What verification is required for a C-SNP, and what happens if the provider doesn’t confirm the qualifying condition?
For a C-SNP, the plan must confirm the applicant's qualifying chronic condition with their current health care provider, either before enrollment or through a post-enrollment verification process. If verification isn't obtained in time, the enrollee must be disenrolled — but if the condition isn't confirmed after enrollment, the individual gets a special election period (SEP) to enroll in another plan.
What the rule says
On verification methods:
“The organization must obtain this information in one of the following two ways described in paragraph (f)(1)(i) or (ii) of this section:”
“Contact the current health care provider or current health care provider's office and obtain verification of the applicant's condition(s) prior to enrollment in a form and manner authorized by CMS.”
“Through an assessment with the enrollee using a pre-enrollment qualification assessment tool (PQAT) where the assessment and the information gathered are verified (as described in paragraph (f)(1)(iii) of this section) before the end of the first month of enrollment in the C-SNP.”
On what happens if verification is not obtained:
“If the organization does not obtain verification of the enrollees' required chronic condition(s) by the end of the first month of enrollment in the C-SNP, the organization must—”
“Disenroll the enrollee as of the end of the second month of enrollment; and”
On the SEP that follows a negative post-enrollment finding:
“Individuals who are found after enrollment not to have the qualifying condition necessary to be eligible for the Chronic Care SNP are eligible for a SEP to enroll in a different MA plan.”
“After enrollment into a C-SNP, an individual who is determined to not have the qualifying condition necessary to be eligible for the C-SNP may use this SEP to enroll in another MA-PD or MA-only plan (e.g., when the required post-enrollment verification with a provider did not confirm the information provided on the pre-enrollment assessment tool).”
This part of the answer relies on the CY 2027 enrollment guidance, which applies to enrollment requests received on or after January 1, 2027.
Carrier and FMO rules are often stricter than CMS rules. This tool reports what CMS sources say and is not legal advice. Enrollment guidance shown is the CY 2027 version. Regulation text reflects the CY 2027 marketing rules, which apply to marketing beginning October 1, 2026.
This answer was generated by mapdbot from the sources listed below on September 23, 2026 and checked against them. Regulation text: eCFR as of 09/15/2026. It is for licensed insurance agents, is not legal advice, and does not cover carrier or FMO rules.