CMS SNPCC Compliance Guide: Protecting Vulnerable Medicare Members Through Care Coordination
Sevana Health Team
December 17, 2025
Medicare Advantage Special Needs Plans serve some of the most vulnerable populations in healthcare. The CMS SNPCC audit protocol ensures these members receive the coordinated care they deserve. Organizations that fail to comply face serious consequences.
The Human Side of Health Risk Assessments
Maria is 72 years old. She has diabetes, congestive heart failure, and early-stage dementia. She lives alone and sometimes forgets to take her medications. Last year, she was hospitalized three times for conditions that could have been prevented.
When Maria enrolled in a Dual-Eligible Special Needs Plan (D-SNP), everything changed. Within 90 days, a care coordinator contacted her to complete a comprehensive Health Risk Assessment. That single conversation uncovered critical gaps: Maria wasn't just forgetting her medications. She couldn't afford them. She hadn't seen her cardiologist in over a year. And she had no one to help her get to appointments.
The HRA triggered an Individualized Care Plan tailored specifically to Maria. Her interdisciplinary care team connected her with a patient assistance program for medications, arranged transportation to specialist visits, and set up weekly check-in calls. Over the next year, Maria's hospitalizations dropped significantly.
This is what CMS SNPCC compliance is really about. Not just checking boxes on an audit, but ensuring that vulnerable Medicare beneficiaries like Maria actually receive the coordinated care that Special Needs Plans promise.
Understanding the SNPCC Protocol
The Special Needs Plans Care Coordination (SNPCC) audit protocol is how CMS verifies that Medicare Advantage organizations are delivering on their Model of Care commitments. It applies to all three types of SNPs:
D-SNP
Dual Eligible: Beneficiaries enrolled in both Medicare and Medicaid
C-SNP
Chronic Condition: Beneficiaries with specific severe or disabling chronic conditions
I-SNP
Institutional: Beneficiaries in institutional settings or requiring institutional-level care
These populations face complex medical, social, and behavioral health challenges. The SNPCC protocol ensures they receive the comprehensive, coordinated care they need.
How Health Risk Assessments Transform Member Care
The Health Risk Assessment isn't just a compliance requirement. It's the foundation of effective care coordination. A comprehensive HRA evaluates:
Medical Needs
- •Chronic condition management
- •Medication review and reconciliation
- •Specialist care requirements
- •Preventive care gaps
Functional Status
- •Activities of daily living (ADLs)
- •Mobility limitations
- •Fall risk assessment
- •Need for assistive devices
Cognitive & Psychosocial
- •Memory and cognitive function
- •Depression and anxiety screening
- •Social isolation risks
- •Caregiver support availability
Social Determinants
- •Food security
- •Housing stability
- •Transportation access
- •Financial barriers to care
The 90-day window for Initial HRAs and 365-day requirement for Annual HRAs exist because timely intervention saves lives.
The 13 CMS Audit Standards
CMS evaluates SNP care coordination through 13 specific standards. Here's what each one measures and why it matters for members:
HRA Timeliness (Standards 1.1-1.2)
| Standard | Requirement | Member Impact |
|---|---|---|
| 1.1 | Initial HRA within 90 days of enrollment | Early identification of urgent needs; prevents gaps during transition |
| 1.2 | Annual HRA within 365 days of previous HRA | Catches changes in health status; ensures care plan stays current |
CMS Testing Method: Universe-level analysis of all enrollees, not just a sample. Every untimely HRA requires an impact analysis showing outreach attempts.
Care Plan Quality (Standards 1.3-1.7)
| Standard | Requirement | Member Impact |
|---|---|---|
| 1.3 | HRA addresses comprehensive needs | Whole-person care; no needs fall through the cracks |
| 1.4 | ICP with measurable outcomes and timeframes | Clear goals; accountability for results |
| 1.5 | ICP reviewed and modified as needs change | Care adapts to changing conditions |
| 1.6 | ICP implementation verified through claims/notes | Plans translate into actual services |
| 1.7 | Enrollee/caregiver involved in ICP development | Person-centered care; member voice heard |
Care Team Effectiveness (Standards 1.8-1.10)
| Standard | Requirement | Member Impact |
|---|---|---|
| 1.8 | Coordinated communication among team | No conflicting instructions; seamless care |
| 1.9 | ICT includes appropriate disciplines and PCP | Right specialists on the team |
| 1.10 | Care transition protocols maintain continuity | Safe hospital discharges; no gaps |
Staff Qualifications & Training (Standards 1.11-1.13)
| Standard | Requirement | Member Impact |
|---|---|---|
| 1.11 | Staff meet professional requirements per MOC | Qualified professionals making care decisions |
| 1.12 | ICT members receive MOC training | Team understands SNP-specific needs |
| 1.13 | Network providers receive MOC training | Consistent care approach across all providers |
The Audit Process: Critical Timelines
Universe Submission Phase
Organizations must submit a complete SNPE (SNP Enrollees) Universe within 15 business days containing all current enrollees with 14 required data fields including:
- •Enrollee identifiers (name, MBI)
- •Contract and PBP information
- •Plan type (D-SNP, C-SNP, I-SNP)
- •HRA completion dates
- •Risk stratification level
- •ICP date and ICT status
Critical: The MOC and SNPCC Supplemental Questionnaire are due within just 5 business days.
Universe Integrity Testing
CMS selects 10 cases for a pre-fieldwork webinar to verify data accuracy. Sample selections are provided approximately one hour before the scheduled call, leaving no time to prepare if your data isn't already clean.
Field Work Phase
CMS selects 30 enrollees for detailed review. For each case, auditors examine HRAs, ICPs, case management documentation, claims, ICT credentials, and MOC training evidence.
Response Timeline: Organizations have just 2 business days to provide supporting documentation upon request.
Impact Analysis Requirements
When noncompliance is identified, organizations must submit detailed impact analyses within 10 business days:
- Table 1IA (Care Coordination): 26-week period, 23 data fields tracking HRA completion, ICP creation, ICT involvement, hospitalizations
- Table 2IA (HRA Timeliness): 12-month period documenting all outreach attempts for untimely HRAs
Common Compliance Failures
1. HRA Timeliness Gaps
The Problem: Many organizations struggle with the 90-day IHRA window, especially for hard-to-reach enrollees.
Member Impact: Delayed assessments mean delayed identification of urgent needs. A member with undiagnosed depression may spiral for months before anyone intervenes.
Best Practices: Initiate outreach within 7 days of enrollment. Use multiple contact methods. Document every attempt with dates and outcomes.
2. Care Plan Documentation Gaps
The Problem: ICPs exist but lack measurable outcomes, specific timeframes, or evidence of member involvement.
Member Impact: Vague goals like "improve diabetes management" don't translate into actionable care.
Best Practices: Include SMART goals. Document member preferences. Show clear linkage between HRA-identified needs and ICP interventions.
3. Transition of Care Failures
The Problem: Members are discharged from hospitals without care team notification or ICP updates.
Member Impact: This is where members fall through the cracks and often end up readmitted within 30 days.
Best Practices: Implement real-time ADT notifications. Update ICPs post-hospitalization. Conduct medication reconciliation. Schedule follow-up appointments before discharge.
Building a Proactive Compliance Program
The organizations that consistently pass SNPCC audits don't prepare for audits. They maintain continuous compliance. This requires:
Automated Timeliness Tracking
- •Real-time dashboards showing IHRA completion rates against 90-day window
- •AHRA due date tracking with escalation alerts
- •Outreach attempt logging with date/method documentation
Care Plan Quality Monitoring
- •Validation that ICPs exist for all enrollees with completed HRAs
- •Completeness checks for required ICP elements
- •Automated flags for ICPs not updated after health status changes
Universe Readiness
- •Pre-validated data fields matching CMS specifications exactly
- •Cross-field consistency checks (IHRA within 90 days of enrollment)
- •Instant universe generation capability
Analytics That Drive Improvement
- •Risk stratification alignment analysis
- •Provider performance tracking
- •Trend analysis over rolling periods
How Universe Scrubber Validates Your SNPCC Data
At Sevana Health, we understand that SNPCC compliance isn't just about passing audits. It's about ensuring vulnerable members receive the care coordination they deserve. Our CMS Universe Scrubber validates your SNPE universe files before submission:
Field-Level Validation
- ✓MBI format verification (11-character structure)
- ✓Date format standardization (CCYY/MM/DD)
- ✓Required field completeness checks
- ✓Plan type verification against contract/PBP combinations
Business Rule Validation
- ✓IHRA date within 90 days of enrollment
- ✓AHRA date within 365 days of previous HRA
- ✓ICP date alignment with HRA completion
- ✓ICT creation for all applicable enrollees
Data Quality Detection
- ✓Identifies leading/trailing spaces that cause mismatches
- ✓Detects hidden characters (tabs, line feeds)
- ✓Flags Excel formatting issues that corrupt date fields
Audit-Ready Reporting
- ✓Row-by-row error identification
- ✓Compliance scorecards by standard
- ✓PDF and Excel exports for documentation
IDS (Invalid Data Submission) findings can invalidate your entire universe.
A single missing field, incorrect date format, or hidden character can result in file rejection. With engagement letters providing limited time for resubmission, pre-validation is essential.
The Bottom Line: Compliance Protects Members
Every data field in the SNPCC protocol exists for a reason. The 90-day IHRA window ensures new enrollees get assessed quickly. The annual reassessment requirement catches changes in health status. The ICP requirements ensure that identified needs translate into actual care.
When organizations treat SNPCC compliance as a checkbox exercise, members suffer. When organizations build robust systems for continuous care coordination monitoring, members like Maria thrive.
Validate Your SNPCC Universe Files Before Submission
Universe Scrubber catches IDS-triggering errors, validates all 14 SNPE fields against CMS specifications, and provides compliance analytics to prepare for audit discussions.