SNP Value Proposition

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SNP Value Proposition Challenge

• SNPs are only MA plans allowed to target
  enrollment
• SNPs are only MA plans (in many cases) allowed to
  market year round
• SNPs are paid better per capita because of
  vulnerable populations they serve
• Because of this, SNPs must prove they are
  different (special)
• Congress is undecided about the programs future
• CMS SNPs must demonstrate value of the program

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Why are SNPs Different?

• Beyond the normal MA requirements
• Self Documenting Internal Control
• SNP Value Analysis Detailed Condition Specific
• (i.e., CCIP - smoking cessation program)
• This years application is venue of SNPs to
  demonstrate SNPs go beyond other MA plans

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Overview of SNPs

• SNPs created by MMA
• SNPs are MA plans that limit enrollment to
  particular vulnerable populations
• Dual Eligible
• Institutional
• Chronic Condition
• SNPs have grown rapidly
• 2005 137 plans, 129,000 enrolled
• 2008 765 plans, 1,300,000 enrolled

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Overview of SNPs, contd

• MIPPA SNPs
• Moratorium largely lifted
• But only if new conditions and rules are met
• SNP sunset pushed back to 12/31/10
• Most new requirements take effect 1/1/10
• States and Plans must prepare now
• MIPPA gives States a new role in helping SNPs
  demonstrate that they are special

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MIPPA Requirements for Dual SNPs

• Dual SNPs (effective 1/1/10)
• New Dual SNPs must have State Contract
• Incumbent SNPs without State contracts can
  continue through 2010, but cannot expand service
  areas
• Incumbent Dual SNPs must meet other MIPPA
  requirements care management, model of care,
  quality improvement
• All enrollees into new SNPs must be duals (no new
  disproportionate share enrollment)

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State/ SNP Contracting Elements

• 8 specific contracting elements will be listed
  later in presentation
• CMS will provide template contract that State
  SNP may choose to use
• CMS will assist States that are considering
  contracting with SNPs for the first time

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State/ SNP Contracting, contd

• Goal is to stimulate coordination of Medicare and
  Medicaid benefits for duals
• States have considerable options
• States and MAs, through negotiation may identify
  benefit package specific benefits not mandated
  by MIPPA or CMS
• States have the option to selectively contract
  (not mandated to contract w/ all Dual SNPs, or
  cover all service areas)
• Contract may cover certain category (ies) or
  target a subset, e.g., frail elderly

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State/ SNP Contracting, contd

• CMS will consider on a case by case basis,
  documented arrangements (i.e. contract) which
  demonstrate substantial coordination between
  Medicare and Medicaid
• Contracts need to document how Medicaid benefits
  are provided or arranged
• Arrangements must also assure cost-sharing
  protection, eligibility verification, sharing of
  provider participation

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MIPPA Changes

• Chronic Condition SNPs
• 15 conditions
• Multi-Condition C-SNPs

• Institutional SNPs
• LOC Tool
• Use of qualified 3rd party

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A Quick Tour of the SNP Proposal in HPMS
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Institutional SNP Proposal
Yes / No
Number of I-SNPs
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SNP Service Area
Item 1
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SNP Service Area Template
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Institutional SNP Uploads

• Several uploads are required in the third segment
  of the proposal including
• List of long-term care facilities
• List of assisted-living facilities (ALFs)
• Attestation from MAO to enroll only beneficiaries
  eligible for institutional residency
• State level of care tool
• Name, address, and credential (if applicable) of
  person administering the State level of care
  assessment tool

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ESRD Waiver Requests
Item 1
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ESRD Waiver Request Uploads

• How you serve enrollees needs
• List of contracted facilities
• List of transplant facilities
• Additional provided services
• ICT coordinator role /responsibilities

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SNP Model of Care

• You have a MOC
• Address ESRD Needs
• Address the needs of the target population

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Model of Care Elements

• Goals (well-defined and measurable)
• Staff structure and roles
• Interdisciplinary care team
• Provider network
• Model of care training
• Health risk assessment
• Individualized care plan
• Communication
• Performance and health outcomes measurement

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Health Risk Assessment Tool
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Quality Improvement Program Requirements

• Health outcomes and indices of quality
• Access to care
• Beneficiary health status
• Continuity of care
• Health risk assessment
• Implementation of the care plan
• Adequacy of the provider network
• Delivery of services across settings and
  providers
• Delivery of add-on services and benefits for the
  most vulnerable (frail/disabled, near
  end-of-life)
• Use of evidence-based clinical guidelines and
  protocols
• Use on integrated systems of communication
• Quality and outcomes measures that enable
  beneficiaries to compare coverage options

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Quality Improvement Program Upload
Remember Must complete narrative in item 1
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Dual-eligible SNP Proposal

• Segment one requires the entry of general
  information (e.g., number of D-SNPs you will
  offer)
• Segment two requires service area information
  (e.g., State names, county names, codes) and the
  upload of the Service Area template

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State Medicaid Agency Contract

• Beginning January 1, 2010, all D-SNPs must have a
  State Medicaid agency contract.
• Segment three requires information on the State
  Medicaid agency contract.
• Contract start and end dates
• Enrollment categories (e.g., QMB, SLMB, QDWI,
  etc.)
• A State Medicaid agency contract template must be
  completed and uploaded (this can occur beyond
  February 26, 2009).

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State Medicaid Agency Contract Template
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State Medicaid Agency Contract Elements

• Contract beginning and ending dates
• Medicaid benefits covered
• Beneficiary cost-sharing protections
• Identification and sharing of information on
  Medicaid provider participation
• MA organizations responsibilities (i.e.,
  financial obligations) to provide or arrange for
  Medicaid benefits
• State Medicaid agency contact person information
• Process to verify beneficiarys Medicaid
  eligibility
• Process to coordinate Medicare Medicaid benefits

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Dual-eligible SNP Proposal

• The fourth segment deals with the request for an
  ESRD waiver.
• The fifth segment covers the model of care.
• The last segment requires the entry of quality
  improvement program information.

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Chronic Condition SNP Proposal

• Segment one requires the entry of general
  information (e.g., number of D-SNPs you will
  offer)
• Segment two requires service area information
  (e.g., State names, county names, codes) and the
  upload of the Service Area template

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15 CMS-approved Chronic Conditions
In the third segment, select the single severe or
disabling chronic condition SNP you will offer

• Chronic alcohol and other drug dependence
• Autoimmune disorders
• Cancer (excluding pre-cancer conditions)
• Cardiovascular disorders
• Chronic heart failure
• Dementia
• Diabetes mellitus
• Stroke

• End-stage liver disease
• End-sage renal disease requiring dialysis
• Severe hematologic disorders
• HIV/AIDS
• Chronic lung disorders
• Chronic and disabling mental health conditions
• Severe neurological disorders

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Chronic Condition SNP Options

• At the time of your plan benefit package bid
  submission, you must select one of the these
  options
• Option 1 Single chronic condition from the
  list of 15 CMS-approved conditions
• Option 2 One grouping of commonly co-morbid
  and clinically linked conditions (see next slide)
• Option 3 Customized multiple conditions SNP in
  which the eligible beneficiary has all of the
  conditions

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Chronic Condition SNP Options

• Option 2 allows you to select from the five
  groupings below
• Group 1 Diabetes mellitus and chronic heart
  failure
• Group 2 Chronic heart failure and cardiovascular
  disorders
• Group 3 Diabetes mellitus and cardiovascular
  disorders
• Group 4 Stroke and cardiovascular disorders
• Group 5 Diabetes mellitus, chronic heart
  failure, and cardiovascular disorders

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Chronic Condition SNP Proposal

• The fourth segment deals with the request for an
  ESRD waiver.
• The fifth segment covers the model of care.
• The last segment requires the entry of quality
  improvement program information.

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Summary

• Since SNPs must prove that they are in fact
  different then the encumbrance becomes
  demonstrating the value of the program
• - Detailed Condition Specific Analysis
• - Self Documenting Internal Control
• - Expect increased CMS monitoring
• Or,
• Congress may decide to sunset the program

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Training Announcement

• CMS will provide in depth SNP specific
• training later in January 2009.

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SME Contact Information

• Model of Care Questions QIP
• Judy Sutcliffe
• 410-786-1159
• judith.sutcliffe_at_cms.hhs.gov
• General Information Service Area Related Issues
• Marvin Glass
• 410-786-6845
• marvin.glass_at_cms.hhs.gov
• Dual State Contracting Benefit Integration
• Eric Nevins
• 410-786-1162
• eric.nevins_at_cms.hhs.gov