NOTE: This blog is published in partnership with Lilac Software. See more about Lilac’s offerings at the end of this blog.
MA plans celebrate the sunset of the SNP-CM measure, but little really changes
Many Medicare Advantage (MA) Special Needs Plans (SNPs) breathed a sigh of relief when the SNP Care Management measure was proposed to be sunset as of Star Year 2029/Measure Year 2027. Just one more year of the measure. The measure tracked the timely conduct of initial and annual reassessment Health Risk Assessments (HRAs).
But I say — wait one moment! Even if the Star measure goes, SNP program audits and regulation remain and the HRA is the foundation of how plans ensure quality in their SNP care management program as well as program audit and regulatory compliance.
Back on September 25 and 29 I published detailed blogs on the tremendous SNP enrollment growth as well as trends in SNP audits (links at the end of the blog).
A little SNP history
It was not too long ago that SNPs were on death’s door. CMS viewed them as marketing gimmicks by MA plans to grow enrollment. They did not see a robust clinical infrastructure or commitment at most plans. SNPs lived on only via short reprieves from Congress. Then, CMS did some soul-searching. It knew that SNPs could be the secret to controlling the poor quality and huge costs associated with dual eligible individuals (those both in Medicare and Medicaid). About 80% of all SNP enrollment is in Dual Eligible or D-SNPs.
CMS then set a course to reauthorize SNPs permanently and to create a much more robust clinical and audit infrastructure. It teamed up with national quality group NCQA to ensure Models of Care (MOCs) mean something and the agency enhanced audit protocols. Those protocols are getting much more rigorous over time. The protocols focused on process before -– were HRAs conducted and care plans issued. Now, they are getting far more complex and directive. They are getting deep into clinical aspects and how care is delivered.
As a side note, the other two SNP types, Chronic Care or C-SNPs and Institutional or I-SNPs, have duals in them as well. Indeed, most of the rest of the SNP enrollment is in C-SNPs. MA plans have invested heavily in 2025 and 2026 to grow SNP plans generally and more importantly C-SNPs specifically. In many ways, CMS sees the growth in C-SNPs as the same marketing ploy MA plans did years back for SNPs overall. CMS is now proposing some reforms to treat C-SNPs more like D-SNPs. Based on a Request for Information (RFI) proposed by CMS in the 2027 MA and Part D rule, contracting requirements with state Medicaid agencies and other changes could result.
HRAs remain the foundation
HRAs and their conduct remain the foundation of SNP care management and compliance. And as SNP growth increases, many plans are struggling to keep up with high rates of initial (within 90 days of enrollment) and annual reassessment (no less than every 365 days thereafter) HRAs. While HRAs are now table stakes, a plan can miserably fail an audit without a good HRA percentage completion rate and the required outreach on any missed assessments. But not meeting the timely HRA mandate has a negative cascading effect on overall SNP clinical management and compliance.
- It may mean individualized care plans (ICPs) responding to the needs of each individual are not issued timely.
- It may mean preventive care plans are not issued for those who are truly unreachable.
- It may mean that any interdisciplinary care team (ICT) is not set up for the member or is inadequate to meet the needs of the individual. Indeed, how do you track and improve outcomes for the member without HRAs and a defined clinical plan.
- It may mean that plans fail to document progress against actionable goals, address individual problems, and clinical engagement by the ICT.
- It may mean plans are not conducting interim assessments when risk changes or a care transition occurs.
- It may mean members are not being engaged to self-manage or self-direct certain critical problems.
- It may mean that the care of each SNP enrollee is not being adequately coordinated with the broader clinical enterprise of the plan.
The challenges
Thus, HRAs remain critical overall and their timely conduct on all eligible members remains key. In one of the earlier blogs, I outlined some best practices that can help plans keep up with the SNP enrollment growth and create a firm foundation for clinical and compliance success.
Plans can leverage agentic AI smartly to outreach to members and even conduct parts or all of an HRA. It is a known fact that as many as ten outreach attempts (on different days and times) may be needed to reach many members for the HRA.
The administrative burden is indeed huge as SNP enrollment grows — outreach, HRAs, issuing care plans, creating care teams, documenting goals achieved and care team activities, and more. Agentic AI options can also help support the SNP clinical team to free them up to work at higher levels to deliver the best care possible. Agentic AI can be used to manage the overall program, gather data, solicit member or caregiver input, and gauge goals achieved, satisfaction and changing risk/needs. Agentic AI can also serve as a critical bridge to inform the rest of the clinical enterprise of developments – and vice versa.
With nurse care managers in high demand, scarce, and with unreasonable caseloads, agentic AI and other technology can help ensure success — all directed by clinical staff at the plan. Plans need to study the ever-changing requirements and think innovatively about how technology can help take on the surge in SNP lives and meet clinical and compliance expectations.
Learn more about Lilac Software’s agentic AI solutions and how they help MA SNP plans here: https: https://lilacsoftware.com/agentic-ai-solutions/ .
Previous SNP bog links:
#medicareadvantage #specialneedsplans #snps
— Marc S. Ryan
