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MEDICARE ADVANTAGE SPECIAL NEEDS PLAN - PowerPoint PPT Presentation


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MEDICARE ADVANTAGE SPECIAL NEEDS PLAN. AN OVERVIEW. SNP Statutory Authority. Established by Section 231 of the Medicare Modernization Act of 2003

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snp statutory authority
SNP Statutory Authority
  • Established by Section 231 of the Medicare Modernization Act of 2003
  • Exclusively or disproportionately serve beneficiaries who are institutionalized or eligible for equivalent level of care, dually eligible for Medicare and Medicaid and those with severe or disabling chronic conditions
  • Authority to limit enrollment to special needs beneficiaries expires December 31, 2009
snp legislative intent
SNP Legislative Intent
  • To improve quality and cost outcomes for high-risk and vulnerable Medicare beneficiaries by providing;
      • Authority to target and specialize in care of high-risk beneficiaries
      • Vehicle for specialty demonstrations to obtain permanent MA authority and replicate program innovations
      • Platform for integrating Medicare and Medicaid for dually eligible beneficiaries
snp types
SNP Types
  • Institutional
      • MA beneficiaries who reside in a long-term care facility
      • MA beneficiaries living in the community who require an institutional level of care based on State approved assessment
  • Dual Eligible
      • MA beneficiaries who are dually eligible for Medicare and Medicaid
  • Chronic Condition
      • MA beneficiaries with severe or disabling chronic conditions
snp program status
SNP Program Status
  • As of May 2008, close to 1.2 million Medicare beneficiaries were enrolled in SNPs offered by 160 MA companies that collectively offer 769 benefit options
      • Dual SNP 844,010
      • Chronic SNP 188,679
      • Institutional SNP 133,982
snp program status cont d
SNP Program Status (cont’d)
  • Nearly 50% of MA contracts include at least one SNP
  • SNP enrollment accounted for about 11% of overall MA enrollment as of July 2007
  • As of November 2007, about 50% of SNP enrollment was concentrated in 9 states and another 23% were in Puerto Rico
snp program status cont d1
SNP Program Status (cont’d)
  • Congress passed legislation in December 2007 placing a moratorium on service area expansion of existing SNPs and new SNP applications
  • Congress has not passed legislation extending SNP authority beyond December 31, 2009
snp provisions
SNP Provisions
  • Must offer all MA services, including Part D drug benefits
  • Are expected to provide specialized benefits and services consistent with the needs of their target population
  • Paid using the same payment methodology used for standard MA plans
snp provisions cont d
SNP Provisions (cont’d)
  • Institutional and dual SNPs have continuous enrollment. There is a “one time” special election period per year for beneficiaries who become eligible to join a Chronic Condition SNP
  • SNPs serving duals not mandated to have state contract for Medicare/Medicaid coordination
snp success factors
SNP Success Factors
  • Program stability
      • Congressional action needed to extend authority
  • Fair and appropriate payment
      • Align SNP reimbursement with specialization requirements
  • Integration of Medicare and Medicaid
      • More work needed for current demonstrations to transition into SNP programs and replication
  • Appropriate quality measures
      • CMS and NCQA are working on SNP specific performance measures
snp contracting considerations
SNP Contracting Considerations
  • Contracts
      • Exclusive or Non-exclusive
      • Rates and payment terms
      • Additional benefits provided
      • Integration of Medicare and Medicaid
  • Medicare Part D
      • What PBM does SNP use
      • What drugs are covered under formulary
  • Care coordination
      • Nurse practitioners on site
      • Telephonic
snp contracting considerations cont d
SNP Contracting Considerations (cont’d)
  • Preauthorization
      • Onsite by nurse practitioner
      • Telephonic
  • Is facility Medical Director contracted with SNP?
  • How does SNP enroll members?
      • Dedicate sales person
      • Agents
  • Does insurance company own other MA products?
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Contact For QuestionsTom C. CobleHMC of Oklahoma1908 12th Avenue N.W., Ste BArdmore, Oklahoma 73401Telephone: 580-223-8805tom_coble@hotmail.com