Chronic Condition Special Needs Plans:
Verification and the Provider’s Role

Chronic condition special needs plans (C-SNPs) are Medicare Advantage plans for individuals with certain chronic health conditions. Peoples Health plan members enrolled in a C-SNP must have at least one of these qualifying conditions: diabetes (excluding prediabetes), a cardiovascular disorder or chronic heart failure.

Verification Process

• Members complete a Chronic Condition Pre-Assessment Form and a Chronic Condition Release of Information Form during enrollment and name a provider on the release form.
• CMS requires that the chronic condition be verified by a treating provider within 60 days of the member’s plan effective date.
• Verification is not required to approve enrollment; however, it is required for the member to remain in the plan.
• If the condition is not verified, the member is disenrolled from the C-SNP and returned to Original Medica

Provider Actions

• Please respond if a member presents a verification form to you.
• Verification Methods: Call the phone number on the verification form or fax the completed form to the fax number listed.
• Our enrollment team may also outreach to you for verification.

Key Points

• A verifying provider can be a primary care provider or a specialist who has seen the member within 12 months.
• CMS rules do not allow plans to use a diagnosis on a previously submitted claim or any other previous proof of diagnosis to support C-SNP enrollment; plans must proactively reach out to the member’s treating providers to validate the condition.