Every special needs plan has a model of care. Far fewer can prove, member by member, that the model is actually being delivered. The gap between the document approved by NCQA and the work happening in care management is where audit findings, weak SNP performance and missed clinical opportunities tend to live. As CMS sharpens its expectations for D-SNPs and turns new attention to chronic condition SNPs, a model of care that holds up has to be both well written and visibly operational.

The Model of Care Framework

Every SNP must have a model of care approved by NCQA, organized around four elements: a description of the SNP population (including the most vulnerable members), care coordination, the provider network and quality measurement and performance improvement. Each element must score at least 50 percent and the model must reach at least 70 percent overall. Approval periods differ by SNP type. D-SNP and I-SNP models can earn three years with a score of 85 percent or higher, two years at 75 to 84 percent and one year at 70 to 74 percent. C-SNP models are approved for one year at a time, so C-SNPs face annual review.

NCQA also evaluates whether goals from the previous model were met. A model that sets ambitious goals and then cannot demonstrate results creates a problem at the next submission.

The Care Coordination Requirements That Matter Most

The regulations at 42 CFR 422.101(f) translate the model of care into specific, testable obligations. The 2026 Medicare Advantage final rule codified timeframes that apply to all SNPs beginning in 2026:

  • Initial health risk assessment within 90 days before or after the effective date of enrollment, using a tool that assesses physical, psychosocial and functional needs and includes standardized questions on housing stability, food security and access to transportation.
  • Annual reassessment for every member.
  • Documented outreach. Before a member is treated as unreachable, at least three non-automated contact attempts on different days and at different times, followed by a letter, with refusals and unsuccessful attempts documented.
  • Individualized care plan within 90 days of the initial HRA or 90 days after enrollment, whichever is later. The plan must be person-centered, developed by the interdisciplinary care team with the member's active participation where feasible, include measurable goals and specific services and be updated when health status changes or a care transition occurs.
  • Interdisciplinary care team with expertise and training appropriate to the target population.
  • Face-to-face encounters at least annually, beginning within the first 12 months of enrollment, in person or by real-time audio-video telehealth, as feasible and with the member's consent.

D-SNP Integration Raises the Bar

D-SNPs carry additional obligations tied to Medicaid integration. Every D-SNP needs a contract with the state Medicaid agency. Coordination-only D-SNPs must notify the state, or its designee, of hospital and skilled nursing facility admissions for designated high-risk members. Beginning in 2027, applicable integrated plans must use a single integrated health risk assessment that satisfies both Medicare and Medicaid requirements, rather than two separate assessments, and must issue integrated member ID cards. Because HRAs can occur up to 90 days before enrollment, assessments for January 2027 enrollees may need to meet the integrated standard as early as October 2026.

For care management teams, integration means one assessment, one care plan and one team accountable across both programs. Models of care that describe integration but run separate Medicare and Medicaid workflows will struggle to show it.

C-SNPs Are Under a Brighter Light

The contract year 2027 proposed rule, released in late November, includes a request for information on the growth of dual-eligible enrollment in C-SNPs rather than D-SNPs, and asks whether C-SNPs and institutional SNPs with high dual concentrations should be required to contract with state Medicaid agencies. It also proposes removing the SNP Care Management measure, which tracks HRA completion, from the Star Ratings beginning with the 2029 ratings. Neither proposal is final, and removing the Star measure would not remove the regulatory obligation to complete assessments on time. C-SNP operators should assume that care coordination for dual-eligible members will receive more scrutiny, not less.

The Documentation That Proves Delivery

CMS program audits test SNP care coordination using data universes and case samples: whether HRAs were completed on time, whether care plans were developed and updated, whether the interdisciplinary team was involved and whether results were communicated. A model of care holds up when the organization can produce, for any sampled member:

  1. A complete outreach trail showing every attempt, date, time, channel and outcome.
  2. The completed HRA with dates, social needs responses and the clinical findings that informed the plan.
  3. An individualized care plan with problems, measurable goals and interventions clearly linked to HRA results, and evidence of member participation.
  4. Interdisciplinary team activity, including who participated, when and what changed as a result.
  5. Care plan updates after hospitalizations, emergency visits and other transitions.
  6. Face-to-face encounter documentation within the required timeframe.
  7. Outcome tracking that connects to the quality measures and goals stated in the model, such as medication review, pain assessment, readmissions and transitions of care.

If producing that evidence requires manual chart pulls across disconnected systems, the model is fragile, even if care is being delivered.

A Framework for a Model of Care That Holds Up

  • Write what you do. The approved model should describe workflows that exist today, not aspirations. Every commitment in the document should map to a system field, report or process owner.
  • Measure what you wrote. Track HRA timeliness, care plan timeliness, ICT participation and transition follow-up monthly, not only before an audit.
  • Close the loop. Make sure HRA findings drive care plans, care plans drive interventions and interventions are reviewed after transitions.
  • Prepare for integration. D-SNPs subject to integrated HRA requirements should be testing combined assessment tools well before October 2026.

How a Platform Approach Helps

Proving a model of care is easiest when assessments, outreach, care plans and quality data share one record. Curitics supports that with connected telephony that logs every outreach attempt against the member, AI-assisted care plans that draft problems, SMART goals and interventions with justifications from assessments, clinical data and call transcripts for clinician review, medication reconciliation that consolidates pharmacy fills, and HEDIS gap tracking that ties care plans to measurable results.

A model of care is a promise to CMS, to states and to some of the most vulnerable members in Medicare. The plans that keep that promise visibly, with documentation that follows each member from first assessment to every care transition, will be the ones whose models hold up.