Medicare Advantage (MA) is a government-sponsored program offering an alternative to what is commonly referred to as fee-for-service (FFS) Medicare or traditional Medicare, where benefits are provided to Medicare beneficiaries by private health plans, otherwise known as Medicare Advantage organizations (MAOs). This paper discusses a specialized type of MA plan called a chronic condition special needs plan, or a C-SNP, which focuses on beneficiaries with particular chronic conditions. Five key takeaways from our analysis of the C-SNP market are:

1. C-SNPs grew significantly from 2021 to 2024, in both number of plans and beneficiary enrollment, though growth varied from one year to the next.
2. As a group of conditions, the most common C-SNP disorders targeted are cardiovascular-related, chronic heart failure, and/or diabetes.
3. While variation exists in C-SNP member premiums, the most frequently offered member premium in 2024 is zero dollars, which is consistent with general enrollment¹ plans.
4. National and regional MAOs² offering C-SNPs differ significantly in their mandatory supplemental benefit coverage. Some benefits are offered more frequently by national MAOs, while others are offered more frequently by regional MAOs.
5. Special Supplemental Benefits for the Chronically Ill (SSBCI), which are available to members with certain chronic conditions, are frequently offered by C-SNPs in 2024. The most common SSBCI offerings are food and produce and general living supports.

What are C-SNPs?

List of C-SNP Chronic Conditions

1. Autoimmune disorders
2. Cancer
3. Cardiovascular disorders
4. Chronic alcohol and other drug dependence
5. Chronic and disabling mental health conditions
6. Chronic heart failure
7. Chronic lung disorders
8. Dementia
9. Diabetes mellitus
10. End-stage liver disease
11. End-stage renal disease (ESRD) requiring dialysis
12. HIV/AIDS
13. Neurologic disorders
14. Severe hematologic disorders
15. Stroke

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C-SNPs are MA plans that enroll beneficiaries with specific severe or disabling chronic conditions. The Centers for Medicare and Medicaid Services (CMS) defines eligible beneficiaries as individuals who have one or more comorbid and medically complex chronic conditions that are substantially disabling or life-threatening; have a high risk of hospitalization or other significant adverse health outcomes; and require specialized delivery systems across domains of care.³

Currently, CMS has approved 15 C-SNP chronic conditions. An MAO may choose to target a single condition, a CMS-approved group of commonly comorbid and clinically linked conditions, or a custom grouping of the 15 chronic conditions. If a plan is targeting a CMS-approved group of conditions, a beneficiary need only have one of the conditions to be eligible for enrollment. If a plan is targeting a custom group of chronic conditions (which cannot include any non-CMS-approved conditions), then beneficiaries must have every condition to be eligible. There are currently no C-SNPs electing a custom group of chronic conditions in the market, perhaps due to this additional requirement.

C-SNP market landscape and growth

C-SNPs are a relatively small MA market segment. There are 322 C-SNPs in 2024 relative to 5,817 total individual MA plans⁴ nationwide. Figure 1 displays the count of C-SNPs in the market from 2021 through 2024, and the number of MAOs offering C-SNPs over the same period. Figure 2 shows the number of beneficiaries enrolled in C-SNPs over the same period.

C-SNPs experienced significant growth in plan count and enrollment from 2021 to 2024. The count of C-SNPs increased by 32% from 2021 to 2022, but growth was flat from 2023 to 2024. Enrollment, on the other hand, increased at a faster pace each year, going from 7% growth from 2021 to 2022 to 35% growth from 2023 to 2024. Enrollment growth does not appear to be driven by new plan entrants, but rather by enrollment growth in existing plans.

The number of MAOs offering C-SNPs increased from 2021 to 2024, but MAOs both entered and exited the market during this time. In 2022, five MAOs entered the C-SNP market and one exited. In 2023, five MAOs entered and five exited, resulting in no change in total. In 2024, five MAOs entered and three exited. Five national MAOs⁵ (Centene Corporation, CIGNA, Elevance Health, Humana, and UnitedHealth Group) have consistently offered plans in the C-SNP market from 2021 through 2024. The three MAOs with the highest C-SNP enrollment in 2024 are national plans (UnitedHealth Group, Humana, and Elevance) and the next three highest are regional plans (Bright Health, MHH Healthcare, and SCAN Group).

Figure 3 displays the count of C-SNPs by targeted chronic conditions from 2021 to 2024, limited to C-SNP types with at least 20 plans in recent years.

C-SNPs targeting the grouping of cardiovascular disorders, chronic heart failure, and/or diabetes are the most common product type in the market. There are 205 of these plans in the market in 2024, with the next most common C-SNP type (ESRD) at 32 plans. C-SNPs targeting the grouping of cardiovascular disorders, chronic heart failure, and/or diabetes drive the growth in the market. Diabetes mellitus and chronic lung disorders were the second and third most popular C-SNP types in 2023, but both experienced a dip in the number of plans in 2024. Plans targeting cardiovascular disorders and/or chronic heart failure also decreased from 2023 to 2024.

Figure 4 displays the count of C-SNPs by targeted chronic conditions from 2021 to 2024 for the least common C-SNPs in the market. Note the difference in scale between Figures 3 and 4.

The count of C-SNPs targeting the less popular condition groupings shown in Figure 4 held steady or decreased from 2023 to 2024, except for cardiovascular disorders and/or diabetes, which grew from nine to 10 plans. These C-SNP types are likely to remain small segments of the C-SNP market given recent trends. MAOs may be exiting the market for these C-SNP types due to unmanageable medical costs or low enrollment. Additionally, four of the C-SNP types in Figure 4 are subsets of the C-SNP type targeting the grouping of cardiovascular disorders, chronic heart failure, and/or diabetes. Plans may be more likely to choose this grouping, given the broader enrollment opportunities, rather than limiting enrollment to a subset of the three conditions.

There are C-SNP chronic conditions approved by CMS for which no plans exist in the market in recent years. This may be because it is challenging to attract significant enrollment with these conditions, or because MAOs do not see an opportunity to manage costs for these chronic conditions in the MA market today. Those conditions are as follows:

• Chronic alcohol and other drug dependence
• Autoimmune disorders
• Cancer
• End-stage liver disease
• Severe hematologic disorders
• Neurologic disorders
• Stroke

The table in Figure 5 displays 2024 enrollment by C-SNP type, for C-SNP types with enrollment in 2024.

As can be seen in Figure 5, the grouping of cardiovascular disorders, chronic heart failure, and/or diabetes has over 10 times the enrollment of the next largest plan type. This makes sense given these plans dominate the market in terms of plan count.

Cardiovascular disorders and/or diabetes has the second most enrollment, despite only 10 plans in the 2024 market offering this condition grouping. This indicates these plans have relatively high enrollment among C-SNPs. The largest has over 15,000 beneficiaries and is offered by Humana.

C-SNP member premiums are most often zero

Some MA plans charge a monthly medical premium to their beneficiaries. Figure 6 displays 2024 C-SNP member premiums by premium range.

About three-quarters of C-SNPs charge zero-dollar premiums. Zero-dollar premium plans are popular with members, regardless of market segment. Zero-dollar premiums are very common in the general enrollment market as well.

The range of C-SNP premiums on the high end is large. The three plans in this bucket have monthly premiums of $72, $78, and $188, respectively. This C-SNP premium range is narrower, however, than observed among general enrollment plans in 2024, where there are six plans with member premiums of $300 or more.

There are 23 C-SNPs in 2024 offering premiums that target the LIPSA. For low-income beneficiaries, the federal government covers the member premium up to the low-income premium subsidy amount (LIPSA), which varies by region and is set by CMS each year. Plans targeting low-income beneficiaries tend to set premiums equal to or less than the LIPSA, thereby providing coverage to these beneficiaries at no cost to the member. There are only six C-SNPs in 2024 offering premiums above the LIPSA, meaning the vast majority of C-SNPs are accessible to low-income beneficiaries.

About 19% of C-SNPs offer a Part B premium buy-down in 2024. Most Medicare beneficiaries are required to pay a Part B premium for Medicare coverage. While MA plans can choose to charge a monthly premium, they also have the option to cover a portion or all of a member’s Part B premium. This is referred to as a Part B premium buy-down. The prevalence of Part B buy-downs decreased slightly from 20% of plans in 2023.

Variation observed in C-SNP supplemental benefits

MA plans typically offer additional benefits not provided under traditional Medicare, referred to as supplemental benefits. This discussion focuses on mandatory supplemental benefits and excludes optional supplemental benefits, for which each individual beneficiary within a plan can elect optional supplemental coverage and pay an additional premium.

Figure 7 contains the most common supplemental benefits offered by C-SNPs in 2024.

All benefits displayed in Figure 7 are offered to at least 90% of C-SNP beneficiaries in 2024. These benefits have similarly high prevalence in the general enrollment market and dual-eligible special needs plan (D-SNP) market, with the exception of nonemergency transportation, which is less popular in the general enrollment market. These benefits have all been offered to the large majority of C-SNP members in recent years.

Figure 8 shows the percentage of C-SNP beneficiaries with coverage for other supplemental benefits in 2024, split between national and regional MAOs. For this analysis, we classified Centene, CIGNA, Elevance, Humana, and UnitedHealth Group as the national MAOs in the 2024 C-SNP market. These same five national MAOs have existed in the C-SNP market in recent years.

National C-SNPs offer podiatry benefits to 79% of beneficiaries, while regional C-SNP beneficiaries only offer podiatry to 46% of beneficiaries. This is not driven by the type of C-SNPs, as the level of podiatry coverage is similar for national MAOs and regional MAOs across the different C-SNP conditions.

Beneficiaries enrolled in regional C-SNPs are more likely to have health education, acupuncture, in-home support services, nutritional/dietary benefits, and support for caregivers than beneficiaries in national C-SNPs. Regional C-SNPs appear to take more tailored approaches with their supplemental benefits than the national C-SNPs, which focus on the supplemental benefits in Figure 4 above, plus podiatry. Regional C-SNPs may serve a much smaller group of individuals residing in specific areas or aligned with certain providers, which allows them to deeply understand the needs of their beneficiaries and design benefit packages most in line with those needs.

Combined benefit packages are frequently offered in 2024 by both national and regional C-SNPs. Combined benefits, or “combo” benefits, are designed to include multiple supplemental benefits in one package and may have a total dollar limit across all benefits in the package.⁶ While shared preventive and comprehensive dental limits fall into the combo benefit category when filed in the Plan Benefit Package (PBP), we do not include them in this discussion—we focus on “true” combo benefits, which include multiple types of unrelated benefit types. Approximately 77% of C-SNP beneficiaries with national MAOs and 71% of C-SNP beneficiaries with regional MAOs are enrolled in plans with true combo benefits in 2024. The most common combined benefit offerings by C-SNPs in 2024 are as follows:

• Over-the-counter (OTC) benefit cards combined with other benefits, such as SSBCI, home and bathroom safety, or fitness
• Dental, vision, and hearing benefits
• Acupuncture and chiropractic benefits

C-SNP non-uniform benefit offerings are led by SSBCI

Through the Value-Based Insurance Design (VBID) demonstration program as well as the benefit flexibility offerings known as Uniform Flexibility (UF) and SSBCI, MAOs can provide reduced cost sharing and/or additional supplemental benefits for enrollees based on condition and, under VBID only, socioeconomic status.⁷ In this paper, we refer to VBID, UF, and SSBCI offerings as ”non-uniform benefits” because they are not offered to all beneficiaries uniformly, as is the case with mandatory supplemental benefits. Because C-SNP beneficiaries must have certain chronic conditions to enroll, C-SNPs can offer additional benefit flexibilities to all beneficiaries through non-uniform programs by using the same qualifying condition as they utilize for plan enrollment.

Figure 9 shows the percentage of C-SNP beneficiaries enrolled in plans offering non-uniform benefits packages from 2021 through 2024.

While non-uniform benefits offerings by C-SNPs all grew in prevalence in recent years, SSBCI is by far the most common non-uniform benefit offered by C-SNPs. SSBCI may be attractive to C-SNPs for the following reasons:

• SSBCI is designed to target beneficiaries with chronic conditions, as are C-SNPs.
• SSBCI allows for a larger variety of benefit flexibilities than UF.
• SSBCI does not require a separate application, competitive bidding,^8,9 and desk review process, which is a requirement of VBID program participation.

The following discussion focuses on SSBCI only, given its high prevalence among C-SNPs. Figure 10 shows the most common SSBCI¹⁰ offered by C-SNPs in 2024.

Food and produce is the most frequently offered SSBCI by C-SNPs in 2024, followed by general living support and nonmedical transportation. General living support benefits typically offer dollar limits for rent and utilities.

C-SNPs often place multiple SSBCI offerings within a combo package. Food and produce and general living supports are offered in a combo package by 126 C-SNPs in 2024, meaning the majority of both food and produce and general living support offerings are part of combo packages.

The average annual dollar limit for an SSBCI package offered by a C-SNP in 2024 is $980. Limits vary significantly by plan, from as low as $300 annually to as high as $3,800 annually.

Bid considerations for 2025 and beyond

Regulatory implications

• In 2025, the Inflation Reduction Act (IRA) is anticipated to transfer more Part D liability to plan sponsors,^11,12,13 leading to a large increase in the direct subsidy. This shift may also have a considerable impact on LIPSAs by region, which are a premium target for some C-SNPs. Additionally, because a large share of C-SNP members may hit the catastrophic phase of the Part D benefit when they utilize high-cost drugs to manage chronic conditions, C-SNPs may face significant fluctuations in Part D costs.
• Part C risk adjustment model changes¹⁴ may also increase revenue pressures for C-SNPs, as CMS is currently in the process of transitioning to a clinically revised CMS-Hierarchical Condition Category (HCC) risk score model for MA payments, which could result in meaningful changes for plan revenue. This new model is expected to be particularly impactful for C-SNPs.¹⁵
• Additionally, under the 2025 CMS Proposed Rule, starting with contract year (CY) 2025, plans would be required to demonstrate at the time of bid submission through “relevant acceptable evidence” that any SSBCI service offered has a reasonable expectation of improving or maintaining the health or overall function of a chronically ill beneficiary.¹⁶ This more stringent regulation could make offering certain SSBCI services more challenging if research on their impact is limited.

Methodology

To perform these analyses, we relied on detailed information on MA benefits, premiums, and enrollment as released by CMS and summarized in the 2024 Milliman Medicare Advantage Competitive Value Added Tool (Milliman MACVAT®), which is available for external license. Enrollment used to calculate weighted averages is from February of each year, with the exception of 2024, which relies on January 2024 enrollment.

The data above was summarized and analyzed in the following groupings:

• Plan type
• Regional versus national organizations
  • National MAOs in the 2024 C-SNP market are Centene, CIGNA, Elevance, Humana, and UnitedHealthcare. The other organizations in the C-SNP market are considered regional for this report.

This analysis excludes all MA special needs plan (SNP) types other than C-SNPs. References to the total individual MA market exclude Employer Group Waiver Plans (EGWPs), the Program of All-Inclusive Care for the Elderly (PACE), and Prescription Drug Plans (PDPs).

Caveats, limitations, and qualifications

The information in this paper is intended to describe changes and trends in the Medicare chronic condition special needs plan market. It may not be appropriate, and should not be used, for other purposes.

We relied on publicly available enrollment and premium data from CMS and the Milliman MACVAT® to support the data and conclusions presented in this paper. If this information is incomplete or inaccurate, our observations and comments may not be appropriate. We reviewed the data for reasonability but did not audit the data.

The credibility of certain comparisons provided in this paper may be limited, particularly where the number of plans in certain groupings is low. Some metrics may also be distorted by premium and benefits in a few plans with particularly high enrollment. Future C-SNP experience may differ from the historical results presented in this paper.

Mary Yeh is a member of the American Academy of Actuaries and meets the qualification standards of the American Academy of Actuaries to render the actuarial opinion contained herein.

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¹ General enrollment plans are individual MA plans excluding special needs plans (chronic conditions, dual-eligible, and institutional special needs plans).

² Please reference the Methodology section below for the distinction between national and regional MAOs.

³ CMS. Chronic Condition Special Needs Plans (C-SNPs). Retrieved April 10, 2024, from https://www.cms.gov/medicare/enrollment-renewal/special-needs-plans/chronic-conditions.

⁴ When referring to the total individual MA market, we exclude Employer Group Waiver Plans (EGWPs), the Program of All-Inclusive Care for the Elderly (PACE), and Prescription Drug Plans (PDPs).

⁵ National MAOs are defined as those with over 500,000 beneficiaries in total, across all plan types. The remaining national MAOs not in the C-SNP market are CVS and Kaiser.

⁶ Yeh, M., & Yen, I. (April 2024). 2024 Combined Benefits in Medicare Advantage: Tracking Benefit Strategy and Options. Milliman White Paper. Retrieved April 10, 2024, from https://www.milliman.com/en/insight/2024-combined-benefits-medicare-advantage-tracking-benefit-strategy.

⁷ Murphy-Barron, C.M., Pelizzari, P.M., & Regan, B. (February 2019). The Medicare Advantage Value-Based Insurance Design Model: Overview and Considerations. Milliman White Paper. Retrieved April 10, 2024, from https://www.milliman.com/en/insight/the-medicare-advantage-value-based-insurance-design-model-overview-and-considerations.

⁸ Laktas, J., Yeh, M., & Friedman, J.M. (March 2024). 2024 VBID Benefit MA Market Landscape and 2025 VBID Model Application Considerations. Milliman White Paper. Retrieved April 10, 2024, from https://www.milliman.com/en/insight/2024-vbid-benefit-ma-market-2025-vbid-model-application.

⁹ Kotecki, L., & Polakowski, M.J. (March 2024). CMS Introduces Competitive Bidding into the Value-Based Insurance Design Program for 2025. Retrieved April 10, 2024, from https://www.milliman.com/en/insight/cms-introduces-competitive-bidding-into-the-vbid-program-2025.

¹⁰ Descriptions of each SSBCI offering are provided by CMS here: https://www.cms.gov/medicare/health-plans/healthplansgeninfo/downloads/supplemental_benefits_chronically_ill_hpms_042419.pdf.

¹¹ Cline, M., Karcher, J., Klaisner, J.K., & Klein, M. (August 2022). Weathering the Reform Storm: The Inflation Reduction Act’s Changes to Medicare and Other Healthcare Markets. Milliman Brief. Retrieved April 10, 2024, from https://www.milliman.com/en/insight/weathering-the-reform-storm.

¹² Ally, A.J., Berman, M., Klein, M., & Pierce, K. (September 30, 2022). The Inflation Reduction Act Passed, Now What? Retrieved April 10, 2024, from https://www.milliman.com/en/insight/the-inflation-reduction-act-passed-now-what.

¹³ Berger, C.N., Engel, T., & Wanta, T.M. (August 30, 2023). Part D Redesign Under the Inflation Reduction Act. Milliman White Paper. Retrieved April 10, 2024, from https://www.milliman.com/en/insight/part-d-redesign-under-ira-potential-financial-ramifications.

¹⁴ Pipich, R., Cross, K., & Rothschild, M. (February 2023). High-Level Impacts of the Proposed CMS-HCC Risk Score Model on Medicare Advantage Payments for 2024. Milliman White Paper. Retrieved April 10, 2024, from https://www.milliman.com/en/insight/analysis-of-2024-cms-proposed-hcc-model.

¹⁵ Ibid.

¹⁶ CMS (November 6, 2023). Fact Sheet: Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Plan Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly, and Health Information Technology Standards. Retrieved April 10, 2024, from https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-policy-and-technical-changes-medicare-advantage-plan-program-medicare.