marketing to Vulnerable Populations & Non-Discrimination in Sales 11.3 Website, Social Media & Advertising Compliance 11.4 Complaint Tracking Module (CTM) & Agent Oversight

12 Chapter 12: Understanding Fraud, Waste & Abuse

12.1 Defining Fraud, Waste & Abuse (and the Difference Between Them) 12.2 The False Claims Act 12.3 The Anti-Kickback Statute

13 Chapter 13: Compliance Laws & Screening

13.1 The Stark Law (Physician Self-Referral) 13.2 HIPAA Privacy & Security Basics 13.3 The OIG Exclusion List & Sanctioned-Provider Screening

14 Chapter 14: Reporting, Compliance Programs & Consequences

14.1 Detecting & Reporting FWA 14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training 14.3 Consequences & Corrective Action Plans

6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans

Key Takeaways Explain This Topic AI

CMS recognizes exactly 15 severe or disabling chronic conditions that qualify a beneficiary for a C-SNP, plus 5 CMS-approved multi-condition groupings (such as diabetes + chronic heart failure).

C-SNP eligibility must be verified by a treating provider's attestation; if verification is not received by the end of the enrollee's second month of enrollment, the plan must disenroll the member.

An I-SNP enrolls beneficiaries who need, or are expected to need, an institutional level of care for 90 days or longer — determined by a state or independent entity, never by the plan itself.

A community-based I-SNP ('institutional-equivalent' I-SNP) can enroll someone living at home who requires a nursing-facility level of care, using a state-approved assessment tool.

If a C-SNP or I-SNP enrollee no longer meets the plan's specific eligibility criteria, CMS generally allows the plan to keep the member enrolled through the end of that calendar year rather than disenrolling immediately.

Last updated: July 2026

Why This Pairing Matters

C-SNPs and I-SNPs are grouped together here because they share a structural feature that sets them apart from D-SNPs: both require the plan to verify a specific clinical or care-level fact about the enrollee — a diagnosed chronic condition or an institutional level-of-care need — rather than a Medicaid eligibility status that a state database can confirm. That verification burden creates real, testable compliance rules: what happens if the condition can't be confirmed in time, and what happens if the enrollee's status changes after enrollment.

Quick Answer: A C-SNP restricts enrollment to beneficiaries with one of 15 CMS-approved chronic conditions (verified by a treating provider), while an I-SNP restricts enrollment to beneficiaries who need an institutional level of care for 90+ days (determined by a state or independent entity, not the plan).

C-SNP: The 15 CMS-Approved Chronic Conditions

A panel of clinical experts from CMS, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC) identified the following 15 conditions as sufficiently severe, disabling, or life-threatening — and requiring a specialized care delivery system — to qualify for a C-SNP:

Autoimmune disorders (including rheumatoid arthritis)
Cancer
Cardiovascular disorders
Chronic alcohol and other drug dependence
Chronic heart failure
Chronic lung disorders (asthma, chronic bronchitis, emphysema)
Dementia
Diabetes mellitus
End-stage liver disease
End-stage renal disease requiring dialysis
Hematologic disorders (hemophilia, myelodysplasia, sickle-cell disease)
HIV/AIDS
Mental health conditions (bipolar disorder, major depression, schizophrenia)
Neurological disorders (epilepsy, ALS, multiple sclerosis, Parkinson's)
Stroke

CMS also approves 5 multi-condition C-SNPs that focus on commonly co-occurring combinations rather than a single condition: (1) diabetes + chronic heart failure, (2) chronic heart failure + cardiovascular disorders, (3) diabetes + cardiovascular disorders, (4) diabetes + chronic heart failure + cardiovascular disorders, and (5) stroke + cardiovascular disorders. A C-SNP's marketing materials will always name the specific condition(s) it targets — an agent cannot enroll a beneficiary in a diabetes C-SNP for a client whose only diagnosed condition is COPD, even though both are on the list.

C-SNP Verification: The Two-Month Deadline

Because a C-SNP can't independently confirm a chronic condition the way a D-SNP can confirm dual-eligible status through a state database, CMS requires provider verification — an attestation signed by a treating provider confirming the diagnosis. The applicant's own attestation may be used to enroll initially, but:

If the plan does not obtain provider verification by the end of the enrollee's second month of enrollment , it must disenroll the member effective the end of that second month.

The plan must notify the enrollee of the pending deadline early in the process and send a disenrollment notice within 7 calendar days if verification isn't received in time.

This two-month window is a frequently tested detail — some older or informal materials describe a "30-day" or "60-day" rule, but the enforceable CMS standard is verification by the end of the second month of enrollment.

This verification requirement also creates an important agent-conduct boundary: an agent's role is to ask about existing, already-diagnosed conditions and route the client to a C-SNP that matches them — never to suggest, coach, or encourage a client toward claiming a condition in order to qualify. Because a licensed provider must independently attest to the diagnosis, an agent cannot manufacture eligibility, and doing so would be both an enrollment fraud issue and a marketing-conduct violation (the kind of behavior Chapter 11's marketing-oversight rules are built to catch).

I-SNP: Institutional Level of Care

An I-SNP enrolls beneficiaries who need — or are expected to need — the level of services provided in a long-term care facility (a nursing facility, an intermediate care facility for individuals with intellectual disabilities, an inpatient psychiatric facility, or similar) for 90 days or longer . Critically, the determination of institutional level of care is made by a state-designated entity or an independent assessment tool — never by the I-SNP itself, since that would create an obvious conflict of interest. CMS also permits institutional-equivalent I-SNPs , which enroll beneficiaries who live in the community (not in a facility) but who require a nursing-facility level of care as determined by the same kind of independent, state-approved assessment.

What Happens If Eligibility Is Lost

Both C-SNPs and I-SNPs face the same practical problem: a chronic condition can improve, or an institutional stay can end. CMS's general rule allows the SNP to keep a member enrolled through the end of the current calendar year if they lose their specific SNP-qualifying status but still meet general MA eligibility rules — the plan is not required to disenroll them mid-year. At the next plan year, however, the enrollee must be re-verified against the SNP's criteria, or must move to a different plan.

Exam Scenario

Mr. Davis enrolls in a C-SNP for chronic heart failure. Eight months later, his cardiologist documents significant improvement and he technically no longer meets the C-SNP's severity threshold. Under CMS's general SNP eligibility-loss rule, the plan may keep Mr. Davis enrolled through the end of the current plan year rather than disenrolling him immediately — but at the next annual enrollment, he would need to either re-qualify for the C-SNP or move to a different Medicare Advantage or Original Medicare option.