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Types of MA Plans

Types of MA Plans. Coordinated Care Plans HMO PSO Local PPO Regional PPO SNP. Other MA Plans. Private Fee-for-Service Medical Savings Account (MSA). What do MA Plans Offer?. Provide the full Medicare Part A and Part B benefits

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Types of MA Plans

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  1. Types of MA Plans • Coordinated Care Plans • HMO • PSO • Local PPO • Regional PPO • SNP

  2. Other MA Plans • Private Fee-for-Service • Medical Savings Account (MSA)

  3. 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

  4. Access to MA Plans • Beginning January 2006, 98% of all Medicare beneficiaries have access to an MA plan

  5. 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

  6. 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

  7. 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

  8. 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

  9. SNPs • Approved Chronic Care SNPs • DM - COPD • CHF - Cancer • ESRD - Cardiomyopathy • CAD - Stroke • Mentally ill - HIV/AIDS

  10. 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

  11. 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

  12. 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

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

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

  15. SNP Concerns • Chronic Care • Inclusion of multiple co-morbidity conditions • Ensuring access to non-institutional care

  16. 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?

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