C-SNP Frequently Asked Questions

Chronic Special Needs Plans

Chronic Care Special Needs Plan (C-SNP) is a type of Medicare Advantage Prescription Drug Plan (MAPD) designed to provide specialized care and tailored benefits for individuals with severe or disabling chronic conditions/diagnosis.

The beneficiary must have at least one of the three chronic conditions as validated by a physician.

The beneficiary must:

  • Have at least one of the three chronic conditions as validated by a physician
    • Diabetes
    • Chronic Heart Failure
    • Cardiovascular Disorders
  • Be Medicare eligible
  • Reside in a service area where the C-SNP is offered

Wellcare By Health Net has C-SNP plan in Kern, Los Angeles, Orange, Riverside, San Bernardino, San Francisco, and San Diego. 

A C-SNP is designed specifically for people living with certain chronic health conditions—such as diabetes, chronic heart failure, or cardiovascular disease. Unlike regular Medicare Advantage or Dual Eligible Special Needs Plans (D-SNPs), C-SNPs offer personalized care management and specialized provider networks tailored to the beneficiary’s condition. This means the care team understands the beneficiary’s health needs more deeply and can coordinate treatments, medications, and follow-up care more effectively.

If a C-SNP member happens to be a dual eligible, the care team will also support coordination with the Medi-Cal covered benefits.

Wellcare Specialty Simple Focus (HMO C-SNP) – H0562- 138 – San Francisco County

Enrollment Process for C-SNPs

Once you confirm the beneficiary’s Medicare eligibility and qualifying chronic condition, complete and submit a “Pre-Enrollment Qualification Assessment Tool” along with an enrollment form.

On the “Pre-Enrollment Qualification Assessment Tool”, at least one or more of the questions in the “Chronic condition questions” section must be answered with a “Yes” or “Not Sure” in order for the beneficiary to enroll into the C-SNP. If enrolling online, the “Pre-Enrollment Qualification Assessment Tool” is available on the Online Enrollment Tool platform.

And it is important to include the provider who has prescribed the medication or has diagnosed the beneficiary so that a verification process can take place by the health plan. Brokers may also provide a Verification Form to the beneficiary so that he/she can get it completed by their provider.

Once the application and the “Pre-Enrollment Qualification Assessment Tool” is received by the health plan Enrollment team, an outbound call to the listed provider(s) in the enrollment form is made to get attestation of the beneficiary’s chronic condition.

During the outreach, providers can take one of 2 actions:

  • Providers provide a verbal attestation of the beneficiary’s conditions so that the C-SNP enrollment application can move forward, or
  • Providers can request a form to be faxed to complete and return within 3 business days as a form of attestation

For new C-SNP eligible beneficiaries, the health plan’s eligibility representative will outreach to the beneficiary and advise to set up an appointment with the PCP/provider so that the beneficiary’s chronic condition could be verified.

If the attestation is received from the provider/PCP and the applicant does not qualify to enroll in the C-SNP, the health plan will outreach to the applicant to advise that:

  • The disenrollment procedure will begin, or
  • They would need to get an attestation through alternate provider/PCP and restart the attestation process

If a beneficiary is unable to verify their eligibility within the required 60 day verification period, or if they are determined not to meet the C-SNP eligibility criteria after provider attestation, the beneficiary will be disenrolled from the C-SNP plan.

  • If eligibility is not verified within 60 days, the beneficiary will be disenrolled from the C-SNP plan.
  •  If attestation is completed but the beneficiary is found not eligible, the beneficiary will be disenrolled or given an option to obtain attestation from another provider/PCP and restart the verification process

Beneficiaries who are disenrolled due to failure to verify C-SNP eligibility will qualify for a Special Election Period (SEP), where the beneficiary will be allowed to enroll in another Medicare Advantage or Prescription Drug Plan without waiting for a standard enrollment period.

No. A beneficiary can be enrolled into a C-SNP plan, and coverage can begin, while their eligibility verification is still in progress. After the plan effective date, the beneficiary has up to 60 days to complete the eligibility verification. This typically includes getting a provider attestation completed by a physician. If eligibility is not verified within the required timeframe, the beneficiary may be disenrolled from the C-SNP plan.

Here is what the general enrollment timeline looks like for a C-SNP beneficiary:

Application Received

Pre-Qual form received

Beneficiary is enrolled in C-SNP

Plan Effective Month 1

Enrollment Team attempts to receive written or verbal confirmation from provider during the 1st month of enrollment

Plan Effective Month 2

If attestation is NOT received, by 7th day of 2nd month, notice sent to the beneficiary & disenrollment will be processed for last day of month 2; SEP Starts

SEP Extends to Months 3 and 4

Last day of 2nd month following prior enrolled period

Beneficiary can join another Medicare Advantage Plan which they qualify for

 

C-SNP and Duals

Yes. 

No, they do not have to be. They just need to meet the requirement to join a C-SNP plan.

Provider Network

Wellcare by Health Net C-SNP network.

Yes. Members new to a C-SNP plan are eligible for continuity of care for 12 months from enrollment if certain circumstances are met. Please see the Provider Operations Manual.

Advise the member to utilize the Find a Provider tool to look up participating providers within the C-SNP network, which can save the member of the out of network provider cost. You can also advise the member to contact the health plan by using the Member Services phone number on the back of their ID card for a provider search or PCP assignment.

Producer Support for Member Inquiries

Inform the member to contact the health plan by using the Member Services phone number on the back of their ID card for any Medicare and Medi-Cal benefits related questions.

Remind the member that any referral for services which require an approval will generate a written response to them. If denied, the member will be provided with their appeal rights.

Member can contact Member Services phone number on the back of their ID card for support.

Common Benefits Questions

Submit the prescription request to the pharmacy. It should go through the normal prior authorization process for exception.

Accu-Chek Guide and True Metrix preferred with quantity limit / Continuous blood glucose monitors Dexcom & Freestyle Libre with PA

You can help the member receive the benefit by getting a referral from case management in one of 2 ways. Advise the member to:

Care Coordination

Care coordination is the organization of a member’s care across multiple health care providers to ensure the member receives safe, effective and appropriate care.

A care coordinator collaborates with the member, the Health Plan, and the member's healthcare providers to ensure the member receives the necessary care. They work with the member to create a care plan and identify the team members responsible for delivering, coordinating, and overseeing the member's healthcare.

The member can call the Care Management toll-free line at 833-340-0083 to get connected with the Care Management team.

Or the member can call Member Services who will help the member contact a care coordinator or with help changing a care coordinator.

The member can call the Care Management toll-free line at 833-340-0083 to get connected with the Care Management team.

Or the member can call Member Services who will help the member contact a care coordinator or with help changing a care coordinator.

Yes, Members may self-refer by calling the Care Management toll-free line at 833-340-0083.

Medi-Cal Benefits that C-SNP Members Who are Dual Eligible May Have Access to When Medically Necessary

The Medi-Cal benefit includes: Long Term Care (LTC), Community Based Adult Services (CBAS), Community Supports, Durable Medical Equipment (DME), and Medi-Cal covered transportation.

The Community Resource/Supports may include, but is not limited to, the following services:

  1. Housing Transition Navigation Services (homeless, or about to become)
  2. Housing Deposits
  3. Housing Tenancy and Sustaining Services
  4. Short-Term Post Hospitalization Housing
  5. Recuperative Care (medical respite)
  6. Respite Services
  7. Day Rehabilitation
  8. Nursing Facility Transition/Diversion to Assisted Living Facilities
  9. Community Transition Services/Nursing Facility Transitions to a Home
  10. Personal Care and Homemaker Services
  11. Environmental Accessibility Adaptations (home modifications)
  12. Meals/Medically Tailored Meals
  13. Sobering Centers
  14. Asthma Remediation

Member can access the Medi-Cal covered benefits in any of these ways below:

  • Members can contact the Member Services number in the back of the card to get more information and get access to their covered Medi-Cal benefits.
    • For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
    • For D-SNP members in all the other counties, call 800-431-9007
  • Members can use the findhelp platform to submit referrals to request Community Support benefits.

 

General information

The member can contact their broker, Member Services 800-431-9007 or 800-MEDICARE (800-633-4227).

Members will be notified of the new plan year changes by mail via the Annual Notification of Changes (ANOC) in September and/or the standard non-renewal notice sent in October.

The Annual Notification of Change will outline specific changes in benefits between the current year and the next plan year.

Advise your patients to ensure their Medicare plan has their current address and phone number so they receive the information.

Producers will receive communications throughout the year as needed. Producers are encouraged to access the C-SNP Resources for Producers page online for the most current resources and updates, as the page is updated regularly. They are also strongly encouraged to stay in contact with the local Medicare Broker Sales Team (Regional Agency Managers) to receive updates on major industry changes, training events, and additional sales opportunities with Wellcare.