Medicare Advantage Other Medicare Plans September, 2015

SNPs may be any type of Medicare Advantage Coordinated Care Plan, including local or regional preferred provider organization (PPO) plan. 3 common types of SNPs: Chronic Condition SNPs (C-SNPs) Dual Eligible SNPs (D-SNPs) Institutional SNPs (I-SNPs) 2 Types of SNPs

Longstanding barrier to coordinating care for Medicare-Medicaid enrollees has been financial misalignment between Medicare and Medicaid. Qualifying states have an option to pursue one or both of the capitated or the FFS financial alignment models. In states with approved demonstrations, CMS will test these models over the next several years. CMS is also working with some states to pursue demonstrations outside the capitated and FFS financial alignment models. 3 Financial Alignment: Medicare and Medicaid

Capitated Model: – State, CMS, and a health plan enter into a three- way contract – Plan receives a prospective blended payment to provide comprehensive, coordinated care. Managed Fee-for-Service (FFS) Model: – State and CMS enter into an agreement by which the state would be eligible to benefit from a portion of savings from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid. 4 Two Models

Restricts enrollment to special needs individuals with specific severe or disabling chronic conditions. Approximately two-thirds of Medicare beneficiaries have multiple chronic conditions requiring coordination of care among primary providers, medical and mental health specialists, inpatient and outpatient facilities, and extensive ancillary services related to diagnostic testing and therapeutic management. 5 Chronic Condition SNPs (C-SNPs)

D-SNPs enroll beneficiaries who are entitled to both Medicare (Title XVIII) and Medical Assistance from a State Plan under Title XIX (Medicaid) 5 CMS-approved enrollment categories for D-SNPs: o All-Dual D-SNPs; o Full-Benefit D-SNPs; o Medicare Zero-Cost-sharing D-SNPs; o FIDE SNPs; and o Dual eligible subset D-SNPs. 6 Dual Eligible SNPs (D-SNPs)

Restrict enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for the mentally retarded (ICF/MR), or an inpatient psychiatric facility. 7 Institutional SNPs (I-SNPs)

1.Description of the SNP-specific target population 2.Measurable Goals 3.Staff Structure & Care Management Roles 4.Interdisciplinary Care Team 5.Provider Network having Specialized Expertise & Use of Clinical Practice Guidelines 6.Model of Care Training for Personnel and Provider Network 7.Health Risk Assessment Tool 8.Individualized Care Plan Communication Network 9.Care Management for the Most Vulnerable Sub- populations 8 Models of Care Elements 1.(HRAT)

HRA: Health Risk Assessment ICP: Individualized Care Plan ICT: Interdisciplinary Care Team C-SNP:Chronic Condition Special Needs Plan D-SNP:Dual Eligible Special Needs Plan I-SNP:Institutionalized Special Needs Plan MOC:Model of Care SNP:Special Needs Plan 9 SNP Acronyms

Medicare OR Medicaid Team of health professionals – May need to use PACE-preferred doctor Services delivered in the home, community, or PACE center Program of All-Inclusive Care for the Elderly

55 or older Live in PACE service area Need nursing-home level of care – As certified by State – But only 7% live in nursing home Can live safely in community with help of PACE 11 PACE Eligibility

May include services Medicare or Medicaid doesn’t cover Adult day primary care Dentistry Emergency services Home care Prescription drugs Transportation if medically necessary 12 Services included

Depends on financial situation – If you have Medicaid, no monthly premium for long-term care Otherwise, pay for long-term care portion of PACE benefit and Part D premium – No deductible or copay for any drug, service, or care approved by your health care team – If no Medicare or Medicaid, can pay for PACE privately 13 What You Pay

Alaska, Arizona, Connecticut, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Kentucky, Maine, Minnesota, Mississippi, Montana, Nevada, New Hampshire, South Dakota, Utah, Vermont, West Virginia 14 States without a PACE Program