NASMD Fall Meeting

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Special Needs Plan Overview

• NASMD Fall Meeting
• Coordination of Duals and SNPs
• November 13, 2008
• Valerie Wilbur, Vice President, NHPG
• Co-Chair, SNP Alliance

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SNP Alliance

• Strategic alliance of SNP leaders, including all
  SNP types, plans from specialty care demo
  predecessors, and affiliations among key dual
  integration States.
• Our mission is to improve the long-term business
  viability of Special Needs Plans.
• Our policy priorities include improving
  risk-adjusted financing for high-risk
  beneficiaries, integration of Medicare and
  Medicaid, and improved performance measurement
  for chronically ill beneficiaries.
• Membership by invitation requires application
  process and agreement to SNP Alliance quality
  standards.

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Session Focus

• SNP overview
• MIPPA reforms and new requirements
• Status of SNP-State contracting HHS study
• Status of SNPs SNP Alliance Profile and
  Advanced Practice Survey

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Special Needs Plans (Definition)

• Any MA Coordinated Care Plan that exclusively or
  disproportionately enrolls beneficiaries who
• Are institutionalized or need an equivalent level
  of care in the community
• Are dually eligible for Medicare and Medicaid or
  
• Have severe or disabling chronic conditions.

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Congressional Intent

• Single umbrella for expiring demos for special
  needs beneficiaries.
• Vehicle for promoting specialization for
  high-risk beneficiaries.
• Vehicle for aligning Medicare Medicaid policy.

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2003 MMA Authority

• Primary authority linked to enrollment options.
• Limited enrollment to target populations.
• Limited subsets of target populations.
• Existing law (not MMA) provided open enrollment
  for duals and institutionalized.
• SNP regs also created one time SEP for C-SNP
  enrollees.
• Requirement to offer Part D benefits.
• No differentiated payment for high-risk.
• No contract or Medicaid benefit rules for D-SNP.
• No specific definition for severe or disabling
  for C-SNP.
• Statutory authority originally expired 12/31/08 .

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SNP Profile
Growth in Number of SNPs

• About 160 MAOs offer SNPs.
• 1.3 million enrolled in 769 SNPs.
• 70 in D-SNPs, 20 in C-SNPs and 10 in I-SNPs.
• Over half of MAOs offer SNPs.
• Half of SNPs had less than 500 enrollees in late
  2007.

769
477
276
136
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04
07
05
06
08
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Key SNP Success Factors

• Advancing SNP authority through targeting and
  specialization.
• Ensuring payment equity for high-risk
  beneficiaries.
• Advancing alignment of Medicare Medicaid
  policy.
• Promoting appropriate performance measurement.

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MIPPA Raises Bar on SNPs

• Strengthens SNP Targeting of Special Needs,
  including 100 enrollment of target population.
• Adds new requirements for complex care management
  and specialization.
• Adds validation rule for institutional SNPs.
• Requires Medicaid contracts/transparency for
  D-SNPs.
• Clarifies expectations for Chronic SNP
  enrollment.
• Establishes MA marketing protections inconsistent
  with nature of special needs populations.

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MIPPA Requirements Care Management

• Evidence-based model of care.
• Appropriate networks of providers specialists.
• Initial and annual assessment of physical,
  psychosocial, functional needs.
• Individual care plans with goals objectives,
  measurable outcomes, specific benefits
  services, with beneficiary input.
• Interdisciplinary teams for care management.

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MIPPA Requirements I-SNPs

• Validation of institutional level of care status
  for those served in community
• Using state-based assessment tool
• Conducted by entity other than plan sponsor.

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MIPPA Requirements C-SNPs

• Beneficiaries 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.
• Clinical Advisory Panel issued recommendations
  about 15 disease categories that meet MIPPA
  criteria.

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C-SNP Eligibility

• Chronic alcohol and other drug dependence
• Autoimmune disorders limited to specific
  conditions
• Cancer excluding pre-cancer conditions or in-situ
  status
• Cardiovascular disorders limited to certain
  conditions.
• Chronic heart failure
• Dementia
• Diabetes mellitus
• End-stage liver disease
• End-stage renal disease
• Severe hematologic disorders
• HIV/AIDS
• Chronic lung disorders
• Chronic and disabling mental health conditions
• Neurologic disorders
• Stroke

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MIPPA Requirements Dual SNPs

• Medicaid contract mandate for D-SNPs
• Effective 2010 for new D-SNPs and SAEs.
• Existing D-SNPs waived in 2010 for current plans.
• Comprehensive written statement of benefits and
  cost-sharing protections under Title XIX.
• Limits on Dual Cost-Sharing for all MA plans.
• CMS resources for state inquires on coordination
  of Federal and state SNP policies.

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Medicaid Contract Mandate

• Requires SNPs to provide or arrange to be
  provided benefits individuals are entitled to
  receive as medical assistance under Title XIX.
• CMS expects SNPs to provide meaningful
  coordination of Medicaid benefits.
• CMS is not expected to require SNPs to provide
  benefits directly, subcontract with another
  entity, or have a financial relationship with
  states.
• CMS recognizes tremendous variation across states
  and is expected to allow SNPs and states to
  negotiate contract coverage consistent with state
  programs.

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Medicaid Contract Issues

• CMS auditing of meaningful coordination.
• CMS requirements for contract execution that
  conflict with state procurement schedules CMS
  will address conflicts on case-by-case basis.
• Differences in state interest and capacity to
  contract with duals.
• CMS level of support in implementing MIPPA
  requirement for state support on integration.

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MIPPA Marketing Issues

• Direct mail marketing methods doesnt work for
  SNPs.
• SNIs dont access information like non-SNIs
  often dont receive or read mail, lack internet
  access, etc.
• SNIs often dont have the ability to make own
  decisions, or track down and evaluate health
  options independently.
• Low-literacy, language barriers result in
  communications challenges conflicting with
  contact, appointment, meals rules.
• Multiple involvement in decisions, guardians hard
  to find.
• Marketing and education venues conflict with meal
  prohibitions.
• Flexibility needed to accommodate nature of SNP
  population and greater use of trusted advisors in
  plan evaluation and enrollment process.

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MIPPA OVERALL IMPACTS

• Raises the bar on SNP targeting and
  specialization.
• Clarifies original intent of Congress re C-SNPs.
• Addresses consumer concerns regarding
  transparency and focus of Dual SNPs.
• Separates serious players from spectators.
• Provides additional momentum for MMI, if
  implemented recognizing state realities.
• Likely will slow growth in number of new plans.
• Lays groundwork for SNP permanence by raising the
  bar.

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HHS Study of SNP-State Contracts

• Based on analysis of 209 SNP applications for
  contract year 2008.
• SNP contract status
• 25 of SNP respondents had contracts
• 11 of SNP respondents had contracts pending
• 63 of SNP respondents had no contracts
• State contract status
• 15 states had contracts (AL, AZ, CA, FL, ID, MA,
  MI, MN, NJ, OR, TN, TX, WI, PR)
• 2 states had contracts pending (LA, NM)
• 35 states had no contracts

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Enrollee and Geographic Distribution

• Distribution of duals served by D-SNPs with state
  contracts
• 9 all duals
• 32 full duals
• 55 subsets
• 4 zero cost-sharing
• Geographic distribution of SNPs with contracts
• 6 statewide
• 22 single county
• 72 multi county

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D-SNP Coordination with States

• D-SNPs with contracts
• 76 use dedicated staff to coordinate services
  and access to Medicaid benefits
• 4 use dedicated staff to coordinate care, but no
  mention of helping with Medicaid and other
  service access
• 9 offered generalizations about coordination of
  services
• D-SNPs without contracts
• 92 intend to work with states to help access
  Medicaid benefits and coordinate care (via
  contracts (11), helping duals access Medicaid
  benefits (69), coordination on cost-sharing or
  Medicaid eligibility verification (5))
• 7 do not intend to work with states

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SNP Alliance Profile Advanced Practices

• SNP Alliance member survey of 2005-07 data.
• 17 MAOs representing 250 plans and 310,000
  beneficiaries.
• Key areas of inquiry
• Are SNPs targeting high-risk subgroups?
• Are SNPs doing anything special?
• Are SNPs making a positive difference?

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SNP Alliance Beneficiary Risk Profile

• 40 higher risk scores than Medicare FFS and MA
  plans.
• 60 more HCCs than Medicare FFS.
• Significantly higher rates of mental health
  disorders and behavioral problems.
• Significantly more socio-economic issues.
• 29 lower inpatient bed days, adjusting for
  health risk, across SNP types.

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SNP Alliance Added Value

• Enrollment of most difficult-to-care-for
  populations.
• Common theme is treatment of whole person.
• Health risk assessments conducted on all members.
• Ongoing care coordination typically provided to
  all beneficiaries in some fashion.
• High-touch approach to care management.
• Greater use of geriatricians, NPs, other
  specialists.
• Richer drug benefits for specific conditions.
• Intensive focus on medication management.

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SNP Alliance Added Value Cont.

• Inter-relationships among mental, behavioral,
  physical health major component of SNP care
  management activities for most SNPs.
• Caregivers are key stakeholders in care planning
  process, often actively participate in assessment
  and care plan development.
• Care managers serve as caregiver liaison, provide
  support, education training, arrange respite,
  etc.
• Establish strong rapport with members, often
  lifetime involvement and special attention to end
  of life care.
• Extensive use of HCBS and non-traditional
  Medicare services, e.g., accessing meals,
  housing, legal aid, etc.

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SNP Gold Standards

• Consumer Empowerment to enable persons with
  serious chronic conditions and family caregivers
  to optimize health and well being based on values
  and preferences
• Specialized Care Systems Expertise to ensure
  benefits are designed to accommodate unique needs
  of high risk groups.
• High-Risk Screening, Assessment, Care Management
  Process to ensure access to the right care at the
  right time at the right place with focus on
  delaying disability progression.
• Aligned Care Providers to address
  multidimensional needs of chronic care
  beneficiaries across time, place, setting.
• System Management Methods to enable all providers
  serving a common population to work
  collaboratively to optimize quality, performance
  and outcomes for high risk beneficiaries.

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Advancing SNP-State Partnerships

• Incentives
• Simplify consumer access to benefits.
• Coordinate all Medicare Medicaid benefits
  administrative efficiency, improve outcomes, cost
  control.
• Extend coverage of dental, vision, HCBS.
• Simplify, stabilize Medicare cost-sharing via
  capitation.
• Strategies
• CMS support of dual initiatives.
• Establish Federal financial support for states.
• Partnerships for outreach, education, program
  development and refinement among SNPs, states,
  CMS, consumers.

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For More Information

• Valerie Wilbur
• Vice-President, NHPG
• Co-Chair, SNP Alliance
• 202-624-1508
• vswilbur_at_nhpg.org