Special Needs Plans

1
Special Needs Plans

• Presented by
• Jill Mendlen
• President/CEO
• [phone]

2
Special Needs Plans What Are They?

• Three Main Types of SNPs
• Dual Eligible
• Institutional
• Chronic Care

3
Dual Eligible SNP

• All Title 19 beneficaries or specific subsets,
  i.e. QMBs, frail elderly, etc.

4
Institutional SNP

• Reside or expected to reside for 90 days or
  longer in a LTC Facility (SNF, NF, ICF or
  inpatient psych)
• Reside in community but meets NF level of care
  as defined by state

5
Chronic Care SNP

• By 2010, enrollees must have one or more
  conditions that are substantially disabling or
  life threatening AND high risk of hospitalization
  or significant adverse outcomes

6
Growth of Special Needs Plans July 2007-July 2008
7
Comparison of Enrollment for Three Types of
Special Needs Plans July 2007-July 2008
8
What Makes a SNP Special?

• Targeted Enrollment
• Continuous open enrollment
• Waiver of 5,000 member rule
• Ability to design specific benefit plan for
  membership
• Specialized clinical programs

9
Whats the Same As Any Other MA Plan?

• Reimbursement
• Paid by HCC-per member payment based on prior
  years clinical experience (hospital, doctor, out-
  patient)

• Regulations
• Provider Network
• Part D
• Medicaid Interface

10
Private Fee For Service Plans

• No quality program requirements
• Must have networks by 2011
• CMS goal 1.8 million reduction in PFFS growth and
  .5 million in total MA by 2013

• Fastest growing MA plans
• 2,271,481 members, 77 Plans as of 8-1-08
• No Network Requirement
• Focus area for regulators and Congress

11
New Regulations 2010

• SNPs originally demo programs
• Now extends through 2010
• Moratorium on approval of new disproportionate
  SNPs
• 100 of SNPs new enrollees must meet criteria for
  plans targeted enrollment
• Institutional SNPs
• Community enrollees must meet institutional
  criteria per state assessment tool

12
New Regulations 2010 (continued)

• Dual SNPs required to have a state contract
• ALL SNPs must have
• Evidence-based model of care with appropriate
  provider/specialist networks
• Systems to collect, analyze and report quality
  data

13
Marketing Reforms for MA Plans as of 1-1-09
Prohibit

• Unsolicited direct contact of prospective
  enrollees- door-to-door sales, cold calling
• Meals at promotional and sales events
• Selling/Marketing in healthcare settings and
  educational events
• Other Requirements
• Limitations on gifts
• Use of state licensed agents and brokers

14
Where Do We Go From Here?

• Current extension through 2010
• Med Pac Report recommended extension through 2012
• Continued focus on quality and clinical program
  requirements

• Major component of state initiatives for Medicaid
  managed care for ABD and dual integration
• Enhanced state/plan interface
• Economic compression
• Cost escalation
• Election outcome???

15
SelectCare of Oklahoma

• An Institutional Special Needs Plan
• Presenter Tom Coble

16
SNP Legislative Intent

• To improve quality and cost outcomes for
  high-risk and vulnerable Medicare beneficiaries
  by providing
• Authority to target and specialize in care of
  high-risk beneficiaries
• Vehicle for specialty demonstration to obtain
  permanent MA authority and replicate program
  innovations
• Platform for integrating Medicare and Medicaid
  for dually eligible beneficiaries

17
Institutional SNP Objectives

• Enhance care for the resident
• Simplify daily life for the families
• Increase compensation, resources and
  communication for the LTC and skilled nursing
  provider

18
Medicare Spending by Service Type, 2004

• All Medicare Eligible
• Hospital Care 55
• Phys Clinical 27
• Other Prof 3
• Home Health 5
• Drugs Other 2
• DME 3
• Nursing Home 5

• LTC Resident
• Hospital Care 47
• Phys Clinical 18
• Other Prof 4
• Home Health 1
• Drugs Other 1
• DME 3
• Nursing Home 26

19
How Does An ISNP Address These Unique Needs?

• Assessment
• Comprehensive assessments and observations to
  identify problems and initiate early
  interventions
• Nurse practitioners visit each member frequently,
  based on the members level of acuity and frailty
• Coordination
• On-going communication between nurse
  practitioners, network providers and nursing home
  staff
• Expedited authorization of services that impact
  member clinical/functional outcomes
• Prevention
• Increased use of skilled level care in the
  nursing home
• Avoid unnecessary hospitalizations and ER visits

20
Benefits To LTC Facility

• Stabilization and preservation of census
• Nurse practitioner available to staff 24/7
• Preauthorization onsite by nurse practitioner
• 3 day hospital stay is waived
• Part B benefits are richer
• Reduces facility transportation cost
• Increases family satisfaction

21
Benefits To Residents

• Treated preventively and proactively
• Nurse practitioner available to see them 24/7
• Can be moved to SNF level without going to the
  hospital
• Can avoid unnecessary hospitalizations and ER
  visits
• DME provided to meet their specific needs

22
Benefits To Families

• Access to nurse practitioner 24/7
• Their loved one is treated in the facility rather
  than the hospital
• Regular updates from nurse practitioner
• Care giver convenience
• Peace of mind

23
In Summary

• Managed Care is the future
• Contracting with an ISNP is a strategic business
  decision
• ISNPs enhances quality of care
• P4P contracts are in the future

24
Contact For QuestionsTom C. CobleHMC of
Oklahoma1908 12th Avenue N.W., Ste BArdmore,
Oklahoma 73401Telephone [phone]tom_coble_at_h
otmail.com
25
Special Needs Plans A Provider Perspective

• Steven Chies
• AHCA Convention 2008
• October 7, 2008

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A Providers Viewpoint

• How do they work from a providers view?
• What are the advantages to the various
  stakeholders?
• What are the challenges in working with the
  plans?
• Is there a future for SNFs and ALFs with these
  plans?

27
How do they work from a providers view?

• Medicaid Eligibles
• Frail and vulnerable individuals
• Chronic diseases
• Care coordination model

28
What are the advantages to the various
stakeholders?

• Care Coordination
• Disease management
• Access to services
• Higher levels of satisfaction

29
What are the challenges in working with the plans?

• Limited number in a single facility
• Decision making
• Restrictions on services

30
Is there a future for SNFs and ALFs with these
plans?

• Opportunity for negotiating a price vs. cost
• Additional resources
• More options and willingness to try
• Ability to share risk and rewards
• Higher patient satisfaction

31
Summary

• The problems that exist in the world today
  cannot be solved by the level of thinking that
  created them.
• Albert Einstein