Michael Fiore, Director Division of Plan Policy Centers for Medicare and Medicaid Services June 6, 2006 Innovations in Medicare Managed Care for Dual Eligible.

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Presentation transcript:

Michael Fiore, Director Division of Plan Policy Centers for Medicare and Medicaid Services June 6, 2006 Innovations in Medicare Managed Care for Dual Eligible Individuals Special Needs Plans:

2 Types of MA Plans  Coordinated Care Plans  HMO  PSO  Local PPO  Regional PPO  SNP

3 Other MA Plans  Private Fee-for-Service  Medical Savings Account (MSA)

4 What do MA Plans Offer?  Provide the full Medicare Part A and Part B benefits  May offer additional benefits to beneficiaries or lower premiums and cost sharing  Each Medicare Advantage Organization (MAO) must offer one MA-PD in each service area

5 Access to MA Plans  Beginning January 2006, 98% of all Medicare beneficiaries have access to an MA plan

6 Special Needs Plans (SNPs)  MMA of 2003 created new type of Medicare coordinated care plan  Allows a SNP to restrict enrollment for certain categories of special needs individuals  Dual Eligibles  Institutionalized Individuals  Severe or Disabling Chronic Conditions

7 SNPs  Dual Eligibles  All Dual Eligibles may be enrolled in a SNP  A Subset of Dual Eligibles may be enrolled, such as Full Dual Eligibles, but not other subsets such as just SLMBs

8 SNPs  Institutionalized Individuals  Reside or expected to reside continuously for 90 days or longer in SNF/NF  Requiring institutional level of care, but living in the community

9 SNPs  Severe or Disabling Chronic Conditions  Case-by-case basis—No specific Federal definition  Appropriateness of target population  Existence of Clinical programs and special expertise  Non-discrimination against sicker members

10 SNPs  Approved Chronic Care SNPs  DM- COPD  CHF- Cancer  ESRD- Cardiomyopathy  CAD- Stroke  Mentally ill- HIV/AIDS

11 SNPs  Disproportionate Percentage May enroll a greater percentage of the target population while include non- targeted Medicare beneficiaries Must enroll target members at a percentage greater than occur nationally in the Medicare population

12 SNPs  Be affiliated with or be an MA plan  Offer all MA services, plus Part D drugs  Provide services tailored to target group  Follow MA plan marketing requirements  Meet all Federal MA plan application requirements

13 SNPs  Set to expire December 31, 2008, But expect/hope for Congressional remedy  Evaluation Report on SNPs due to Congress by December 31, 2007  Assess impact on cost savings  Assess impact on quality of services

14 SNP Concerns  Dual Eligible SNPs  Integration with State efforts  Different Medicare vs. Medicaid enrollment periods  On/off the Medicaid roles

15 SNP Concerns  Institutionalized  Restricting enrollment to designated facilities  Steerage of sicker vs. health individuals  Medicaid medically needy issues  Marketing barriers

16 SNP Concerns  Chronic Care  Inclusion of multiple co-morbidity conditions  Ensuring access to non-institutional care

17 SNP Concerns  How are they providing superior quality?  More open formularies? Fewer restrictions on access?  Which Medicaid services can be provided under the SNP benefit package?