Medicare Advantage Special Needs Plans

Alissa Eden Halperin, Esq.Pennsylvania Health Law

ProjectCopyright © 2008

The Pennsylvania Health Law Project.

Medicare Advantage Special Needs Plans

Coordinated Care Plan that provides A, B, and D and is allowed to exclusively or disproportionately enroll

– dual eligibles– persons with defined chronic conditions– “institutionalized” individuals

For 2007 contract year, must designate on application that want to be a SNP and answer limited questions

For 2008 contract year, SNPs must articulate their “model of care” but, CMS sets no requirements for the model of care, the network, the coordination of care or benefits, etc.

Who are Special Needs Individuals

Chronic Conditions – Individuals with severe or Disabling Conditions – SNP can choose which condition groups they want to serve and apply for approval to serve just that population

Dual eligible Medicare beneficiaries. That is, beneficiaries entitled to Medical Assistance under a State Plan under Title XIX, (Medicaid) – SNP can choose to serve all duals or subset of duals (as of 2007)

Who are Special Needs Individuals

CMS’s Final SNP Guidance states that an “institutionalized individual” for purposes of an Institutional SNP is a Medicare Advantage eligible

– who resides or is expected to reside continuously for 90 days or longer in a long-term care facility that is either a skilled nursing facility (SNF), nursing facility (NF), SNF/NF, intermediate care facility for the mentally retarded (ICF/MR) or an inpatient psychiatric facility.

– In addition, individuals residing in a community setting but requiring an institutional level-of-care may also be considered long-term institutional residents for purposes of determining who can enroll in a special needs plan, subject to CMS approval

What are MA-SNPs??

Growth since 2003– 2004: 11 SNPs approved– 2005: 125 approved– 2006: 276 approved (in 41 states and PR)

226 for dual eligibles 37 for institutionalized individuals 13 for individuals with chronic conditions

What are MA-SNPs?

Mid Year 2007: 469 approved, enrolling 842,840 beneficiaries:– Dual eligibles: 310 plans/621,986 enrollees– Institutionalized: 85 plans/139,761 enrollees– Chronic conditions: 74 plans/81,093 enrollees

End Year 2007: 477 approved, enrolling 1,080,593 beneficiaries:

– Dual eligibles: 320 plans/751, 784 enrollees– Institutionalized: 84 plans/183, 881 enrollees– Chronic conditions: 73 plans/144,928 enrollees

Total SNPs approved for 2008 – 775– Dual eligible – 441– Chronic or disabling condition – 245– Institutional – 89

Why should you care about MA SNPs?

One mechanism through which to get Part D benefits

Tremendous growth and massive marketing efforts

Significant Enrollment was not “actively” chosen– Passive Enrollment in 2006 - ~210,000 beneficiaries

in 13-14 states– Puerto Rico – 240,000 enrolled

Potential for future passive enrollments as per “State Guide to Integrated Medicare and Medicaid Models,” CMS March 2006

Why should you care about MA SNPs?

Rapid growth of MAs and MA SNPs is due, in part, to increased payments, aggressive promotion within the industry and aggressive marketing

MA SNPs do hold potential for integrated, coordinated care which could greatly benefit each of these designated populations

Significant problems experienced by consumers due to lack of requirements imposed on SNPs

What are the Requirements for SNPs?

To date, no regulations concerning either– What is needed to be approved as a SNP or– What is needed to continue to function as a SNP

Most guidance to date concerns enrollment and marketing activities that plans may undertake

CMS has put out Guide for States on how and why to contract with SNPs

CMS and NCQA are proposing to evaluate quality in SNPs

Big Picture Look at SNPs

SNPs are authorized through the end of 2008 Report to Congress due the end of 2007 Congress RIGHT NOW considering whether/how to

reauthorize Enrollment in a SNP is enrollment in a Medicare Advantage

plan and all that comes with that – including:– Limited networks of participating providers– Referrals and prior authorization

requirements SNPs are permitted to hold selves out as specially

equipped and designed to meet target population’s special needs without being held to do much of anything in particular to achieve this end

Issues in advising clients about SNPs

There are so many questions and concerns about what the SNP does, how it adds value for the consumer, and whether it is “special”

Our clients’ experiences raise considerable questions about this

SNP Enrollees’ Problems

Information Enrollment and Transition Issue Coverage Issues Network and Provider Issues

SNP Enrollees’ Information Problems

Upon Initial Enrollment, Special Needs Individuals are unfamiliar with Managed Care. They lack clear information on how the SNP works, what it costs, or who is in the network.

Throughout enrollment, SNP enrollees lack sufficient information of changes to their coverage and they lack a means of obtaining realtime answers to questions about their coverage.

Upon disenrollment, SNP enrollees lack clear information of how to transition to new coverage.

SNP Enrollees’ Enrollment and Transition Problems

Upon Initial Enrollment, Special Needs Individuals have trouble transitioning into their new coverage

– They do not get continuity of care when they are in an ongoing course of treatment.

– They do not get time to transition to new plans network, through new plan’s procedures for service approvals, etc.

Upon Disenrollment, SNP enrollee is not provided with continuity of care from SNP.

SNP Enrollees’ Coverage Problems

During Enrollment, SNP enrollees have been unable to obtain

– Coordination of benefits or coordination of care For duals – between SNP coverage and Medicaid coverage For others – between SNP coverage and other private

insurances– Assistance in navigating the SNP’s benefits or internal

processes for prior authorization, formulary exception, or appeals

– Continuity of care when benefits or networks change

SNP Enrollees’ Provider and Network Problems

SNP enrollees have been unable to – Obtain accurate information about or help in accessing

providers– Help from SNPs in stopping SNP providers from balance

billing SNPs have had

– Insufficient networks to meet consumer need– Unwillingness to ensure network providers take Medicaid and

refrain from balance billing dual consumers SNP providers have

– Refused to participate in Medicaid, to balance bill Medicaid, or to understand Medicaid coverage rules

Additional Questions Raised About Institutional SNPs

For Institutionalized individuals– What does the SNP offer that is not required by the

federal nursing home reform law, or, in the case of services for people with mental retardation, by the requirements of intermediate care facilities for the mentally retarded?

– How reconcile the requirements of NHRA?– What cost?– How is care limited or managed?– What network for HCBS folks? How helped?

Additional Questions Raised About Chronic Condition SNPs

For individuals with Chronic Conditions– What is the breadth of the SNP’s

enrollment?– How is their specialty/network/panel

comprised to serve enrollees?– What are network access requirements?– How is care coordinated?– Can specialists be PCP or are referrals to

“specialists” required?