6.1 Special Needs Plans (SNPs) Overview

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

6.1 Special Needs Plans (SNPs) Overview

Key Takeaways Explain This Topic AI

There are exactly three SNP types authorized by Congress: D-SNP (dual-eligible), C-SNP (chronic condition), and I-SNP (institutional) — no fourth category exists.

Every SNP, regardless of type, must include Part D prescription drug coverage bundled into the plan; there is no such thing as an MA-only SNP.

Every SNP must operate under a Model of Care (MOC) approved by the National Committee for Quality Assurance (NCQA), renewed on a 1-, 2-, or 3-year cycle based on the MOC's score.

CMS requires a 100% completion goal for the Health Risk Assessment (HRA), Individualized Care Plan (ICP), and Interdisciplinary Care Team (ICT) touchpoints for every enrollee.

Enrolling a beneficiary in a SNP who does not belong to that SNP's target population is a compliance violation, not a clerical error — agents must verify eligibility before submitting an application.

Last updated: July 2026

Why SNPs Matter on the AHIP Exam

Special Needs Plans (SNPs) are a form of Medicare Advantage plan, but they are legally restricted to enrollees who fit a specific "special needs individual" category defined by Congress. Because SNP enrollment is restricted by statute — not just by plan design — misenrolling a beneficiary into a SNP they don't qualify for is treated by CMS as a serious compliance failure, not a paperwork mistake. AHIP's Module 2 tests SNPs heavily because agents who sell Medicare Advantage are very likely to encounter SNP-eligible clients (roughly half of all Medicare Advantage enrollees now sit in a D-SNP, C-SNP, or I-SNP), and because the rules governing who can enroll, how the plan must manage their care, and what happens if they lose eligibility are all independently testable.

Quick Answer: A Special Needs Plan (SNP) is a Medicare Advantage coordinated care plan that restricts enrollment to one of three CMS-defined populations: dual-eligible (D-SNP), chronic-condition (C-SNP), or institutionalized (I-SNP) beneficiaries. All SNPs must include Part D drug coverage and operate under an NCQA-approved Model of Care.

The Statutory Basis and the Three SNP Types

Congress first authorized SNPs on a temporary, demonstration basis under the Medicare Modernization Act of 2003. The Bipartisan Budget Act (BBA) of 2018 made D-SNPs a permanent part of the Medicare Advantage program and added new Medicare-Medicaid integration requirements — a detail worth remembering because older prep materials sometimes still describe D-SNPs as temporary or subject to periodic reauthorization votes; that is no longer accurate.

The law identifies three categories of "special needs individuals," and each maps directly to one SNP type:

SNP Type Statutory Population Plain-Language Definition

D-SNP (Dual-Eligible SNP) Individuals entitled to both Medicare and Medicaid Enrollees who qualify for full or partial Medicaid benefits in addition to Medicare

C-SNP (Chronic Condition SNP) Individuals with a severe or disabling chronic condition specified by CMS Enrollees with one (or an approved combination) of 15 CMS-defined chronic conditions

I-SNP (Institutional SNP) Individuals who need an institutional level of care Enrollees residing in, or requiring the level of care of, a long-term care facility for 90+ days

Chapter 6.2 and 6.3 cover each type's eligibility rules and verification process in depth. This section focuses on what all three share.

What Every SNP Must Have: The Model of Care

The single biggest structural difference between a SNP and a standard Medicare Advantage plan is the Model of Care (MOC) — a CMS- and NCQA-reviewed framework describing exactly how the plan will identify each enrollee's needs and manage them over time. Every SNP must submit its MOC to CMS, and NCQA scores it on clinical and non-clinical elements. Based on that score, CMS approves the MOC for a 1-, 2-, or 3-year cycle — a lower score means more frequent resubmission and review.

The MOC is not a marketing document; it drives real operational requirements that CMS expects the plan to execute for 100% of enrollees:

Health Risk Assessment (HRA) — a standardized initial assessment used to identify each enrollee's medical, psychosocial, cognitive, and functional needs, generally completed within 90 days of enrollment and at least annually thereafter.

Individualized Care Plan (ICP) — a care plan built from the HRA results, developed with enrollee (or caregiver) input.

Interdisciplinary Care Team (ICT) — a coordinated team of clinical and non-clinical staff (which can include the enrollee's own treating providers) that reviews and updates the ICP; ICT encounters may occur in person or via real-time interactive telehealth.

CMS's stated goal for HRA, ICP, and ICT completion is 100%, or a "5-star" internal goal — anything less is considered a shortfall, which is why SNP care-coordination staffing and outreach cadence tend to be more intensive than a standard MA plan.

Shared Rules Across All Three SNP Types

Regardless of D-SNP, C-SNP, or I-SNP status, three rules apply universally:

Mandatory Part D. Every SNP must include Part D prescription drug coverage. There is no MA-only SNP, because the special-needs populations these plans serve almost always depend on ongoing medication management.

Restricted enrollment. A SNP may only enroll members of its defined special-needs population. Unlike a standard MA plan open to any Medicare-eligible person in the service area, a SNP must verify — not assume — that an applicant belongs to the target population before enrollment is effective.

Verification is ongoing, not one-time. Eligibility for a SNP can be lost (a chronic condition resolves, dual-eligible status ends, an institutional stay ends), and each SNP type has its own specific re-verification and grace-period rules, covered in the next two sections.

Exam Scenario

An agent meets with a client who has Medicare and full Medicaid benefits, and separately mentions a nephew who has diabetes and lives independently. The agent cannot enroll the nephew in a D-SNP (he isn't dual-eligible) and cannot enroll the aunt in a C-SNP for her diabetes unless she is also independently found eligible under that plan's chronic-condition criteria — SNP type must match the specific qualifying category, and a beneficiary who happens to qualify for one SNP type is not automatically eligible for another.