In fulfillment of a grant from The Commonwealth Fund, the Center for Medicare Advocacy recently issued a report and recommendations aimed at protecting members of Medicare private plans known as "Special Need Plans."

According to the Center's recommendations, all Medicare Special Needs Plan (SNP) enrollees must be assured that their special needs are actually met by SNPs. To that end, the Center recommends that these plans guarantee SNP-specific beneficiary protections, standards for care, and coverage. Further, all of these SNP-specific protections must be enforceable, and actively enforced, by the Centers for Medicare & Medicaid Services (CMS).  The Center for Medicare Advocacy's report and recommendations are available on our website at http://www.medicareadvocacy.org/SNP%20Conference/Home.htm.

The SNP Recommendations Fall into Several Categories, Including:

·    Greater accountability of SNPs in assuring that Medicare beneficiaries receive necessary Medicare-covered services;

·         Improvements to notices about appeal rights and access to services;

·        Better coordination of services for persons eligible for Medicare and Medicaid (the dually eligible);

·         Stronger oversight and enforcement actions by CMS; and

·         Collection and public reporting of outcomes data to demonstrate how SNPs meet the special needs of SNP enrollees.

Many Stakeholders Were Involved in Developing the Center's Report & Recommendations

As part of the process to develop its SNP Recommendations, the Center for Medicare Advocacy convened a group of experts and advocates to examine SNPs at a full-day conference in October 2007.  Based on the conference discussions, published articles, and reports from advocates in the field, the Center developed these Recommendations for consideration by Congress and CMS. (All materials related to the conference are available on the Center's website at the link provided above.)

The Center's conference, "Medicare Advantage Special Needs Plans: A Beneficiary Perspective," was supported by The Commonwealth Fund, an independent foundation working toward health policy reform and a high performance health system.

Background - SNPs: An Old Idea in a New Package

Created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), SNPs were conceptually related to government-supported demonstrations, such as On Lok, the Program of All Inclusive Care for the Elderly (PACE), and the dual eligible integration demonstrations that have, for decades, delivered focused services to populations of Medicare beneficiaries who generally need more intense health care services than the average Medicare beneficiary.  The MMA laid out three specific categories of SNPs: Dual SNPs for those beneficiaries who are dually eligible for Medicare and Medicaid; Chronic SNPs for those beneficiaries who have a specific severe or disabling chronic condition identified by the SNP; and Institutional SNPs for those beneficiaries residing in specified institutions for extended periods of time.

SNPs have proliferated since 2004, the first year of operation, due in part to the revenue they generate for plans.  In 2004, 11 SNPs were approved by CMS.  In 2007, 477 SNPs were approved, enrolling over 800,000 beneficiaries.  As of November 2007, CMS has approved 775 plans to be SNPs in 2008, with enrollment now exceeding 1 million beneficiaries.  On December 29, 2007, President Bush signed a law[1] which placed a moratorium on new SNPs through December 31, 2009.

In marked contrast with "regular" Medicare Advantage (MA) plans, which are prohibited from discriminating among Medicare beneficiaries in their enrollment, SNPs are designed to serve, either exclusively or disproportionately, specific Medicare subpopulations.  SNPs must be coordinated care plans. They cannot be Medicare Savings Accounts or Private Fee-for-Service plans.  Unlike other MA plans, SNPs must offer a Part D (prescription drug) benefit in addition to all benefits under Parts A and B.  Aside from these two conditions, SNPs operate with few requirements from either the law or implementing regulations and with little oversight of how or whether they deliver what they promise.

SNPs are put forward by CMS, health plans, and by some policymakers as having the potential to significantly improve the health outcomes of populations with substantial and complex health care needs.  To date, however, little is known about what SNPs provide to beneficiaries or whether what is provided is different from and better than that which is provided through traditional Medicare or regular MA plans.  In fact, the Center for Medicare Advocacy's interest in SNPs was triggered in part by reports from advocates that SNPs were not meeting the needs of their clients, particularly those who are dually eligible for Medicare and Medicaid.  Concerns about enrollment in SNPs, access to health care including prescription drug coverage, and quality of care were raised in a lawsuit filed in Pennsylvania,[2] as well as in two law review articles about SNPs co-authored by Center for Medicare Advocacy attorneys.[3],[4]

Center for Medicare Advocacy's Recommendations

As noted earlier, these Recommendations are based on the proceedings of a full-day working conference of experts from various disciplines, on the papers prepared for the conference, and on related articles and reports.  Presented here are the overarching Recommendations; more specific and detailed recommendations can be found in the full document, available at:  http://www.medicareadvocacy.org/SNP%20Conference/Recommendations.htm.

            Beneficiary Protections and Standards for Care and Coverage

All SNP enrollees must be guaranteed protections and standards for care and coverage, some of which must be particular to the type of SNP and others of which have general applicability.  These protections and standards must be enforceable and enforced by CMS against plans.  The failure to provide mandated protections or to meet mandated standards must trigger beneficiary appeal rights through the Medicare Part C appeals process.

Coordination of Care

Care coordination, within care settings and as beneficiaries move from one care setting to another, must be an essential element of the services provided to all SNP beneficiaries.  Care coordination should be readily available upon an enrollee's request or upon a determination by another source of the need for same.  Demonstration of the ability to identify persons in need of care coordination and to provide care coordination must be a prerequisite for CMS approval of a sponsor's application to operate a SNP.

Coordination of Benefits for Dual and Institutional SNP Enrollees

SNPs serving dual eligibles, regardless of whether they are Dual SNPs, must demonstrate the capacity to deliver or coordinate the SNP benefits with Medicaid services and with related social services.  CMS must identify specific areas in which the plan must demonstrate competence.  Beneficiary-oriented plan materials must include clear and accurate information about the benefits available under the state's Medicaid program.

            Enforcement

The protections and standards outlined above must be enforced through 1) the creation by Congress through statute of minimum requirements for care coordination and coordination of benefits, 2) periodic reviews by the Government Accountability Office or the Office of Inspector General of the Department of Health and Human Services of CMS's oversight of plans, and 3) increased audits and other compliance reviews of SNPs by CMS.

Research/Data
 

Data must be collected, analyzed and made available to researchers.  New data and uniform data reporting may be needed to promote the ability of CMS and researchers to review and compare the actual success of SNPs.  Analyses must be disseminated to the public to promote better understanding of whether and how SNPs are meeting the special needs of their enrollees.  SNPs must also be required, by statute or regulation, to share utilization, encounter, diagnostic, and key health events data with the state Medicaid program of each dually eligible enrollee.