Open Dialogue with CMS on Key Regulatory Issues Vanessa Duran, Director Division of Policy, Analysis & Planning Medicare Drug & Health Plan Contract Administration Group October 28, 2011

Overview Summary of the CY 2012 SNP Model of Care (MOC) approval process Review of MOC implementation Highlights of the CY 2013 Parts C & D regulation

SUMMARY OF THE CY 2012 SNP MOC APPROVAL PROCESS

NCQA SNP MOC Approval All SNPs must be approved by the National Committee for Quality Assurance (NCQA) based on standards developed by CMS. CMS established the SNP Model of Care (MOC) as the basis of NCQA’s approval of SNPs.

Standards for NCQA SNP Approval Multi-year approval schedule: Incentives for SNPs to exceed our minimum passing score of 70% Decreased burden for MAOs and CMS Benchmarks for approvals: 3-year: scores of 85% or greater 2-year: scores of 75-84% 1-year: 70-74%

Approval Process Implementation MOC approval implemented as part of the SNP application process: Leveraged an existing process Provided two opportunities for MAOs to cure MOCs (to include improving already passing scores) in parallel with MA application process

Implementation Challenges New process for all SNPs First time CMS has developed benchmarks for the Models of Care (MOC) and reviewed and scored them on specified standards. Timing of the regulatory process Regulations and specific standards for approval not released until after the first submission

Throughout the approval process, CMS and NCQA hosted: Technical Assistance Throughout the approval process, CMS and NCQA hosted: 4 Initial Review TA calls 2 Cure 1 TA Calls 1 Cure 2 TA Call Many one-on-one TA calls with individual MAOs

SNP MOC Approval Results No SNPs were non-renewed as a result of the MOC review and approval process Most plans received multi-year approvals MOC approval information posted at: http://www.cms.gov/SpecialNeedsPlans/03_SNPMOC.asp

Taking Stock of 2012 Approval Process “Lessons Learned” session with the industry this fall Review of MOC implementation for a sample of plans in 2012 Stable MOC elements and scoring criteria for 2013

Evaluation of moc implementation

MOC Review - 2012 Goal: To determine whether SNPs are indeed implementing their NCQA-approved MOCs Reviews of 150 contracts, including all SNP types Representative sample of SNP types and geographic locations Timeline: April 2012 - November 2012.  Individual results from these reviews will be shared with SNPs

Highlights of the CY 2013 Parts C & D regulation

CY 2013 Parts C & D Proposed Rule CMS 4157-P was published in the Federal Register on October 11th Public comment period ends December 12th Proposals specifically impacting SNPs: New Benefit Flexibility for FIDE SNPs Application Requirements for SNPs

Benefit Flexibility for FIDE SNPs Proposal to give certain high-quality FIDE SNPs new flexibility to offer additional Medicare supplemental benefits beyond those that CMS currently allows for other MA plans Proposal developed jointly by the Medicare Contract Administration Group & the Medicare-Medicaid Coordination Office

Benefit Flexibility for FIDE SNPs (cont.) Considering supplemental benefits that may prevent health status decline and reduce the quantity & cost of health care needs Types of supplemental benefits may include: Personal care services in the home Non-skilled nursing activities in the home Custodial care In-home food delivery

Benefit Flexibility for FIDE SNPs (cont.) Proposed criteria to qualify for proposed benefit flexibility: FIDE SNP Operational in current and previous contract year High-quality (as defined by CMS in the CY 2013 draft/final call letter) Other criteria that CMS establishes

Application Requirements for SNPs Proposal broadens our regulations on application requirements and evaluation and determination procedures to also apply to SNP applicants Current regulations pertain only to applicants that have been determined unqualified to enter into an MA contract, and do not provide for appeal rights to applicants who have been determined unqualified to offer a SNP

Application Requirements for SNPs (cont.) The proposed provision would: Specify the documentation SNP applicants must provide to complete an application Provide SNP applicants with the same rights and responsibilities as applicants applying to contract as MAOs Provide each applicant that has been determined unqualified to offer a SNP the same right to an administrative review process as each applicant that has been determined unqualified to enter into an MA contract

Questions? Vanessa Duran, 410-786-8697, vanessa.duran@cms.hhs.gov Jaya Ghildiyal, 410-786-6573, jaya.ghilidayal@cms.hhs.gov Sabrina Ahmed, 410-786-7499, sabrina.ahmed@cms.hhs.gov Vanessa Sammy, 410-786-2613, vanessa.sammy@cms.hhs.gov