1. Medicare Advantage Special Needs Plans Alissa Eden Halperin, Esq. Pennsylvania Health Law Project Copyright © 2008 The Pennsylvania Health Law Project.

2. Medicare Advantage Special Needs Plans Coordinated Care Plan that provides A, B, and D and is allowed to exclusively or disproportionately enroll – dual eligibles – persons with defined chronic conditions – institutionalized individuals For 2007 contract year, must designate on application that want to be a SNP and answer limited questions For 2008 contract year, SNPs must articulate their model of care but, CMS sets no requirements for the model of care, the network, the coordination of care or benefits, etc.

3. Who are Special Needs Individuals Chronic Conditions – Individuals with severe or Disabling Conditions – SNP can choose which condition groups they want to serve and apply for approval to serve just that population Dual eligible Medicare beneficiaries. That is, beneficiaries entitled to Medical Assistance under a State Plan under Title XIX, (Medicaid) – SNP can choose to serve all duals or subset of duals (as of 2007)

4. Who are Special Needs Individuals CMSs Final SNP Guidance states that an institutionalized individual for purposes of an Institutional SNP is a Medicare Advantage eligible – who resides or is expected to reside continuously for 90 days or longer in a long-term care facility that is either a skilled nursing facility (SNF), nursing facility (NF), SNF/NF, intermediate care facility for the mentally retarded (ICF/MR) or an inpatient psychiatric facility. – In addition, individuals residing in a community setting but requiring an institutional level-of-care may also be considered long-term institutional residents for purposes of determining who can enroll in a special needs plan, subject to CMS approval

5. What are MA-SNPs?? Growth since 2003 – 2004: 11 SNPs approved – 2005: 125 approved – 2006: 276 approved (in 41 states and PR) 226 for dual eligibles 37 for institutionalized individuals 13 for individuals with chronic conditions

6. What are MA-SNPs? Mid Year 2007: 469 approved, enrolling 842,840 beneficiaries: – Dual eligibles: 310 plans/621,986 enrollees – Institutionalized: 85 plans/139,761 enrollees – Chronic conditions: 74 plans/81,093 enrollees End Year 2007: 477 approved, enrolling 1,080,593 beneficiaries: – Dual eligibles: 320 plans/751, 784 enrollees – Institutionalized: 84 plans/183, 881 enrollees – Chronic conditions: 73 plans/144,928 enrollees Total SNPs approved for 2008 – 775 – Dual eligible – 441 – Chronic or disabling condition – 245 – Institutional – 89

7. Why should you care about MA SNPs? One mechanism through which to get Part D benefits Tremendous growth and massive marketing efforts Significant Enrollment was not actively chosen – Passive Enrollment in 2006 - ~210,000 beneficiaries in 13-14 states – Puerto Rico – 240,000 enrolled Potential for future passive enrollments as per State Guide to Integrated Medicare and Medicaid Models, CMS March 2006

8. Why should you care about MA SNPs? Rapid growth of MAs and MA SNPs is due, in part, to increased payments, aggressive promotion within the industry and aggressive marketing MA SNPs do hold potential for integrated, coordinated care which could greatly benefit each of these designated populations Significant problems experienced by consumers due to lack of requirements imposed on SNPs

9. What are the Requirements for SNPs? To date, no regulations concerning either – What is needed to be approved as a SNP or – What is needed to continue to function as a SNP Most guidance to date concerns enrollment and marketing activities that plans may undertake CMS has put out Guide for States on how and why to contract with SNPs CMS and NCQA are proposing to evaluate quality in SNPs

10. Big Picture Look at SNPs SNPs are authorized through the end of 2008 Report to Congress due the end of 2007 Congress RIGHT NOW considering whether/how to reauthorize Enrollment in a SNP is enrollment in a Medicare Advantage plan and all that comes with that – including: – Limited networks of participating providers – Referrals and prior authorization requirements SNPs are permitted to hold selves out as specially equipped and designed to meet target populations special needs without being held to do much of anything in particular to achieve this end

11. Issues in advising clients about SNPs There are so many questions and concerns about what the SNP does, how it adds value for the consumer, and whether it is special Our clients experiences raise considerable questions about this

12. SNP Enrollees Problems Information Enrollment and Transition Issue Coverage Issues Network and Provider Issues

13. SNP Enrollees Information Problems Upon Initial Enrollment, Special Needs Individuals are unfamiliar with Managed Care. They lack clear information on how the SNP works, what it costs, or who is in the network. Throughout enrollment, SNP enrollees lack sufficient information of changes to their coverage and they lack a means of obtaining realtime answers to questions about their coverage. Upon disenrollment, SNP enrollees lack clear information of how to transition to new coverage.

14. SNP Enrollees Enrollment and Transition Problems Upon Initial Enrollment, Special Needs Individuals have trouble transitioning into their new coverage – They do not get continuity of care when they are in an ongoing course of treatment. – They do not get time to transition to new plans network, through new plans procedures for service approvals, etc. Upon Disenrollment, SNP enrollee is not provided with continuity of care from SNP.

15. SNP Enrollees Coverage Problems During Enrollment, SNP enrollees have been unable to obtain – Coordination of benefits or coordination of care For duals – between SNP coverage and Medicaid coverage For others – between SNP coverage and other private insurances – Assistance in navigating the SNPs benefits or internal processes for prior authorization, formulary exception, or appeals – Continuity of care when benefits or networks change

16. SNP Enrollees Provider and Network Problems SNP enrollees have been unable to – Obtain accurate information about or help in accessing providers – Help from SNPs in stopping SNP providers from balance billing SNPs have had – Insufficient networks to meet consumer need – Unwillingness to ensure network providers take Medicaid and refrain from balance billing dual consumers SNP providers have – Refused to participate in Medicaid, to balance bill Medicaid, or to understand Medicaid coverage rules

17. Additional Questions Raised About Institutional SNPs For Institutionalized individuals – What does the SNP offer that is not required by the federal nursing home reform law, or, in the case of services for people with mental retardation, by the requirements of intermediate care facilities for the mentally retarded? – How reconcile the requirements of NHRA? – What cost? – How is care limited or managed? – What network for HCBS folks? How helped?

18. Additional Questions Raised About Chronic Condition SNPs For individuals with Chronic Conditions – What is the breadth of the SNPs enrollment? – How is their specialty/network/panel comprised to serve enrollees? – What are network access requirements? – How is care coordinated? – Can specialists be PCP or are referrals to specialists required?