By John Cole, Talha Bhatti, Harbinder Raina and Pritpal Virdee

Note: The third and final article on entry into the Chronic Condition Special Needs Plan (CSNP) market; the first made the strategic case, the second covered assessing readiness.

Key takeaways

· This article provides an execution roadmap focused on three leadership questions: Can we meet the timeline, maintain a sustainable budget and launch successfully on day one?

· C-SNP implementation requires multiple workstreams to progress in parallel, including clinical infrastructure, centers for Medicare and Medicaid services (CMS) application activities, provider alignment, IT and data exchange, sales enablement and Star Ratings governance

· Plans with an existing dual eligible special needs plan (D-SNP) can typically launch within 18 months, while de novo entrants should expect 24+ months

Health plans entering the C-SNP market should treat implementation as a cross-functional launch program anchored to fixed CMS deadlines, parallel capability build and early operational readiness. The most important workstreams are clinical operations, provider attestation, IT and electronic health record (EHR) integration, regulatory compliance, sales enablement, Star Ratings governance, procurement and program management.

What is the C-SNP implementation timeline?

The C-SNP implementation timeline is dictated by CMS deadlines. The Notice of Intent to Apply (NOIA) is due mid-November, roughly 14 months before the target effective date. The Part C / Part D (prescription drug) application follows in mid-February. Beginning with the CY2027 cycle, the model of care (MOC) is no longer submitted with the February application: CMS moved the MOC deadline to the Friday before the first Monday in June (May 29, 2026, for CY2027), aligning it with the bid deadline, and the National Committee for Quality Assurance (NCQA) scores the MOC on CMS’s behalf over the summer. While the revised MOC timeline provides additional development time, it also shortens the window for revisions before the annual election period (AEP), increasing the importance of getting the MOC right the first time.

Three deadlines drive the timeline: the NOIA, Medicare Advantage application and MOC/bid submission. Missing any deadline delays market entry by a full year. The primary internal constraint is IT and EHR integration, which typically requires 12–18 months and should begin in phase 1 alongside MOC development to support year-one hierarchical condition category (HCC) capture and risk-adjusted revenue performance.

How much does C-SNP implementation cost?

IT and data exchange, clinical programs and sales-channel development account for roughly three-quarters of implementation spend. Most spending occurs before launch, covering regulatory activities, IT infrastructure, MOC development, network contracting and sales-channel build. Ongoing costs are driven primarily by care management staffing and IT maintenance. Plans typically reach operating breakeven by year three.

The D-SNP capability credit is the primary cost lever. Mature D-SNP plans can adapt care management infrastructure, interdisciplinary care team (ICT) workflows, the MOC (roughly 60%-70% reusable), and SDOH (social drivers of health) programs rather than rebuild them. The largest net-new investments are PCP alignment and attestation, HCC gap analytics and PCP data exchange, and C-SNP-specific broker certification and marketing. Plans without a D-SNP should expect to build all six capabilities from scratch.

IT depth is the largest controllable swing. Options range from a minimum-viable build (claims aggregation, ADT [admission, discharge and transfer] feeds, manual gap reports) to full integration (bidirectional EHR write-back, predictive alerts, specialty feeds, remote monitoring). For most plans with an existing D-SNP, a fast healthcare interoperability resources (FHIR)-enabled base case with real-time ADT feeds, PCP-facing dashboards, care-gap analytics and core integrations captures most HCC and care-gap value at a fraction of full-integration cost.

What capabilities are required to launch a C-SNP?

The MOC is both the CMS approval vehicle and the operational DNA of the C-SNP. It spans four domains: SNP population, care coordination, provider network and quality measurement. Plans must score above 70% overall and above 50% in each domain. Strong care coordination, especially ICT documentation and individualized care plan (ICP): update protocols, is the key differentiator between an average and top-performing MOC.

Care management is the operational core and must be condition-specific, proactive, and MOC-aligned. Typical staffing includes condition-specialist RN care managers (1:100–125 high-risk members; 1:200 medium-risk), social workers or navigators (1:300–400), a shared clinical pharmacist (0.5–1.0 FTE per 1,500–2,000 members), and one supervisor for every 8–10 care managers. Disease-management programs are typically outsourced. Wages vary widely by geography with RN care managers ranging from roughly $75K to $155K, clinical pharmacists from $125K to $162K, supervisors from $100K to $165K, and social workers from $52K to $93K, excluding benefits and employer load of 25%-40%. Plans with existing D-SNP teams typically need a 20%-30% staffing uplift for an initial 1,500–2,500 members.

Core workflows must be documented in the care-management platform: Health risk assessment (HRA) completion within 90 days (30 for high-risk members), ICP completion within 30–60 days of the HRA, ICT review at least annually and quarterly for high-risk members, and ADT-triggered transition-of-care outreach within 48–72 hours of discharge. This documentation supports both NCQA scoring and risk adjustment data validation (RADV) audits.

How do provider attestation and PCP alignment affect C-SNP enrollment?

Provider alignment is a clinical-partnership function, not a contracting one. The PCP relationship determines HCC capture completeness, ICT quality, member retention and Star Ratings performance.

Attestation is the enrollment gatekeeper. Every C-SNP enrollment requires physician attestation of the qualifying condition, a CMS-mandated process with no D-SNP analog, which is why it is the largest greenfield build. Weak workflows create compliance exposure, broker friction and early provider-partnership strain. A digital portal with prepopulated, e-signature, enrollment system feeds, automated outreach and escalation typically takes four to six months to build and must be live before AEP.

HCC documentation is a partnership, not a coding exercise. PCPs are the primary documentation source, so capture rates and risk-adjusted revenue depend on coding-education and data-exchange. The highest-concentration practices warrant the deepest engagement: quarterly coding-educator visits, monthly prospective gap reports, value-based amendments tying documentation bonuses to HCC capture and ICT participation, and priority FHIR data exchange. Specialist adequacy must also be documented at the condition level, not through generic Medicare Advantage (MA) network files.

What IT systems are needed for C-SNP implementation?

IT is the longest-lead and the most frequently underestimated workstream. Core systems need C-SNP-specific configuration across enrollment (plan codes, attestation tracking, Chronic Condition special enrollment period (SEP) logic, reattestation); the care-management platform (C-SNP HRA and ICP templates, ICT documentation, SDOH screening, transitions-of-care workflow); claims adjudication; risk adjustment; and Star Ratings analytics. Risk-adjustment submission is now entirely encounter-based, the legacy Risk Adjustment Processing System (RAPS) is retired, o systems should target daily encounter submission and reconciliation against the CMS Model Output Report (MOR).

EHR integration is the highest-return investment and the program’s critical path. A base-case build runs from discovery and design, to core integration (FHIR APIs across the top platforms covering most priority PCPs, ADT setup, care-gap analytics, PCP portal), to pilot and scale over 12–18 months. ADT feeds should be prioritized because they trigger required transitions-of-care outreach; major hospital systems should be live before first enrollment to avoid missed SLAs.

Regulatory compliance and financial management

The application package includes the Part C forms and plan benefit package (PBP), condition-specific network-adequacy documentation, financial-solvency filings and supplemental-benefit evidence. Since CY2027, the MOC is submitted separately, due the Friday before the first Monday in June, aligned with the bid deadline. After the February filing, CMS issues deficiency notices in March and application approvals arrive in spring; bids are due the first Monday in June; NCQA scores the MOC over the summer; and marketing materials must clear CMS review roughly eight to 10 weeks before AEP.

RADV readiness must be built in from day one. C-SNPs face elevated audit risk because of high risk adjustment factor (RAF) scores and condition-specific populations. Every submitted HCC code needs physician documentation from a face-to-face encounter in the relevant year, with the condition reflected in notes, discharge summaries or problem lists, not attestation alone. Attestation forms must be retained and linkable to risk-adjustment submissions; annual chart review and physician coding education complete the process. Year 1 medical loss ratio runs high. Adverse selection (members converting from standard MA tend to be the highest utilizers), immature care-management savings, and conservative benefit design typically put first-year MLR near 89%. It improves toward the mid-80s by Year 3 or 4 as care-management savings build, risk scores stabilize, and a Star Ratings bonus arrives. The trajectory, not the Year 1 number, determines whether the C-SNP reaches its target margin.

Sales, broker and member engagement

Plans that rely on existing MA sales infrastructure often underperform enrollment targets without dedicated C-SNP training and materials. The build requires a C-SNP sales lead with SNP experience, FMO contracting, condition-specific broker certification and a marketing pipeline that allows eight weeks for CMS review. First-year targets should be built bottom-up by channel: internal member conversion (30%-40% of Year 1, at the lowest cost per enrollment); FMO and broker distribution (50%-60%, the largest and most expensive channel); provider-assisted referral (10%-20%, with lower early disenrollment, because a trusted-physician referral holds better than a cold broker contact); and direct digital and mail (5%-10%). Internal conversion should be limited to members with clear diagnosis documentation to avoid compliance risk.

The Chronic Condition SEP supports year-round enrollment. Qualifying beneficiaries may enroll for as long as they have the condition, so provider-referred and internally identified enrollment continues after AEP. Plans must resource enrollment and attestation operations year-round.

How should health plans manage Star Ratings for a new C-SNP?

The 5% quality bonus at 4+ Stars is the largest swing factor in C-SNP unit economics after enrollment scale, and it should be managed as a financial objective. C-SNPs hold a structural advantage: their populations concentrate in the heavily weighted chronic-condition outcome measures (glycemic control, blood pressure control and plan all-cause readmissions) and in the Part D medication adherence measures. These move through structured hemoglobin A1c and blood-pressure programs, PCP gap-closure visits, pharmacist-led medication therapy management and 90-day supplies with mail-order conversion.

The contract (H number) decision is a revenue decision

Star Ratings are calculated and assigned at the contract level — the H number — not the plan level. Every PBP offered under a contract carries the same Star Rating as that contract. This single mechanic makes the choice of which H number hosts the C-SNP one of the most consequential financial decisions in the implementation — and it is frequently treated as an administrative afterthought.

● There are two paths with materially different early-year economics: Host the C-SNP under an existing H number. The C-SNP is added as a new PBP and immediately inherits that contract’s current Star Rating — both the rating displayed to shoppers and the rating that drives the quality bonus payment (QBP). If the host contract is at 4+ Stars, the C-SNP earns the 5% bonus from its very first member.

● Stand up a new H number. A new contract has no performance data of its own, and cannot earn its own Star Rating until it has accumulated a full measurement period and the ratings cycle catches up — roughly three years, because a given year’s Star Ratings reflect a measurement period two years earlier. In the interim, CMS assigns a QBP rating by rule: for a new contract under a parent organization that already holds rated MA contracts, the assigned rating is the enrollment-weighted average of the ratings of the parent’s other MA contracts. Only a true de novo entrant (a parent with no other MA contract in the prior three years) is treated as a “new MA plan” and assigned 3.5 Stars for bonus purposes.

Recommendation: place the C-SNP under the highest-rated H number covering the target counties.

Hosting the C-SNP on a 4+ Star contract delivers the quality bonus from day one. A new H number is paid on the enrollment-weighted average of the parent’s other contracts, which may fall below the 4-Star threshold, and waits roughly three years for its own rating. The gap is real revenue until the new contract matures.

The trade runs must be managed. Because SNP-specific measures roll into the host contract score on an enrollment-weighted basis, a poorly performing C-SNP can dilute the host contract rating and put QBP at risk across a broader book of business. Exposure is limited while C-SNP enrollment is small but grows with scale. Plans should choose a host contract with headroom and manage Stars governance as protection for the full contract, not just the C-SNP.

Governance and trajectory

Governance must be live before first enrollment because Star Ratings are measured by calendar year. Before January 1, every relevant measure needs an owner, data source, baseline and target. The monthly dashboard should include medical director and care-management leadership review; C-SNP-specific HEDIS supplemental data collection must be configured; and the Part D adherence program should launch in the first operating month. A realistic trajectory for a plan with an existing D-SNP is 3.0–3.5 Stars in the first measured year, 3.5–4.0 in the first published rating, and 4.0+ by Year 3. Under the recommended hosting approach, this trajectory governs the C-SNP contribution to the host contract while the plan earns the host contract bonus during maturation.

Procurement and vendor management

Vendors support many core C-SNP capabilities, especially IT and data exchange, disease management and sales enablement, making procurement a critical-path discipline. FHIR and EHR integration are the binding items, so RFP and vendor selection should occur in Phase 1 before application filing. Care-management platforms, ADT feeds, specialist and ancillary networks, disease-management programs and broker-certification systems follow across Phases 1–3; delaying procurement is a common cause of weak Year 1 performance.

Any vendor touching Medicare members or data is an FDR (first-tier, downstream or related entity) for which the plan remains accountable. Contracts must include CMS compliance flow-downs, HIPAA terms with clear data ownership and portability, service levels tied to auditable MOC obligations, and practical termination and transition rights. Oversight should include predelegation audits, annual audits and a monthly vendor scorecard; missed service levels are early indicators of Year 1 operational risk.

What governance is needed for a successful C-SNP launch?

Coordinating six workstreams against one fixed launch date requires strong program governance. The minimum structure includes an executive sponsor for gate decisions, a dedicated program lead or PMO managing the integrated plan and gate calendar, workstream owners with costed plans and milestones, weekly status meetings and monthly steering reviews. The PMO must manage cross-workstream seams, including attestation (provider, IT, enrollment), marketing approval (compliance, sales, CMS timing), and ADT feeds (IT, network).

The operational readiness review (ORR) is the true launch gate. Before AEP, the plan should run a formal go/no-go covering CMS approval, approved marketing, an operational MOC with staffing to ratio, a live and tested attestation portal, configured enrollment, active ADT feeds, deployable care-gap analytics, certified brokers, executed FMO agreements, assigned Star Ratings owners, a live dashboard and member onboarding readiness. CMS approval allows the plan to sell; the ORR confirms it can operate.

A successful start is measured by stabilization, not enrollment count. From the first effective date, plans should track weekly early-warning metrics: HRA completion within SLA, attestation completion above 95% before finalized enrollment, ICP timeliness, ADT outreach within 48–72 hours, channel-level enrollment and 90-day disenrollment. Key launch risks include missed filing deadlines, MOC scores below the three-year threshold, IT slippage affecting Year 1 HCC capture, attestation friction, adverse selection, and missed Star Ratings measurement windows. Each risk requires a Phase 1 mitigation plan.

How ZS helps

ZS’s Government Markets Center of Excellence supports C-SNP implementation across all six workstreams, budget, procurement and governance, including MOC development, attestation-portal design, IT architecture, CMS application management, broker enablement and Star Ratings governance. ZS combines regulatory fluency, financial discipline and execution support through first enrollment, medical loss ratio stabilization and the Year 2 Star Ratings review.

Contact ZS to begin C-SNP implementation planning across clinical design, regulatory management, IT architecture, budget discipline and go-to-market execution.

Read more insights from ZS.

This article reflects the authors’ personal views and does not necessarily represent any official position of ZS.

CSNP market entry: From capability build to sustained market presence was originally published in ZS Associates on Medium, where people are continuing the conversation by highlighting and responding to this story.

By: Avinash Prasad, Harbinder Raina and Talha Bhatti

Bundled payments are no longer a side experiment in Medicare reimbursement. They are becoming a central mechanism for shifting providers from volume-based payment to episode-level accountability. Under models such as TEAM, hospitals are responsible for the cost and quality of defined surgical episodes, with financial performance measured against CMS target prices. The result is a more demanding operating environment where health systems must manage clinical variation, post-acute utilization, readmission risk and patient outcomes with far greater precision.

This shift matters because bundled payments sit in the middle of the value-based care risk continuum. They are more financially consequential than pay-for-performance programs, but more operationally bounded than full capitation. That makes them a practical but unforgiving test of whether a provider organization can translate data, care coordination and clinical governance into measurable performance.

For many providers, the question is no longer whether to participate. Mandatory models are expanding, and the organizations that build stronger episode management capabilities now will be better positioned as CMS continues to move more reimbursement into accountable payment models. TEAM, CJR-X, ASM, ACCESS, LEAD and WISeR signal that episode-based accountability, chronic care management, specialist alignment and technology-supported oversight are becoming more prominent parts of the federal payment landscape.

Winning in this environment requires more than a dashboard or a retrospective claims review. Providers need a repeatable operating model that identifies the right patients early, stratifies risk accurately, guides discharge planning, directs patients to high-performing post-acute partners, and gives leaders near real-time visibility into episode economics. AI and advanced analytics can help, but only when they are embedded into the clinical and operational workflows that determine cost and quality at the point of care.

ZS helps health systems build this bridge between analytics and action. Our approach combines episode strategy, data infrastructure, AI-enabled risk and referral tools, care management workflow design and performance management capabilities that support both near-term execution and longer-term value-based care readiness.

1. Bundled payments change the economics of care delivery

Traditional fee-for-service reimbursement pays providers for each separate service delivered during a patient’s care journey. A physician visit, imaging study, implant, lab test, hospital stay and skilled nursing facility day are each reimbursed as individual transactions. This model rewards volume and does not require the provider to manage total episode cost across the full care journey.

Bundled payments change that logic. A single prospective or retrospective payment covers care from an anchor event through a defined post-discharge window, often 30 to 90 days. If the provider manages the episode below the target price while meeting quality requirements, it can retain a share of the savings. If the episode exceeds the target price, the provider may owe a repayment. In practical terms, the health system takes on both the upside and the downside associated with variation in care delivery, post-acute referrals, readmissions, and resource use.

This creates a different management problem for health systems. Success is not determined only by the procedure itself; it depends on whether the organization can standardize the care pathway, reduce avoidable variation, manage discharge disposition, coordinate post-acute care, and monitor patient risk after discharge. Taking hip replacement as an example, the opportunity comes from areas like eliminating duplicative imaging, optimizing implants, shortening skilled nursing facility stays when clinically appropriate, and managing the overall episode below the payer’s bundled amount.

2. Mandatory participation is raising the urgency

CMS’s recent model activity points to a clear direction of travel. TEAM requires selected hospitals to participate in 30-day surgical episodes across five procedure categories. CJR-X would expand mandatory joint replacement accountability across a much broader hospital footprint, with a 90-day episode window. Other models, including ASM, ACCESS, LEAD and WISeR, further reinforce CMS’s focus on specialty care management, chronic condition support, accountable care and utilization oversight.

TEAM is especially important because it makes episode accountability operationally unavoidable for participating hospitals. The model covers lower extremity joint replacement, surgical treatment for hip femur fracture, spinal fusion, coronary artery bypass graft and major bowel procedures. Hospitals in selected geographic markets are required to participate, and the model runs through December 31, 2030.

The TEAM methodology uses historical spending, regional adjustments and a CMS efficiency discount to establish target prices. Hospitals that outperform their target price can receive reconciliation payments, while those that overspend can face repayment obligations. Quality scores affect reconciliation outcomes, which means financial performance and clinical quality are directly linked.

CJR-X raises the stakes further. The proposed model serves as an expansion of mandatory joint replacement accountability, with a 90-day episode window and broader post-acute cost exposure. That longer episode window increases the importance of discharge planning, preferred post-acute networks, home health utilization, skilled nursing facility management and patient monitoring after discharge.

The implication for providers is straightforward: waiting for reconciliation data is too late. Organizations need to understand episode performance while there is still time to intervene.

3. Six operating challenges determine episode performance

First, many providers choose bundles without enough analytic rigor. Historical cost data, risk-adjusted benchmarks, case mix, surgeon-level variation and competitor context are needed to understand where the organization can reasonably perform below target prices. Without that analysis, providers may enter episodes where they have limited ability to manage cost or quality.

Second, patient identification is often too manual. If eligible patients are identified late, care teams lose the most valuable window for preadmission planning, risk stratification and proactive intervention. Automated identification using ADT and EHR feeds is becoming a baseline capability for effective episode management.

Third, clinical variation drives avoidable cost. Differences in implant selection, imaging frequency, length of stay, discharge planning and post-acute referral patterns can materially change episode economics. Standardized care pathways do not remove clinical judgment, but they do create a consistent baseline from which exceptions can be managed more deliberately.

Fourth, resources are often allocated too evenly. High-risk patients may not receive enough care management support, while lower-risk patients receive interventions they may not need. Risk stratification helps care teams decide where to focus outreach, follow-up, medication checks and escalation resources.

Fifth, post-acute care remains one of the largest controllable cost levers. Referrals to out-of-network or high-cost post-acute providers can materially affect episode profitability. Preferred post-acute networks and decision support at discharge are therefore critical to performance.

Finally, limited performance visibility prevents timely course correction. If leaders only understand performance after CMS reconciliation, they cannot address emerging cost or quality issues while the episode is still active. Continuous performance tracking is required to manage bundled payments as an operating discipline rather than a retrospective finance exercise.

4. AI can improve episode management when it is tied to workflow

AI is most valuable in bundled payments when it improves a concrete operational decision, and can be deployed across six capability domains: bundle selection, patient identification, risk scoring, referral optimization, care management and analytics. These domains provide a practical way to think about where AI can improve performance.

In bundle selection, predictive models can analyze historical episode cost, case mix, surgeon variation and regional benchmarks to estimate expected financial performance. This helps providers decide which episodes to prioritize and which operational improvements are required before taking on more risk.

In patient identification, rules-based engines and natural language processing can monitor ADT feeds, EHR data and order streams to identify eligible patients earlier. Earlier identification gives care teams more time to coordinate preadmission planning, flag high-risk patients, and prepare discharge pathways.

In risk stratification, AI can combine clinical, social and behavioral variables to identify patients at higher risk of readmission or avoidable utilization. These insights can drive targeted outreach, follow-up scheduling, medication adherence support and escalation to clinicians when needed.

In referral optimization, AI can help discharge planners compare post-acute providers based on cost, quality, network status and geography. This moves referrals away from purely relationship-based patterns and toward evidence-based site-of-care decisions.

In care management, intelligent worklists can prioritize outreach based on missed follow-ups, medication adherence signals, predicted deterioration, and other risk indicators. This helps care coordinators focus their time where it is most likely to reduce avoidable utilization.

In performance analytics, dashboards can combine claims and EHR data to identify cost outliers, physician variation, skilled nursing facility utilization patterns, network leakage, and projected financial exposure. Generative AI can help summarize performance drivers in plain language, but it should support decision-making rather than replace clinical or operational judgment.

5. The ZS approach: connect analytics to execution

Our perspective is that providers do not need another disconnected analytic tool. They need an integrated operating model that turns episode data into timely action. Providers can follow a four-layer framework that connects the data foundation to performance management.

The first layer is the data and analytics foundation. Providers need to ingest and harmonize EHR, ADT, CMS claims and post-acute care data into a usable episode analytics environment. This enables historical cost benchmarking, real-time patient identification and the model inputs required for risk scoring and referral optimization.

The second layer is intelligent episode operations. This includes automated patient identification, AI-enabled risk stratification, preferred post-acute provider lists and patient-reported outcome data capture where required. These capabilities help move bundled payment management upstream, before cost and quality issues are locked in.

The third layer is care management and coordination. Standardized protocols, role-based workflows and patient-facing communication help translate analytics into actions taken by care coordinators, physicians, post-acute partners and patients.

The fourth layer is performance management and strategy. Leaders need episode-level financial dashboards, quality composite tracking, network leakage analysis, physician variation reporting and scenario modeling for future model participation. These tools help the organization decide when to expand, where to intervene, and how to prepare for models such as CJR-X.

6. A practical readiness agenda

For providers participating in TEAM or preparing for future bundled payment expansion, the next 12 months should focus on execution.

In the foundation phase (Q1), providers should assess data infrastructure, analyze historical episode costs, review target prices, establish baseline quality performance, and define their convener strategy. In the operations build phase (Q2), they should integrate ADT and EHR feeds, automate patient identification, build risk stratification models, define care protocols, and establish preferred post-acute networks.

Once those capabilities are in place, organizations can shift toward performance lift (Q3). This includes launching episode dashboards, reviewing physician variation, analyzing network leakage, simulating reconciliation performance and assessing the likely impact of expanded joint replacement accountability. Over time, the same infrastructure can support broader specialist alignment, ACO integration, generative AI workflow support and commercial bundle strategy (Q4 and beyond).

Providers should also establish a focused set of success metrics. These could include risk-adjusted cost per episode, in-network referral rate, 30-day readmission rate and home health utilization ratio. These metrics give leaders a practical view of financial performance, referral discipline, avoidable utilization and post-acute care mix.

Bundled payments are becoming a more prominent and more demanding part of the value-based care landscape. TEAM is already active for selected hospitals, CJR-X points toward broader joint replacement accountability, and CMS’s broader model activity suggests that episode and specialty accountability will continue to expand.

For providers, success will depend on building durable operating capability before financial exposure increases further. That means stronger data infrastructure, earlier patient identification, more precise risk stratification, better post-acute referral management, standardized care pathways and performance visibility that supports in-flight intervention.

The organizations that invest now will be better positioned to protect margin, improve quality, and compete in a reimbursement environment where value-based accountability is no longer optional. ZS can help providers accelerate that journey by connecting episode strategy, AI-enabled analytics, care management workflow and performance management into one practical operating model.

Read more insights from ZS.

This article reflects the authors’ personal views and does not necessarily represent any official position of ZS.

Bundled payments: Navigating the next era of value-based care was originally published in ZS Associates on Medium, where people are continuing the conversation by highlighting and responding to this story.

By John Cole, Talha Bhatti, Harbinder Raina and Pritpal Virdee

Note: The second of three articles on entry into the Chronic Condition Special Needs Plan (CSNP) market; the first made the strategic case, the third covers implementation.

Executive summary

The first article made the strategic case for CSNP entry; the next step is not to file but to determine readiness. Done right, the assessment is not a checklist but the decision itself: is the opportunity real and capturable, can the plan operate a CSNP to the standard CMS and NCQA require, and which gaps must close before filing.

It runs in three stages: a strategic screen of entry prerequisites, a capability maturity assessment across every operational capability a CSNP demands, and a financial model translating the findings into multiyear cost and return.

Within the second stage, a handful of capabilities including the model of care and care management, risk documentation, the provider network and the broker and sales channels that reach eligible members determine most outcomes. These capabilities are where entries most often fail and where the economics are won or lost. For a DSNP sponsor, the assessment usually confirms the foundation is in place; the question is less whether a capability exists than how ready it is for a new, clinically defined population.

1. Why the assessment is the decision

Filing before ready is costly and largely irreversible within an application cycle. A Model of Care below the NCQA threshold earns a shorter or denied approval instead of the multiyear approval that brings operating stability. A first year staffed for a population the plan does not yet understand produces a poor member experience, leading to member disenrollment and damaging its standing with brokers and providers that were recruited over months. Thin risk documentation or immature care management leaves money on the table in the very population whose acuity was supposed to make the economics work.

These consequences cannot be undone, and by then the cycle has little room to absorb them. The fix is timing: run the assessment before committing capital and locking into a build calendar, while there is time to close gaps.

2. Stage one: the strategic screen

The strategic screen tests whether entry makes sense at all: a real, capturable local-market opportunity rather than a saturated one; Medicare Advantage experience and infrastructure to build on; capital and genuine board-level commitment; the clinical, broker and sales-channel relationships a CSNP depends on; and leadership alignment. For plans with a Medicaid footprint, it also weighs dual-eligible access and integration status.

These prerequisites are gating. If there are two or more foundational gaps, it is too early to invest in capabilities and the foundation should be addressed first. A single gap, or a cluster of less critical concerns, indicates that entry is feasible only through a sequenced implementation plan. A clean screen clears the way to stage two.

3. Stage two: capability maturity and the critical factors

The second stage scores every capability a CSNP requires across clinical operations, the provider network, sales channels and member engagement, information technology and operations, financial management and compliance, and Medicaid integration (for dual plans). Each is rated absent, developing, entry-ready or leading; entry-ready is the minimum to file, leading is where the strongest operators separate financially.

Most dimensions matter, but a smaller set is critical because they determine whether the filing decision can move forward and cannot be remediated after approval. These include proactive care management, PCP alignment and attestation, HCC risk-adjustment documentation, the Model of Care, core SNP systems configuration and clinical data exchange.

Clinical operations carry the largest share of the critical factors. Care management must be proactive: risk stratification that finds members before they deteriorate, health risk assessments within CMS timeframes, individualized care plans maintained, not filed, and an interdisciplinary care team that truly convenes and documents decisions. The Model of Care sits at the center: NCQA scores what genuinely operates, not what is planned; the score decides multiyear approval or a short leash. Transitions of care matter equally: chronic populations cycle through hospital and post-acute settings; a plan that cannot see admissions and discharges in near-real time cannot manage them. A DSNP sponsor has much of this infrastructure; the net-new work is tuning it to condition-specific protocols and acuity tiers.

The provider network faces two questions standard Medicare Advantage never asks. First, can it identify, confirm, and document the qualifying population? Physicians confirm each member’s condition at enrollment and supply the diagnoses driving the care plan and risk-adjusted revenue; the assessment examines SNP training, attestation workflow, physician participation in the interdisciplinary care team, and documentation kept audit-ready between visits, not reconstructed from claims. Second, can it deliver condition-specific care? Standard adequacy is not the test — condition-specific depth is: cardiology for cardiac, nephrology and dialysis for renal, endocrinology for diabetes, plus the durable medical equipment and home health chronic populations rely on. Contracts must reward the work: attestation turnaround, data-sharing obligations and incentives tied to documentation and outcomes, not volume. A DSNP sponsor usually starts ahead; net-new work concentrates in condition-specific protocols and specialist depth.

Sales channels and member engagement decide whether the plan reaches members. The assessment starts with reach and capacity, evaluating whether the broker and field marketing footprint covers the eligible population in target counties. It then tests C-SNP-specific capabilities. Agents must understand condition-based eligibility, physician attestation and the chronic condition special enrollment period, which allows year-round enrollment while the qualifying condition persists and is subject to provider verification. Misinterpreting these requirements can create compliance risk and lead to lost sales.

The assessment also considers certification, training, CMS-approved marketing materials available before the selling season, and compensation that makes participation worthwhile for agents. Once selling begins, the focus shifts to monitoring application quality, rapid disenrollment and complaint trends to identify agent-related issues before they attract CMS scrutiny. Channel mix matters: brokers dominate, provider referrals bring members who stay, and converting the plan’s own eligible members is the lowest-cost, best-defended channel. A DSNP sponsor reuses its brokers but needs C-SNP-specific certification.

Information technology and operations determine whether the clinical model runs at scale. Core SNP systems configuration is critical: enrollment must carry a condition-verification workflow, the care management platform must support stratification, care plans and interdisciplinary documentation, and encounter data must reach CMS complete and on time. Clinical data exchange binds the plan to its network — admission, discharge and transfer feeds, lab and pharmacy data, and bidirectional flow letting care managers and physicians work from the same picture.

Financial management and compliance convert clinical work into sustainable economics: HCC documentation and coding programs, audit readiness, bid development for a condition-defined population, and a compliance function fluent in SNP-specific obligations — Model of Care audits, enrollment verification and marketing rules governing sale of the product.

Medicaid integration, for plans pursuing dual-eligible members alongside or instead of a chronic-condition product, adds state contract status, data-sharing arrangements and coordination requirements — determining which SNP types are even available to file.

4. Stage three: building the financial model

With the market confirmed and capability gaps known, stage three builds the business case: not a revenue estimate but a multiyear profit-and-loss view, actuarially grounded and stress-tested against the variables that move it.

On the revenue side, a clinically defined population carries higher risk scores and supports more complete, well-documented risk capture, lifting risk-adjusted revenue; a four-star contract adds a quality bonus. Because Star Ratings are contract-level, a C-SNP placed under the plan’s highest-rated existing contract carries that rating and bonus from year one rather than earning one anew. These dynamics help explain why MedPAC’s latest published margin analysis (2022 data) put C-SNP operating margins at roughly twice standard Medicare Advantage.

That margin is earned, not granted, so the cost side and ramp matter as much as revenue. The first year typically runs hot: the members most likely to switch are the highest utilizers, and care-management savings have not yet materialized; the trajectory improves as the book matures and care coordination takes hold. Implementation cost is real, but a DSNP sponsor reusing its existing chassis substantially offsets it rather than incurring it anew. The model must reflect this honestly, not assume a smooth first year.

Above all, a credible model is stress-tested. The highest-impact variables, including medical loss ratio, enrollment ramp and underlying risk score and benchmark trend assumptions, require scenario and sensitivity analysis. This approach provides the board with a range of potential outcomes rather than a single point estimate.

The model also ties the assessment together, translating provider-network findings into documentation completeness and risk-adjusted revenue, and sales-channel findings into acquisition cost and enrollment ramp. Built without these inputs, a model is just a guess.

5. From evidence to decision

The lesson easiest to ignore under deadline pressure: on critical dimensions, what counts is what genuinely runs, not what is planned. The Model of Care is scored on the specificity and credibility of the operations it describes, and CMS audits and members’ first-year experience later test whether they are real. A well-written model the organization cannot execute fails where it matters most.

That principle ties the assessment to the fixed CMS calendar, not an internal timeline. The Model of Care and a network that meets adequacy standards must be fully prepared at the time of application. Letters of intent may be used in place of signed contracts, but these areas are evaluated immediately. Systems configuration, care management staffing, clinical data exchange and member materials follow defined CMS deadlines between filing and the effective date and must be implemented, tested and operational before the first member is served.

The output is a weighted maturity profile and a clear recommendation. A strong scorer files on its timeline, using the runway to push from entry-ready toward leading. One organization that meets the threshold but has gaps should develop a prelaunch plan, with the Model of Care and network ready at filing and the remaining capabilities sequenced against required deadlines. An organization that falls short is not yet ready to enter the market. In that case, the appropriate next step is a roadmap that closes critical clinical, network and IT gaps first.

For an established Medicare Advantage plan, particularly a D-SNP sponsor, very little must be built from scratch. Much of the care model and quality infrastructure can be leveraged from existing operations. The remaining work focuses on SNP-specific configuration, condition-specific protocols and the provider and broker engagement that no plan can bypass. As a result, these organizations can often make an entry decision within a single planning cycle, whereas a de novo entrant typically cannot.

6. Readiness is the start, not the finish

A decision to proceed is the beginning of execution, not the end of analysis. The same fixed calendar governing the application also governs the broker and sales-channel engine and the provider build — work that must run in parallel with capability remediation, not after it. The third and final article turns to that implementation.

How ZS helps

ZS’s readiness assessment runs all three stages in one diagnostic: a strategic screen of whether entry is worth pursuing, a capability-maturity assessment spanning clinical, provider-network, sales-channel, IT, compliance and Medicaid-integration dimensions, and a financial model turning findings into cost and return. It draws on two evidence streams. The first is CMS data, which sizes the opportunity and establishes realistic baselines for risk scores, medical loss ratios and Stars performance. The second is primary field research with members, agents and providers, which uncovers demand, channel friction and provider willingness that are not visible in existing datasets. Together, these inputs support a weighted maturity assessment, an actuarially grounded financial model and an evidence-based go/no-go recommendation tied to a specific application cycle.

Contact ZS to assess your CSNP readiness against your target application cycle.

Read more insights from ZS.

This article reflects the authors’ personal views and does not necessarily represent any official position of ZS.

CSNP market entry assessment: Assessing readiness before you file was originally published in ZS Associates on Medium, where people are continuing the conversation by highlighting and responding to this story.

By: John Cole, Talha Bhatti, Harbinder Raina, Pritpal Virdee

Note: This is the first in a three-part article series on the considerations of a health plan to enter the CSNP market. Stay tuned for parts two and three, where we will cover how a plan can assess their readiness and how to implement their CSNP strategy.

Executive summary:

Medicare Advantage (MA) plans are entering a different growth cycle. After years of broad market expansion, overall MA enrollment growth has slowed, while Chronic Condition Special Needs Plans (CSNPs) continue to grow from a relatively small base. There is a timely opening for health plans that already serve large numbers of members with diabetes, cardiovascular disease, congestive heart failure and other qualifying chronic conditions, but have not yet built a product and operating model specifically around them. This article argues that CSNP entry should be viewed as a strategic growth, retention and care-model decision rather than a narrow product expansion.

We explore the opportunity that matters now, how the strategic path differs for non-SNP health plans, DSNP sponsors and plans with both MA and Medicaid managed care assets, and what capabilities must be in place to enter responsibly. Plans that move deliberately can use CSNPs to better serve existing chronic members, strengthen provider and broker relationships, improve documentation and care coordination, and build a more defensible high-acuity Medicare platform; plans that wait risk allowing competitors to define the market before they are ready to compete.

Our recommendation is clear: health plans with significant chronic membership should begin a structured CSNP readiness assessment now.

For plans that already operate a DSNP, the path to CSNP entry is particularly efficient: the Model of Care infrastructure, NCQA approval processes, care management workflows, and Stars governance programs required for CSNP are largely the same as those already in place for DSNP, making incremental entry faster, lower-cost, and lower-risk than a de novo build.

1. Why CSNP and why now?

The Medicare Advantage market is decelerating. MA enrollment growth slowed to 4% in 2025, the lowest rate since 2007, and millions of members have been displaced by plan terminations in consecutive years. Against that backdrop, CSNP enrollment has grown at ~43% per year on average since 2022 and surged 71% in a single year from 2024 to 2025. This is not a rounding error in a flat market; it is the fastest-growing segment in Medicare Advantage.

The opportunity begins with your existing membership. Approximately two-thirds of Medicare Advantage members have at least one of the chronic conditions that qualify for CSNP enrollment. Those members are already in your plan — the question is whether you are serving them through a product and care model designed for their needs, or whether a CSNP competitor will. The question is whether your plan is capturing the revenue and delivering the care model those members warrant or leaving both to competitors.

National carriers are not waiting. UHG, Humana and Elevance have already captured more than 75% of the national CSNP market, and CSNP plan counts grew sharply from 2025 to 2026 across all major entrants. Plans that delay entry are ceding clinical infrastructure, broker relationships and provider loyalty to competitors building moats now.

Three structural advantages make CSNP attractive relative to both standard MA and DSNP: no Medicaid contract is required; the member population is clinically defined and homogeneous, enabling more targeted care management; and the payback period on clinical infrastructure investment is faster than DSNP entry. A fourth advantage applies specifically to plans that already operate a DSNP: the CSNP can be built on the same operational chassis. The Model of Care, NCQA approval process, care management infrastructure and Stars governance required for CSNP are the same four domains already running in a DSNP. For these plans, CSNP entry is not a new build — it is an extension of infrastructure already in place, making it the most capital-efficient path to expanding high-acuity market coverage.

2. The strategic case by plan profile

Profile A: Non-SNP MA plans (no SNP)

Your chronic members receive benefits designed for an average population. A CSNP would be designed specifically for this group and paid more accurately.

The structural mismatch

A standard MA plan is built for a broad Medicare population. Members with chronic conditions are included in that pool, but the benefits, care management model and clinical workflows are not always designed around their specific needs. For members managing diabetes, cardiovascular disease or heart failure, that can create a real gap. This population may need more coordinated support than the standard MA model provides, and the plan may not be capturing the full clinical picture through HCC documentation.

That gap becomes more exposed when a CSNP competitor enters the market. A plan offering condition-specific benefits, clearer care coordination and a more targeted member experience has a strong value proposition for chronic members. Once those members move, they can be difficult to win back, particularly if the new plan builds stronger provider relationships and becomes the default option for that population.

The financial case

CSNP operating margins averaged 7.4% in 2022, compared to 3.6% for typical MA plans (this is the most recent year for which published plan-level margin data is available; although decreasing more recently, trends are consistent with this benchmark and estimate that CSNP operating margins are roughly double typical MA plans). This reflects more complete HCC capture for a clinically defined population, combined with higher county benchmark rates that apply to CSNP-eligible conditions, which are set separately from standard MA rates and generally reflect the higher expected cost of serving a clinically complex population. Plans achieving 4+ Stars receive an additional 5% benchmark uplift, which is more attainable for plans with concentrated CSNP populations, as the homogeneity of the member mix and focused care management model can support stronger performance on the chronic condition quality measures that drive Stars scores. The financial case for a well-operated CSNP is compelling from year one.

In many cases, a CSNP should be implemented under an existing HMO H-contract with the highest Star rating unless there is a significant difference between the PPO and HMO Star ratings. This allows plans to leverage its current Medicare platform while building the required SNP application, Model of Care and condition-specific operating capabilities.

MA-only plans have one structural entry advantage that competitors cannot quickly replicate: an existing enrolled chronic membership. Internal conversion of members who already qualify offers a substantially lower acquisition cost. A further financial advantage applies in Year 1: CMS uses a blend of plan-specific and MA-wide risk scores for new enrollees, but CSNP plans benefit from a more favorable risk adjustment methodology in their initial year of operation because the enrolled population is clinically defined by condition, which typically supports stronger HCC documentation and more complete risk capture from the outset.

Bottom line

Your chronic members likely need a more targeted care model than standard MA can provide, and their acuity may not be fully reflected in current documentation. A CSNP will give the plan a cleaner way to serve that population, support better risk adjustment and protect members who competitors are already targeting with more tailored products.

Profile B: Plans with DSNP, no CSNP

You have an established plan that has the MOC infrastructure, care management workflows and Stars discipline that can transfer directly toward a CSNP plan.

Built to expand

CSNP and DSNP share the same four Models of Care domains required by CMS, as well as the same NCQA approval process. Your DSNP care management team, Stars governance program and specialist network are all directly reusable. The primary additions are condition-specific eligibility verification and tailored benefit design, which represent an administrative increment relative to your existing infrastructure.

CSNP can typically be added to an existing H-contract. For DSNP plans with MOC infrastructure already in place, the preparation timeline is significantly shorter than for a de novo entrant, providing a meaningful competitive advantage given the fixed application cycle.

The population DSNP cannot reach

DSNP serves full-benefit dual eligibles. CSNP serves an adjacent, larger population: Medicare beneficiaries with serious chronic conditions who are not Medicaid-eligible and partial duals with lower social complexity. Adding CSNP means covering three high-acuity segments with one coherent clinical model, and a product portfolio competitive with national carriers.

Bottom line

You have already built much of the infrastructure a CSNP would require. Adding CSNP is not a ground-up effort; it is an extension of the capabilities you already use to serve high-acuity members. That makes the incremental cost of entry lower, while opening access to a broader chronic population that your DSNP alone cannot reach.

Profile C: Plans with MA and a Medicaid MCO, no CSNP

Your Medicaid contract is the scarce asset that excludes every MA-only competitor from DSNP that you can lead with

The strategic position you already hold

Plans that operate both MA and Medicaid managed care start from a stronger position than most competitors. They possess two capabilities that define the ceiling of SNP strategy: (1) Medicare clinical infrastructure and (2) Medicaid integration depth. In States with restrictive DSNP integration requirements — note that these apply to DSNP, not CSNP, which does not require a Medicaid contract; however, where state DSNP rules effectively require a Medicaid relationship for DSNP market access, that same relationship becomes a structural barrier competitors cannot replicate, your Medicaid contract may be the requirement that makes market entry possible.

Much of the Medicaid infrastructure already in place can support SNP operations. Community health worker programs, SDOH referral networks, care management teams and Medicare-Medicaid data sharing all align closely with what a strong SNP MOC requires. No competitor without both contracts can replicate this starting position.

The sequencing opportunity

For a plan with Medicaid capabilities, the recommended sequence is clear: launch DSNP first, then add CSNP once DSNP is operational.

Step 1: Establish your SNP foundation. Plans with a Medicaid managed care contract hold an asset that most MA-only competitors cannot quickly replicate. Leveraging that relationship to enter the dual-eligible market first allows you to build the Model of Care infrastructure, provider alignment and Stars governance that form the operational foundation for any SNP strategy. Where applicable, pursuing FIDE or HIDE SNP designation can provide additional per-member payment advantages and stronger positioning as integration requirements continue to evolve — though FIDE and HIDE designations carry meaningfully higher operational and integration requirements than a coordinated DSNP and should be evaluated carefully against the plan’s Medicaid integration depth and state partnership readiness.

Step 2: Extend to the broader chronic population. Once SNP infrastructure is in place, adding a CSNP extends your reach to the large chronic non-dual population — Medicare beneficiaries with qualifying conditions who are not Medicaid-eligible and cannot enroll in a DSNP. The shared MOC framework, care management team and quality infrastructure make incremental entry substantially faster and lower risk. Together, the two products allow a plan to serve the full high-acuity Medicare spectrum with a coherent clinical model.

Bottom line

A Medicaid contract will give you a path into a market that MA-only plans may not be able to access. Launching a DSNP first to establish SNP infrastructure, then adding CSNP in a subsequent plan year once DSNP operations are stable, is the logical sequence that will allow you to serve chronic members who do not qualify for DSNP. These are sequential steps, not concurrent launches — attempting both in the same application cycle would compress the MOC development timeline and increase operational risk. Together, the two products create a broader high-need Medicare platform built on infrastructure competitors cannot easily replicate.

3. Capability readiness: What it actually takes

Most plans underestimate the gap between standard MA operations and CSNP requirements. Two areas are especially critical and difficult to build quickly: PCP alignment and clinical data exchange. Without deep PCP relationships that support condition-verification workflows, and without structured bidirectional data exchange to support HCC documentation between visits, both revenue capture and Model of Care execution will perform below potential regardless of care management team quality.

Entry at insufficient operational maturity carries real regulatory risk: MOC scores below CMS thresholds result in limited approval periods or denial. The right approach is to assess current capability honestly before filing, invest in the gaps and enter with infrastructure that can sustain a multiyear approval.

ZS has developed a structured capability assessment framework across seven dimensions — from care management maturity and data exchange to broker readiness and Stars governance — that maps each plan’s current state, identifies the critical path to CSNP entry readiness and sizes the investment required. A companion article details the full assessment methodology, capability scoring framework and financial modeling approach. A third article in this series addresses go-to-market execution — including broker and distribution channel strategy, agent education and provider-assisted enrollment — as well as capability gap remediation and the end-to-end implementation roadmap from CMS application through first member effective date.

4. The cost of waiting

The CSNP market is growing faster than the broader Medicare Advantage market, and the underlying need is not going away. By 2030, roughly 40% of Medicare beneficiaries are expected to have three or more chronic conditions. Plans that want to compete for that population need to make decisions now, because CSNP entry is not immediate. Between the CMS application cycle, Model of Care development, provider alignment, data readiness and broker preparation, a plan that starts today may not see its first CSNP enrollment for close to two years.

That timing matters. Early entrants have more time to build broker confidence, secure provider participation and become the familiar option for chronic members before the market becomes crowded. National carriers are already moving. For regional and local plans, the window to establish a credible position is still open, but it is narrowing.

Contact ZS to begin your CSNP Market Entry Assessment for market sizing, capability gap analysis, financial modeling and CMS application support.

Read more insights from ZS.

This article reflects my personal views. They do not necessarily represent any official position of ZS.

A strategic case for health plans to enter the chronic special needs plan market was originally published in ZS Associates on Medium, where people are continuing the conversation by highlighting and responding to this story.