SNP - Narrative

On October 18, 2007, the Center for Medicare Advocacy, Inc. (the Center) convened a working conference to address concerns of Medicare beneficiaries about whether and how Medicare Advantage Special Needs Plans (SNPs) are offering better care and services than are available through other health care delivery options. The conferees' conversation helped shape recommendations for improvement and further study for Congress, the Centers for Medicare & Medicaid Services (CMS), and health policy developers. The conference was supported by The Commonwealth Fund, an independent foundation working toward health policy reform and a high performance health system.

The idea for the Center's conference came, in part, from advocates' concerns that SNPs were not meeting the needs of their clients, particularly those who are dually eligible for Medicare and Medicaid (dual eligibles). Concerns about enrollment in SNPs and access to health care, including prescription drug coverage were raised in a lawsuit filed in Pennsylvania,[1] as well as in two law review articles about SNPs.[2]

Two background papers written by health policy researchers and commissioned by The Commonwealth Fund helped provide a framework for discussing the topics at hand. The first paper provided a primer on SNPs for dual eligibles. It described the role of SNPs in the Medicare Advantage program, and the reason these entities were authorized by Congress to serve distinct subpopulations of Medicare beneficiaries, with a special focus on dual eligible SNPs.[3] The second paper provided a snapshot of the enrollment and participation levels in SNPs, and described the opportunities and challenges presented by this new type of specialty health plan.

The Center commissioned a third background paper to present issues encountered by beneficiaries who enrolled in SNPs, either voluntarily or through actions authorized by CMS. The paper, written from the perspective of an attorney for older people and people with disabilities, outlined specific problems raised by SNP enrollment and provided examples from Pennsylvania SNP enrollees.

The three background papers and other materials were and are available on a dedicated page of the Center's website (www.medicareadvocacy.org/SNP%20Conference/Home.htm), providing conference participants with ready access to background materials, including reports, CMS guidance to plans and states, and relevant legislative language.

Forty-five invited experts from across the country participated in the working conference. (Click here for a complete list of participants.) Participants came from a diverse set of disciplines: attorneys and other advocates for older people and people with disabilities, health plan representatives, state Medicaid agency representatives, health policy researchers, Congressional staff, and representatives from CMS. Several participants were involved with state demonstration projects approved by CMS for the integration of Medicaid and Medicare services to older people and people with disabilities.

The conference was divided into six sessions, including a working lunch. (Click here for the Conference Agenda.) Four of the six sessions had directed questions, developed by the Center with the assistance of the conference steering committee, for participants to consider.

Judith Stein, Executive Director of the Center for Medicare Advocacy, welcomed participants to the conference and thanked The Commonwealth Fund and the members of the steering committee for their support and assistance. She explained that the objective of the conference is to consider what is working and what is not working about Special Needs Plans from the perspective of the beneficiary. She asked participants to keep in mind that the concern is the beneficiary interest and with that framing, she posed several questions to guide the discussion: What exactly do we mean by beneficiary perspective? How can we set standards? Can people get the care they need from the providers they want to get care from at a cost that they can afford? And can they get this access at least as easily and as well as they could from the traditional Medicare program? If not, what is special about these plans for the beneficiary? She further explained that the purpose of the first session was to hear from participants about their experience with SNPs.

In his welcoming remarks, Stuart Guterman, Senior Program Director, Medicare's Future at The Commonwealth Fund, described his long-standing interest in SNPs through his previous work for CMS. He raised the potential of SNPs for treating people with chronic conditions and coordinating their care better, including the long-time unsolved problems for low-income beneficiaries in coordinating Medicare and Medicaid benefits. Because the SNP program will expire on January 1, 2009 if it is not reauthorized,[4] Mr. Guterman said, this is an appropriate time to bring people together to talk about how SNPs are working, or could work, from the perspective of beneficiaries.

Participants introduced themselves and described their experiences with SNPs. The experiences reflected the varying backgrounds and perspectives of participants. A Congressional staff member described the SNP provisions contained in legislation passed by the House of Representatives in August 2007.

Vicki Gottlich, an attorney with the Center, gave the first presentation. She described the legal basis for the SNP program, and noted that CMS has issued no regulations concerning what is needed to be approved as a SNP or what is needed to continue to function as a SNP. Most of the guidance issued by CMS concerns issues of enrollment, including rules that allow those SNPs whose enrollment does not exclusively comprise the special needs population to limit enrollment of their special population to a percentage of enrollees that is greater than the percentage of the special population than occurs nationally in Medicare. (This circumstance is referred to as disproportionate enrollment.) There is no SNP-specific guidance on quality issues or on coordination of care. Furthermore, SNPs are a Medicare product designed in part for people who use Medicaid services. The Medicare Advantage (MA) rules do not apply to Medicaid services.

Patricia Nemore, an attorney with the Center, led the participants in their discussion. She noted that while most MA plans are required to coordinate care, the feature that distinguishes SNPs from other MA plans, other than the requirement that they offer a Part D plan, is that they must exclusively or disproportionately enroll a certain class of beneficiary. She began the discussion by asking two questions:

Representatives from the SNP community stated that SNPs offer the opportunity to design a care management approach that focuses on the special needs of those people. In such a plan, special needs people are not viewed as financial outliers as they are in other MA plans; they are the focus of the plan. SNPs can design their models based on the needs of their specific population, and can rely more on medical literature concerning treatment of their population.

CMS representatives pointed out that the enabling legislation set up a special election period for marketing to certain populations. It did not set up a different benefit. SNPs have given CMS the opportunity to think about these requirements in a way the agency never did under Medicare Advantage because the SNP populations were lost in the program, except for social Health Maintenance Organizations (HMOs). With respect to disproportionate enrollment, very few SNP enrollees don't fit the definition of the plan they are in, but, for example, a couple might want to join the same plan, although only one member qualifies as a special needs individual for the plan. With respect to Dual SNPs, usually both people in the couple are poor so both are dual eligibles.

Others pointed out the limitations of allowing enrollment of a disproportionate share of the designated population. For example, the SNP's enhanced benefits are part of the bidding process and are designed to support the needs of the particular population. In theory, people not interested in those benefits should enroll in a different product offered by the plan sponsor.

Advocates raised the concern that disproportionate enrollment gives Dual SNPs an excuse not to have written material explaining to dual eligibles what their benefits are, since not all plan enrollees will have the same cost-sharing and Medicaid wrap-around benefits as duals. This creates confusion for dual beneficiaries. CMS agreed that marketing materials should describe the plan's program specifically, and that a disproportionate plan should describe the benefit both ways.

A researcher reminded participants that there still is not sufficient information about what plans are doing. Some Medicaid plans argue that specialization allows them to do more for the specific population. Another question to consider is what scale is needed to achieve the plan's goals? Some SNPs may not be large enough to create an effective program design that will add value.

Participants noted that legislation passed by the House of Representatives in 2007, H.R. 3162, that redefines "disproportionate" to mean that ninety percent of the plan's enrollment comprises people meeting the special needs definition.

Advocates also questioned how care coordination adds value to SNPs if most "regular" MA plans are supposed to be coordinating care. This question remained open for further discussion during the day.

Charles Milligan, Executive Director of the Center for Health Program Development and Management at the University of Maryland, Baltimore County, gave the second presentation of the day. He noted that Dual SNPs are not the dominant form of delivery of Medicare services for dual eligibles, with only about 10% of duals enrolled in Dual SNPs for 2007. Even fewer duals are enrolled in Medicaid managed care. Minnesota, Arizona, and Texas have the largest such enrollments, which total 79,000 for the three states.

Milligan sees Medicare and Medicaid coordination as a key to the viability of Dual SNPs. An important objective for a SNP would be the creation of an individual plan of care for each enrollee that might draw on physician, hospital, skilled nursing facility, and home health services (primarily Medicare) as well as personal care attendant, home- and community-based services and transportation (primarily Medicaid), the elements of which are coordinated by the SNP. SNPs cannot achieve their objective if they operate without some level of coordination – a contractual coordination agreement – with the state. Such an agreement might be limited to information-sharing for issues like health records, alerts on care, claims, and crossover claims. But contracting with SNPs is a contentious issue for many states.

An issue related to care coordination is the coordination of the grievance and appeals systems. What is the recourse for a beneficiary denied a benefit in both programs when both deny responsibility?

Pam Meliso, an attorney with the Center, led the discussion. Participants raised a few clarifying points before addressing several questions. Advocates pointed out that there are two different sorts of coordination: the coordination of benefits and financial responsibility and the coordination of a beneficiary's medical care. The fiscal coordination may get in the way of the care coordination. They also raised the need for monitoring and enforcement.

Participants also discussed some of the problems of coordinating Part D for dual eligibles as an example of the challenges in coordinating benefits among states, CMS, and private plans.

1. What additional services should Medicare SNPs provide that state Medicaid plans do not?

A researcher said that he has heard from SNPs that they tend to add easily marketable services like vision, dental, and hearing. These services do not add value for duals in states like Connecticut where Medicaid already provides those services. We want more effort at care coordination and health education, but the plans say it is hard to market those things to people who have never experienced them. It is much easier to talk about one-stop shopping and one card.

A state representative explained that her state puts in plan contracts that the state can back out of services covered by Medicaid so the plans are not double-paid. The state contract includes an expectation for care coordination, and the state enforces that provision. A representative of a state plan said that the plan includes dental benefits because dentists in the state will not accept the low Medicaid payment rate. Plan representatives discussed the different benefits they provide to their enrollees, not all of which are medical, and admonished against being overly prescriptive so as to stifle creativity.

An advocate raised the problem that many providers do not take both Medicare and Medicaid, and that they are not familiar with rules about not billing dually eligible beneficiaries for cost sharing. The potential of a SNP is in having networks of providers that either accept Medicare and Medicaid or hold harmless dually eligible beneficiaries for cost-sharing.

2. How can SNPs add value for persons receiving services under
Medicaid home- and community-based waivers or in institutions?

A participant asked what it means to meaningfully include folks in their community. He suggested that the SNP had the potential to assist the beneficiary in identifying the types of activities s/he would like to pursue. Participants described social services such as transportation which are not usually covered by Medicare but which may be covered by Medicaid.

An advocate for people with disabilities raised concerns about the home- and community-based services issue. She expressed doubts about whether the fiscal incentives to serve this population exist, and about the goals and values of managed care plans. She gave the example of a health plan having trouble because there were "unwarranted" variations in the amount of personal care time beneficiaries were receiving at home. The plan was accustomed to a medical model and did not consider the activities of life and the special problems, including environmental problems, of enrollees when determining the amount of services that might be needed. She underscored the need for good standards and good data and for fiscal incentives aligned with the objective of keeping people at home. She raised the issue, seconded by other beneficiary advocates, that ignoring enrollees saves plans money, and that case management sometimes turns in to cost management.

3. What is it about SNPs that makes their existence "an unprecedented opportunity" for better coordination between Medicare and Medicaid?

A SNP representative said that there are many opinions when it comes to care coordination depending on who you talk to and depending on the site of care. He suggested that all SNPs should have the capability to undertake complex long-term care management. He noted that the ideal is integration of both financing and of acute and long-term care services and only three states, Minnesota, Massachusetts, and Wisconsin, have full integration. A participant stated that beneficiaries like having a nurse available 24 hours every day, as is the case in some Institutional SNPs that place geriatric nurses in the nursing facilities with which they contract.

An advocate asked how we can get plans to think about a care coordination model. What requirements do we impose? What is the value of keeping people at home? A plan representative added that plans need to look at and adopt best practices. A researcher stated that she had seen a California plan that did a fairly extensive home visit, including a safety and environmental assessment, and that perhaps an initial assessment should be required.

A CMS representative pointed out that, under the Medicare regulations, care coordination is considered as an administrative cost not a health care benefit cost. Another challenge lies in the fact that the CMS contracting year may differ from the state's contracting year. If states can see the potential, it advances the dialogue.

An advocate expressed concern about the added value if there is not consistency, not only among states but among different plans in the same state. How is the beneficiary to determine which of the different services offered by the different plans is more important?

Other participants gave examples of care coordination models. They opined that an assessment and care plan were benefits that provide added value. They referred to guidelines developed with support from the Robert Wood Johnson Foundation and provided by organizations around the country that have been providing care management for decades. They raised the need for the plan to be pro-active and contact the beneficiary, rather than wait for the beneficiary to contact the plan. The issue of problems for beneficiaries due to a delay in discharge planning was also raised.

The caution was raised that benefits tend to be based on the medical model, not the social model, and that the more social benefits are harder to market. It was suggested that beneficiaries be given more control, and that attendant care be available.

Several participants discussed the need for enrollment in SNPs to remain voluntary. The House-passed bill, H.R. 3162, would prevent auto-enrollment of dual eligibles into managed care.

Advocates returned to the concept of coordination, both of benefits and of care. Though it is important, plans cannot market care coordination and they cannot bid on it (because it's an administrative cost). Nonetheless, since care coordination seems to be universally viewed as valuable, from the beneficiary perspective, there should be enforceable requirements that SNPs provide care coordination. A related and widely-held assumption is that care coordination saves money, but little evidence supports this view. The SNP business model seems to be constructed on the assumption that highly needy populations can be served cost-effectively by grouping them together and coordinating their care. What are the implications of this premise proving false?

In response to a story about "care coordination" that seemed suspiciously like "cost management," a researcher raised the need to distinguish between the desirability of a particular aspect of care and whether the provider or payer performs the service well or effectively. CMS has the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to gauge the latter. We may not be able to define coordinated care in a generic sense; we should ask the patient if the care has been coordinated and attach money to that. There is no Pay-for-Performance program for managed care's performance; we can get at it without being over-regulatory.

A propos the implications of care coordination being considered an administrative cost rather than a benefit, a CMS representative clarified that the MA bids include administrative costs. She also noted that the CMS definition of the health benefit affects how plans describe the plan benefits. And, in response to the suggestion that all plan enrollees should get care coordination without having to "qualify" for it, she stated that there is no service under health insurance that people should get at any time. Risk assessment means matching the availability of services and that is valuable. Managed care can do that well. CMS is working on a multi-year project with the National Committee for Quality Assurance (NCQA) to develop performance measures for SNPs.

According to a researcher, whether care coordination is called an administrative cost or a benefit, the difference is whether you can use the savings from more efficiently delivering services under Parts A & B to do it. With SNPs, we should be looking for organizations that will be committed to doing something different that will give them a good reputation. Of the numerous plans now, some are just different benefit packages for the same organization, and some got in as placeholders. Over time, can you whittle it down to the organizations that are serious about the business, and how do you do that? Maybe make it more difficult to enter.

State representatives discussed the barriers to states' willingness to coordinate with SNPs. One barrier is the standard summary of benefits that discusses only Medicare benefits and cannot say what Medicaid provides, which is not good for SNPs. MA plans, including SNPs, must follow MA rules, which require use of this summary of benefits. Some states try to push the envelope, but it may be more difficult for states that are just starting, that do not run one of the existing waiver programs.

David Parrella, Director of Medical Care Administration with the Connecticut Department of Social Services (DSS), joined the conference by telephone to describe that state's experience. Connecticut does not have a Medicaid wrap-around contract for dual eligibles in Medicare Advantage plans. The Legislature authorized DSS to spend up to $25 million to contract with SNPs to provide wrap-around coverage, but DSS is not yet convinced of the value to the state. Ten years ago Connecticut entertained the development of an 1115 waiver for managed care for its long-term care population.

Parrella described two problem areas. First, marketing to a population that includes individuals who are in home- and community-based waivers is problematic because the folks in those programs do not fully comprehend what is in the plan with its closed provider network. They sign and get complimentary gifts. Then, the homemaker companion whom they have seen for four years can't come and there is a disruption in the continuity with their home-care provider. That has occurred with some frequency. The state has had meetings with agencies that have home- and community-based service waivers and with SNPs to discuss the adequacy of their networks and to have more robust disclosure of who's in which network. It has gotten better, but it remains an issue.

Second, he described Connecticut's successful program, over several decades, of getting Medicare coverage for dual eligibles for benefits such as home health and Skilled Nursing Facility (SNF) services. The state shifts these costs appropriately from the Medicaid program to the federal program. The modus operandi for SNPs is different from what the state is used to dealing with. It is good that they don't put people in an ambulance from a SNF and they may do more to treat a person in a SNF. But it doesn't align exactly with the skilled level of care that is recognized in fee-for-service Medicare. There is not much cooperation with SNPs for appealing a skilled level of care denial in Medicare.

The larger issue for the State of Connecticut, according to Parrella, is fiscal impact. Whether contracting with Medicare managed care on a capitated basis will ultimately result in an advantage to the state or to the Medicare program has yet to be seen. The state has not completed its analysis because of the press of other issues. In response to a question concerning contracting with an Institutional SNP, Parrella stated that the dilemma is in determining the benefit to the state and whether the plans are shifting costs to the state or whether contracting with them would level the playing field.

Parrella explained that SNPs are interested in having the ability to confirm Medicaid eligibility. They do so now by contacting case workers because they do not have access to the state's automatic eligibility system. SNPs are not providers with the state and do not have contracts with the state. In Connecticut, in the absence of being a Medicaid provider or having a contractual relationship with the state, the state cannot legally share protected health information. A CMS representative said that there is variation among states in the ability to share eligibility information. CMS is interested in facilitating state efforts to share that information, perhaps by going through the providers within a SNP's network.

A researcher pointed out that a new system could be globally cost-effective and deliver better quality, but it could be more costly for each individual. Medicaid does not get any benefit if there is an avoided hospitalization. What are the components of what we're looking at to decide good policy? Are we looking in to whether this provides better health outcomes, even if it's break-even or costs Medicaid more?

Participants discussed the impact on beneficiaries of cost-shifting between the two programs. Beneficiaries are more concerned about getting care than whether the wrong payer is paying. There is no general authority under Medicare or Medicaid to allow the two streams of funding to come together. Some states like Minnesota have done that, but others are concerned that the state will not benefit. The different Medicare and Medicaid payment rates may create disincentives at the provider level. The proposal was made that states should get some financial incentive from the bid process, some share with Medicare.

James Verdier, Senior Fellow at Mathematica Policy Research, described his research on SNP enrollment. Of the 1 million people enrolled in a Dual SNP, 250,000 are in Puerto Rico and 200,000 were passively enrolled. Another 50,000 are from Kaiser Permanente and about 100,000-plus were from the conversion of social HMOs in California and New York. The overwhelming majority of duals are autoenrolled in stand-alone Part D Plans. In aggregate, they are still in the plans into which they were autoenrolled. Duals are hard to identify and market to. And how does an individual know up front whether a plan is special or if the plan's networks and services will meet their needs? It is a hassle to disenroll and the next plan may not be better.

This past year there has been a tremendous growth in Chronic SNPs led by UnitedHealth/Evercare (in 34 states) and Humana (in 24 states). Chronic SNPs have an enrollment of about 170,000 with 60,000 in Puerto Rico and 70,000 in Care Improvement Plus in 6 states. How do plans get the records of diagnosis from the year before because that's what drives payment? How do the plans change care patterns to keep people out of emergency rooms, hospitals, and SNFs? MA-PDs (MA plans combined with a Part D plan) have disease management programs, but is it better to have a plan providing an array of other services or some targeting? Half of the beneficiaries in Chronic SNPs are not dual eligibles.

With respect to Institutional SNPs, most of the enrollment is in Evercare. How do they contract with and work with nursing facilities? The only claims data we have are about drug usage. Our other essential data tools are the CAHPS survey and the Healthcare Effectiveness Data and Information Set (HEDIS). Small enrollment may be a problem as plans need a critical mass to justify the special focus.

Alfred Chiplin, an attorney with the Center began by asking, "If enrollment is low, what is going on?"

Jim Verdier said that it is easy to exaggerate the growth in numbers and in enrollment. At the same time, small enrollment may be a problem because these plans need some critical mass to justify their special focus. There are about half a dozen states contracting with plans and about six more working it out. Difficulties states are having in relationships with plans can be mitigated by looking at the experiences of other states. He thinks Institutional SNPs have potential but he does not know about Chronic SNPs.

A plan representative said that the plan initially wanted a disease management waiver, but that morphed into a Chronic SNP that never caught on. It was difficult to market because what the plan was doing was too subtle and people could not see how what it was offering is better than Medicaid or traditional Medicare. Participants discussed that the marketing problems stem from a difficulty in describing the benefit. Beneficiaries look at the small gifts they get from the plans, but they do not see or understand what plans describe as the real value.

A participant asked what data researchers need to understand what is going on. CAHPS and HEDIS have an impact but the problem is the small sample size for SNP data. It would be helpful if CMS could summarize the SNP models of care included in their application and make that information available. A researcher described the difficulties in getting the data. Data on patterns of disenrollment will never be public. CMS could generate analyses of their files, which would not violate confidentiality, and which would allow researchers to look at targeted disenrollment. CMS could also take the complaint data from advocates and convert that to some information. If the Medicare program is going to follow the model of more private plans, the fiduciary responsibility to Congress should be to require statistical reporting of patterns and trends to understand what is happening within states and among the different types of plans. The personal plan finder needs to be available earlier so researchers can look at the benefits being offered.

A plan representative said that a group of Medicaid directors is looking at performance measurement in SNPs. One problem is that information systems are designed around systems they are trying to change, from a focus on where care is delivered to a focus on acute events. There are not ways of measuring continuity of care, multiple co-morbidities. There are not quality indicators for safe and effective transitions. The current HEDIS measures are mostly not appropriate. A CMS representative reminded participants of their timeline for NCQA to create a set of measures to be used in 2008.

A beneficiary advocate stated that having the basic claims pattern data could help describe whether the beneficiary understands who is in the network, the benefit package and the role the SNP plays in helping enrollees get through the process. A researcher said that plans have the data but not in a standardized form. While Medicaid requires plans to report some data, it would burden CMS and the plans to determine what and how to report.

A CMS representative explained that, although CMS was given authority for risk adjustment, which included plans having to report encounter data, they decided on diagnosis reporting rather than use of encounter data. In regard to Part D, CMS does not have the authority to use prescription claims information for any other purpose than payment. A plan representative stated that encounter data was not necessarily risk adjusted. A researcher said that claims have little effect because they are missing the clinical side. What specific data would be useful to monitor quality? It was pointed out that Wisconsin constructed HEDIS-like measures from selected encounter data.

A beneficiary advocate pointed out that there has not been much discussion about the complexity posed to beneficiaries and their helpers trying to understand what the SNP is and how it differs from Medicare Advantage and traditional Medicare. Beneficiaries think MA plans are supplemental to their Medicare—that they have Medicare and something more (the advantage). People in the policy sphere underestimate the possibilities for confusion. A plan could be perfectly honest in its marketing, but the situation is too complex. The need for claims data is related to the issue of the failure of the beneficiary to understand the complexity of the plan's design.

A researcher said that one advantage of MA, if it is done right, is the credentialing of providers. There is an important balance in how a plan builds its network. There are financial components and also quality components. NCQA drives the credentialing process for plans to build provider networks and that drives quality too. Having an open panel is valuable and having high quality providers is valuable. A poor-performing SNF (one with a high rate of hospitalization or a lot of deficiencies) can be shut out of a plan's network. An advocate for people with disabilities countered that existing surveys, including the CAHPS survey, are inadequate for people with complex needs. An instrument needs to be designed to ask questions that elicit beneficiary experiences and what is important to them.

"The Medicare Advantage Special Needs Plan Experience:
Beneficiary Perspective from Pennsylvania"

Alissa Halperin, Managing Attorney at the Pennsylvania Health Law Project, presented on problems faced by SNP enrollees. She reminded participants that this population has significant complex health needs, has low health literacy, and is often in a health care crisis. It is not possible for them to comprehend the marketing material or to read it. There is a lot of information out there and not all of it is accurate. Every beneficiary thinks the plan must be "special," which is the way the plans are presented and understood by consumers. Caseworkers often think that the Dual SNP is the only plan dual eligibles can have.

Based on her work in Pennsylvania (over 3,500 calls per year from consumers statewide), she and other staff in her program have identified three key timeframes in which specific issues arise: initial enrollment, disenrollment, and the period of participation in the plan. Dual eligibles have historically been excluded from managed care and they do not understand the framework of managed care. They cannot understand a Summary of Benefits (SOB) and the SOB misstates their coverage because it does not include what is covered by Medicaid. A SNP in Pennsylvania sent a summary to the Medicaid agency. The agency asked the plan to make changes to the SOB because of misstatements. The plan refused and the CMS Regional Office said it had no authority to tell the plan to change its SOB. One plan was allowed to passively enroll beneficiaries without a network of providers. Throughout the period of enrollment, there are changes. What should the requirements be for SNPs? The plan should not be able to bury in its Annual Notice of Change (ANOC) that the only hospital in its network in a rural area has left the plan. Beneficiaries cannot wade through the ANOC. They do not get adequate information because written notice is often not adequate for this population.

A possible requirement with regard to transitioning would be the provision of a 60-day window starting at enrollment for a beneficiary who enters a SNP that does not include her provider in its network. The 60-day window would allow her to find a new provider or to persuade her old provider to join the network, either of which would foster continuity of care. There should also be a transition period for benefit changes. The beneficiary should be permitted to keep using a hospital that is no longer in the network until she can change to a network hospital or switch plans.

It is often hard to find out which providers are in a SNP's network and SNPs do not know which of their providers accept Medicaid's payment rate. There appear to be serious issues of network adequacy, especially as folded into Medicaid managed care because there are no network adequacy rules for SNPs. For example, under Mediciad law, urgent care must be available within a select number of minutes, miles, or days, but SNPs serving a wider area than the city of Philadelphia had no services outside the city.

One SNP for dual eligibles refused to let a passively-enrolled beneficiary have the full subsidy for Part D, even though dual eligibles are automatically eligible for the subsidy. There are also coverage problems. SNPs decline to coordinate benefits and SNPs do not take an active role in knowing which of the services that the SNP does not cover are covered by Medicaid. SNPs are not required to know what Medicaid covers. SNPs are not required to give a modified denial, in the event the denied service is covered by Medicaid or other insurance. For example, a SNP for dual eligibles does not cover benzodiazepine drugs but does not know that the state Medicaid plan does cover benzodiazepines.

Regarding institutional SNPs, the Nursing Home Reform Law imposes requirements on facilities. How do those requirements align with the SNPs requirements? Where does any conflict between the two sets of requirements get resolved? And, with respect to home- and community-based services, there may be issues of network adequacy.

The financial incentive on the plan does not provide the protection for beneficiaries and their advocates that is provided by regulations against which advocates can hold plans accountable.

Brad Plebani, Deputy Director of the Center for Medicare Advocacy, moderated the discussion.

1. Would structural changes to the requirements for SNPs improve beneficiary experience? If so, what are those structural changes? Are they legislative or regulatory?

Participants began by discussing the need for a legislative change to share some of the savings achieved, possibly half of the 25% rebate received by MA plans, with state Medicaid programs. It was unclear if such a proposal would address the beneficiary problems raised in the presentation.

Participants from states with successful waiver programs were asked to describe how they handle the coordination of Medicare and Medicaid, in particular with regard to provider networks. The suggestion was made that CMS consult with the leading states to identify best practices and to develop standards for provider access for SNPs that serve dual eligibles. In Minnesota, all SNP plans are also Medicaid plans and they have contracts for Medicaid so the network is the same. The transition issue is built into the state's contract with the plans. If a service is authorized for a period prior to joining the SNP, the SNP must provide it and provide for continuity of care. They do not distinguish between Medicare and Medicaid covered services. SNPs have Medicaid contracts and they have to be non-profit to operate in Minnesota as a risk-based plan.

Massachusetts uses a three-way contract among the state, the plan, and CMS; all the requirements are in a single agreement. Addressing the adequacy of an integrated network is challenging. The state allowed for a provisional start-up period and the networks were not full blown in 2004. Massachusetts plans have the flexibility to be creative. They can help people when an aspect of their housing is an issue, such as needing a wheelchair ramp. They can do things outside the box and that works. A Massachusetts advocate said that quality care comes down to what providers are willing to accept and that often depends on what the plan will pay. Good providers are not part of the network because they will not accept what is paid.

Participants discussed a suggested recommendation that SNPs must have a contract with the state Medicaid agency to some degree and conduct aggressive care coordination. They raised questions about what the contract would say and require, and whether the issues could be addressed without a contract. Some expressed concern that a contract does not solve problems, but recognized that the state needs to be on board in some way or else the SNP does not add value.

A researcher suggested adoption of a common Medicaid managed care protection which provides a transition period for people entering and leaving a plan. A contract with the state would alleviate the problem of the SNP not knowing the diagnostic history of a new enrollee. He said there are positive ways of approaching cross-over claims (claims going from Medicare to Medicaid for payment of the Medicare cost-sharing), which is different from diagnostic data for risk adjustment.

Another participant noted that years of planning went into the programs in Massachusetts, Minnesota, and Wisconsin, which is why they have not been replicated in the recent proliferation of SNPs. The requirements need to go beyond that a SNP needs an arrangement with the state. Such an arrangement only works if the state wants to put in the time to develop a program.

A plan representative supported having a relationship with states and noted her efforts to get states interested. Beyond information sharing, she said the minimum relationship should have some coordination of non-Part D drugs. She said the attention of Medicaid directors is focused on other areas, including the uninsured, and expressed the need to develop some incentive to get states interested.

Mr. Plebani asked for a clarification of the term "placeholder plan" and whether such plans lend themselves to the problems identified in the presentation. A researcher described a placeholder as a plan that is not actively marketing and enrolling. A sponsor wanted to enter the market and see what it is like. It is easy for plans to enter and they were not sure how things would shake out in 2006 so they did not spend much time developing anything. The researcher had not reviewed the data to know if such plans are causing problems. One question is whether it makes sense to allow these plans to continue to exist if they do not have a certain enrollment after a certain number of years.

An advocate pointed out that the discussion has focused on good relationships with full integration. There are a lot of SNPs and we cannot make every state do what Massachusetts, Minnesota, and Wisconsin have done. But the absolute minimal requirements should be that the plan has staff members who know the state Medicaid program and a designated place to call to find out what the Medicaid benefits are, and that there be a regulatory requirement to that effect that is enforceable. These requirements should be independent of plan and state involvement.

A researcher suggested that it might be difficult for a SNP to help enrollees navigate the Medicaid system if the enrollee is in Medicaid managed care. Advocates disagreed. They raised the issue of providing information about where to get assistance. They also expressed the concern that no one in an MA plan who is dually eligible should get fewer benefits than are offered by both programs. Medicare Advantage should have the same level of coordinated care that we require of SNPs. The purpose of SNPs should not be to migrate people to private plans. People in traditional Medicare should have the same coordinated services (medical, not administrative) and these services should be enforceable. Care coordination should become an expected and coverable service in traditional Medicare prescribed in the statute or in the regulations so that it is enforceable CMS policy.

A plan representative agreed that it is appropriate for SNPs to be required to provide comprehensive complex care management. All SNPs should assist dually eligible beneficiaries in accessing and coordinating Medicare and Medicaid. He agreed that contracting with the state may be good, but said some states do not want anything to do with a SNP. He referred to some concerns about the wording of H.R. 3162, the bill passed by the House of Representatives in 2007, with regard to contracts with states, including that the language says nothing about either care coordination or fiscal coordination between Medicare and Medicaid.

Several advocates pointed out that there is no right to a SNP, and asked why dual eligible SNPs should be allowed to participate in a state that does not want to cooperate. It was pointed out that some states, such as Arizona, believe they have no authority to place any requirements on SNPs.

A state representative said that CMS helped the state with its Evidence of Coverage to add SNP language. There are other things CMS could do administratively to help things along. In 2006, there was a major reprogramming when Part D started and CMS took over the drug benefits. Minnesota had an integrated program and CMS gave the pharmacy benefit managers software to help them. CMS could produce materials for Dual SNPs to promote better communication.

A CMS representative said that it is difficult for the state to provide the information. Preemption relates to licensure. What can the state require before it licenses a plan? States can't require a SNP to behave in a certain way that is contrary to Medicare rules, but they can put specific terms in the contract.

A beneficiary representative queried the need for SNPs. Another returned to the lack of federal oversight, regulation, and enforcement, and said that states should not have to pay SNPs to do what they should already be doing. States are not the bad guys.

A researcher reminded participants that the idea for SNPs came out of a long series of initiatives that responded to a perceived need of these special populations. Otherwise, there was just managed care that deals with healthy people. Plans, states, and CMS should work together. Plans also have an incentive to coordinate with states otherwise to validate their product. CMS needs to regulate at some point and decide what it wants to demand. From the beneficiary's perspective, it should not matter to the beneficiary if the plan is a SNP or a Medicaid plan. It should depend on what the plan offers.

A plan representative said there also needs to be an opportunity for dialogue about integration. The value to beneficiaries is undeniable if it would result in integration between the two programs. It is no small investment for states to get into this and it is no small investment for the plans. The plans are accountable for delivering services and there are good reasons for accountability. Plans think the quality measures under development are an excellent idea, but do not want requirements to be set in stone so that good plans have difficulty.

Another plan representative said there is an obvious need for integration because the Medicare benefit package does not respond to chronic care needs. If you want to be a SNP, you must have integration as a goal, not just the Medicare benefit, but be really interested in serving the dual-eligible population. He asked how plans relate to the beneficiaries they are trying to serve. How do we begin to understand the true needs of beneficiaries so they can see the value in a particular service delivery system? Educating dual eligibles about their choices is very difficult because there are basic issues of literacy. How can we get Medicare to work with other groups in our community that have relationships with enrollees? Medicare's focus on containing acute care costs makes addressing chronic care needs difficult.

3. What should SNPs be required to demonstrate? What are the essential elements of the contract between CMS and SNPs?

A researcher reminded participants of CMS's initiatives related to people with chronic conditions in the traditional Medicare program. People with chronic illnesses are served well neither by traditional Medicare nor by MA. The entire Medicare program needs to move in the direction of serving this population better, but it may be easier in managed care. Making SNPs special is the whole purpose of this day. We can either say CMS must make sure these SNPs are special and serve the needs of enrollees, or tell Congress what tools CMS should be given to be able to do that.

A beneficiary advocate said CMS needs legislative authority to make SNPs more special. They need more of a mandate to integrate Medicare and Medicaid and more specific requirements to protect beneficiaries.

A researcher suggested that when a SNP submits its bid to CMS, it should describe its relationship with its host state (a formal relationship, data sharing, benefit coordination, or some other connection). CMS has not had a mandate or the resources to oversee plans. There are bad marketing abuses, including misleading marketing information. If there is a market failure here (the plan is not delivering on the promise in all places), how is the market failure addressed? Is disenrollment a sufficient protection? If not, what are the statutory and regulatory protections to deal with the market failure? The MMA language is premised on the notion that consumers would bail out if there were a market failure.

Given the size and format of the meeting, participants found it difficult to identify with great specificity requirements for SNPs. It was noted that some different requirements might be needed for each type of SNP. On a larger scale, they should have to show what makes them special. It was suggested that CMS, in consultation with all of the interests, should come up with requirements that all SNPs have to meet. Perhaps CMS should be required to monitor disenrollment, complaints, and beneficiary reports from the field. Where there is a pattern, CMS should look at the particular plans.

Because it was not possible in the time allotted to develop consensus recommendations, the recommendations are presented as those of the Center for Medicare Advocacy, based on the conference experience and related papers. The recommendations can be found here.

[1] Erb v. McClellan, No. 2:05-vc-6201 (E.D. Pas. Filed Nov. 30, 2005).

[2] Alissa Eden Halperin, et al., "What's so Special about Medicare Advantage Special Needs Plans? Assessing Medicare Special Needs Plans for ‘Dual Eligibles.'" 8 Marquette Elder's Advisor 215 (Spring 2007); Alissa Eden Halperin, et al., "Medicare Advantage Special Needs Plans for ‘Institutionalized Individuals:' What Advantage to Enrollment?" St. Louis Journal of Health Policy (in press).

[3] There are three types of SNPs, SNPs for dual eligibles, which we will refer to as ‘Dual SNPs;' SNPs for individuals with severe or disabling chronic conditions, which we will refer to as ‘Chronic SNPs;' and SNPs for institutionalized individuals, which we will refer to as ‘Institutional SNPs.'

[4] After the conference, Congress passed the Medicare, Medicaid, and SCHIP Extension Act of 2007 which extended SNP authorization through January 1, 2010, created a moratorium on the Secretary's ability to designate existing MA plans as SNPs, and a moratorium on enrollment in new SNPs through December 31, 2009. Pub. L. No. 110-173.


Conference Home The Center for Medicare Advocacy's Recommendations Conference Narrative Conference Agenda Conference Papers Background Materials Conference Presentation Slides Conference Participants Conference Steering Committee About the Center for Medicare Advocacy Conference Sponsor	Narrative OF PROCEEDINGS I. Introduction On October 18, 2007, the Center for Medicare Advocacy, Inc. (the Center) convened a working conference to address concerns of Medicare beneficiaries about whether and how Medicare Advantage Special Needs Plans (SNPs) are offering better care and services than are available through other health care delivery options. The conferees' conversation helped shape recommendations for improvement and further study for Congress, the Centers for Medicare & Medicaid Services (CMS), and health policy developers. The conference was supported by The Commonwealth Fund, an independent foundation working toward health policy reform and a high performance health system. The idea for the Center's conference came, in part, from advocates' concerns that SNPs were not meeting the needs of their clients, particularly those who are dually eligible for Medicare and Medicaid (dual eligibles). Concerns about enrollment in SNPs and access to health care, including prescription drug coverage were raised in a lawsuit filed in Pennsylvania,[1] as well as in two law review articles about SNPs.[2] A. Background Papers Two background papers written by health policy researchers and commissioned by The Commonwealth Fund helped provide a framework for discussing the topics at hand. The first paper provided a primer on SNPs for dual eligibles. It described the role of SNPs in the Medicare Advantage program, and the reason these entities were authorized by Congress to serve distinct subpopulations of Medicare beneficiaries, with a special focus on dual eligible SNPs.[3] The second paper provided a snapshot of the enrollment and participation levels in SNPs, and described the opportunities and challenges presented by this new type of specialty health plan. The Center commissioned a third background paper to present issues encountered by beneficiaries who enrolled in SNPs, either voluntarily or through actions authorized by CMS. The paper, written from the perspective of an attorney for older people and people with disabilities, outlined specific problems raised by SNP enrollment and provided examples from Pennsylvania SNP enrollees. The three background papers and other materials were and are available on a dedicated page of the Center's website (www.medicareadvocacy.org/SNP%20Conference/Home.htm), providing conference participants with ready access to background materials, including reports, CMS guidance to plans and states, and relevant legislative language. B. Participants Forty-five invited experts from across the country participated in the working conference. (Click here for a complete list of participants.) Participants came from a diverse set of disciplines: attorneys and other advocates for older people and people with disabilities, health plan representatives, state Medicaid agency representatives, health policy researchers, Congressional staff, and representatives from CMS. Several participants were involved with state demonstration projects approved by CMS for the integration of Medicaid and Medicare services to older people and people with disabilities. C. Description of the Conference The conference was divided into six sessions, including a working lunch. (Click here for the Conference Agenda.) Four of the six sessions had directed questions, developed by the Center with the assistance of the conference steering committee, for participants to consider. II. Session I - Introductions A. Welcoming remarks Judith Stein, Executive Director of the Center for Medicare Advocacy, welcomed participants to the conference and thanked The Commonwealth Fund and the members of the steering committee for their support and assistance. She explained that the objective of the conference is to consider what is working and what is not working about Special Needs Plans from the perspective of the beneficiary. She asked participants to keep in mind that the concern is the beneficiary interest and with that framing, she posed several questions to guide the discussion: What exactly do we mean by beneficiary perspective? How can we set standards? Can people get the care they need from the providers they want to get care from at a cost that they can afford? And can they get this access at least as easily and as well as they could from the traditional Medicare program? If not, what is special about these plans for the beneficiary? She further explained that the purpose of the first session was to hear from participants about their experience with SNPs. In his welcoming remarks, Stuart Guterman, Senior Program Director, Medicare's Future at The Commonwealth Fund, described his long-standing interest in SNPs through his previous work for CMS. He raised the potential of SNPs for treating people with chronic conditions and coordinating their care better, including the long-time unsolved problems for low-income beneficiaries in coordinating Medicare and Medicaid benefits. Because the SNP program will expire on January 1, 2009 if it is not reauthorized,[4] Mr. Guterman said, this is an appropriate time to bring people together to talk about how SNPs are working, or could work, from the perspective of beneficiaries. B. Participant discussion of experiences with SNPs Participants introduced themselves and described their experiences with SNPs. The experiences reflected the varying backgrounds and perspectives of participants. A Congressional staff member described the SNP provisions contained in legislation passed by the House of Representatives in August 2007. Several common themes emerged from the comments by participants: The need to determine expectations of the SNP program and how the expectations can be translated into requirements and guidelines for what SNPs should do, including: care coordination; reduced preventable hospitalizations; and fewer emergency room visits. The need to identify and address beneficiary concerns with the SNP program, including: passive enrollment of dual eligibles in Medicaid managed care plans into SNPs; non-compliance with beneficiary rights and protections, including appeal rights; lack of coordination with existing services; lack of protocols for navigating different Medicare and Medicaid rules to coordinate services; and lack of protocols to address particular concerns of beneficiaries under age 65. The need to apply the information and experiences from the state integration demonstration projects to SNP programs, including: care coordination; nurse management programs; social models of care versus medical models; and maintenance of the integrity of existing demonstration programs. The need for improved data and data-sharing systems: to describe and understand what SNPs are actually doing; to determine what is going well and what is not working; and to improve data sharing among plans, states, and the federal government. The need to improve communication: to keep and improve relationships among plans, states, providers and beneficiaries; to provide beneficiaries with a better understanding about SNP benefits and how they relate to Medicaid, the Nursing Home Reform Law, and other existing beneficiary protections; and to improve SNP understanding and knowledge of state Medicaid programs. The need to look closely at SNP program design and assess: the impact of rapid growth on the ability of SNPs to serve the special programs; the added value, if any, of having exclusive or disproportionate enrollment of a particular population in a SNP; and the benefit, if any, an Institutional SNP can provide that an institution is not already required to provide under its own federal obligations. III. Session II - What Makes SNPs Special for Beneficiaries? Moderator: Patricia Nemore A. Presentation "Medicare Advantage Special Needs Plans: Overview of Law and Regulations" Vicki Gottlich, an attorney with the Center, gave the first presentation. She described the legal basis for the SNP program, and noted that CMS has issued no regulations concerning what is needed to be approved as a SNP or what is needed to continue to function as a SNP. Most of the guidance issued by CMS concerns issues of enrollment, including rules that allow those SNPs whose enrollment does not exclusively comprise the special needs population to limit enrollment of their special population to a percentage of enrollees that is greater than the percentage of the special population than occurs nationally in Medicare. (This circumstance is referred to as disproportionate enrollment.) There is no SNP-specific guidance on quality issues or on coordination of care. Furthermore, SNPs are a Medicare product designed in part for people who use Medicaid services. The Medicare Advantage (MA) rules do not apply to Medicaid services. B. Participant Discussion Patricia Nemore, an attorney with the Center, led the participants in their discussion. She noted that while most MA plans are required to coordinate care, the feature that distinguishes SNPs from other MA plans, other than the requirement that they offer a Part D plan, is that they must exclusively or disproportionately enroll a certain class of beneficiary. She began the discussion by asking two questions: 1. What is the added value of exclusive or disproportionate enrollment? 2. Why shouldn't we require all MA plans to coordinate care? Representatives from the SNP community stated that SNPs offer the opportunity to design a care management approach that focuses on the special needs of those people. In such a plan, special needs people are not viewed as financial outliers as they are in other MA plans; they are the focus of the plan. SNPs can design their models based on the needs of their specific population, and can rely more on medical literature concerning treatment of their population. CMS representatives pointed out that the enabling legislation set up a special election period for marketing to certain populations. It did not set up a different benefit. SNPs have given CMS the opportunity to think about these requirements in a way the agency never did under Medicare Advantage because the SNP populations were lost in the program, except for social Health Maintenance Organizations (HMOs). With respect to disproportionate enrollment, very few SNP enrollees don't fit the definition of the plan they are in, but, for example, a couple might want to join the same plan, although only one member qualifies as a special needs individual for the plan. With respect to Dual SNPs, usually both people in the couple are poor so both are dual eligibles. Others pointed out the limitations of allowing enrollment of a disproportionate share of the designated population. For example, the SNP's enhanced benefits are part of the bidding process and are designed to support the needs of the particular population. In theory, people not interested in those benefits should enroll in a different product offered by the plan sponsor. Advocates raised the concern that disproportionate enrollment gives Dual SNPs an excuse not to have written material explaining to dual eligibles what their benefits are, since not all plan enrollees will have the same cost-sharing and Medicaid wrap-around benefits as duals. This creates confusion for dual beneficiaries. CMS agreed that marketing materials should describe the plan's program specifically, and that a disproportionate plan should describe the benefit both ways. A researcher reminded participants that there still is not sufficient information about what plans are doing. Some Medicaid plans argue that specialization allows them to do more for the specific population. Another question to consider is what scale is needed to achieve the plan's goals? Some SNPs may not be large enough to create an effective program design that will add value. Participants noted that legislation passed by the House of Representatives in 2007, H.R. 3162, that redefines "disproportionate" to mean that ninety percent of the plan's enrollment comprises people meeting the special needs definition. Advocates also questioned how care coordination adds value to SNPs if most "regular" MA plans are supposed to be coordinating care. This question remained open for further discussion during the day. IV. Session III – How Does the SNP-State Connection Help Beneficiaries? Moderator: Pam Meliso A. Presentation "Connecting SNPs with State Medicaid Programs" Charles Milligan, Executive Director of the Center for Health Program Development and Management at the University of Maryland, Baltimore County, gave the second presentation of the day. He noted that Dual SNPs are not the dominant form of delivery of Medicare services for dual eligibles, with only about 10% of duals enrolled in Dual SNPs for 2007. Even fewer duals are enrolled in Medicaid managed care. Minnesota, Arizona, and Texas have the largest such enrollments, which total 79,000 for the three states. Milligan sees Medicare and Medicaid coordination as a key to the viability of Dual SNPs. An important objective for a SNP would be the creation of an individual plan of care for each enrollee that might draw on physician, hospital, skilled nursing facility, and home health services (primarily Medicare) as well as personal care attendant, home- and community-based services and transportation (primarily Medicaid), the elements of which are coordinated by the SNP. SNPs cannot achieve their objective if they operate without some level of coordination – a contractual coordination agreement – with the state. Such an agreement might be limited to information-sharing for issues like health records, alerts on care, claims, and crossover claims. But contracting with SNPs is a contentious issue for many states. An issue related to care coordination is the coordination of the grievance and appeals systems. What is the recourse for a beneficiary denied a benefit in both programs when both deny responsibility? B. Participant Discussion Pam Meliso, an attorney with the Center, led the discussion. Participants raised a few clarifying points before addressing several questions. Advocates pointed out that there are two different sorts of coordination: the coordination of benefits and financial responsibility and the coordination of a beneficiary's medical care. The fiscal coordination may get in the way of the care coordination. They also raised the need for monitoring and enforcement. Participants also discussed some of the problems of coordinating Part D for dual eligibles as an example of the challenges in coordinating benefits among states, CMS, and private plans. Ms. Meliso asked the first question: 1. What additional services should Medicare SNPs provide that state Medicaid plans do not? A researcher said that he has heard from SNPs that they tend to add easily marketable services like vision, dental, and hearing. These services do not add value for duals in states like Connecticut where Medicaid already provides those services. We want more effort at care coordination and health education, but the plans say it is hard to market those things to people who have never experienced them. It is much easier to talk about one-stop shopping and one card. A state representative explained that her state puts in plan contracts that the state can back out of services covered by Medicaid so the plans are not double-paid. The state contract includes an expectation for care coordination, and the state enforces that provision. A representative of a state plan said that the plan includes dental benefits because dentists in the state will not accept the low Medicaid payment rate. Plan representatives discussed the different benefits they provide to their enrollees, not all of which are medical, and admonished against being overly prescriptive so as to stifle creativity. An advocate raised the problem that many providers do not take both Medicare and Medicaid, and that they are not familiar with rules about not billing dually eligible beneficiaries for cost sharing. The potential of a SNP is in having networks of providers that either accept Medicare and Medicaid or hold harmless dually eligible beneficiaries for cost-sharing. Ms. Meliso posed the next question: 2. How can SNPs add value for persons receiving services under Medicaid home- and community-based waivers or in institutions? A participant asked what it means to meaningfully include folks in their community. He suggested that the SNP had the potential to assist the beneficiary in identifying the types of activities s/he would like to pursue. Participants described social services such as transportation which are not usually covered by Medicare but which may be covered by Medicaid. An advocate for people with disabilities raised concerns about the home- and community-based services issue. She expressed doubts about whether the fiscal incentives to serve this population exist, and about the goals and values of managed care plans. She gave the example of a health plan having trouble because there were "unwarranted" variations in the amount of personal care time beneficiaries were receiving at home. The plan was accustomed to a medical model and did not consider the activities of life and the special problems, including environmental problems, of enrollees when determining the amount of services that might be needed. She underscored the need for good standards and good data and for fiscal incentives aligned with the objective of keeping people at home. She raised the issue, seconded by other beneficiary advocates, that ignoring enrollees saves plans money, and that case management sometimes turns in to cost management. Ms. Meliso asked the session's final question: 3. What is it about SNPs that makes their existence "an unprecedented opportunity" for better coordination between Medicare and Medicaid? A SNP representative said that there are many opinions when it comes to care coordination depending on who you talk to and depending on the site of care. He suggested that all SNPs should have the capability to undertake complex long-term care management. He noted that the ideal is integration of both financing and of acute and long-term care services and only three states, Minnesota, Massachusetts, and Wisconsin, have full integration. A participant stated that beneficiaries like having a nurse available 24 hours every day, as is the case in some Institutional SNPs that place geriatric nurses in the nursing facilities with which they contract. An advocate asked how we can get plans to think about a care coordination model. What requirements do we impose? What is the value of keeping people at home? A plan representative added that plans need to look at and adopt best practices. A researcher stated that she had seen a California plan that did a fairly extensive home visit, including a safety and environmental assessment, and that perhaps an initial assessment should be required. A CMS representative pointed out that, under the Medicare regulations, care coordination is considered as an administrative cost not a health care benefit cost. Another challenge lies in the fact that the CMS contracting year may differ from the state's contracting year. If states can see the potential, it advances the dialogue. An advocate expressed concern about the added value if there is not consistency, not only among states but among different plans in the same state. How is the beneficiary to determine which of the different services offered by the different plans is more important? Other participants gave examples of care coordination models. They opined that an assessment and care plan were benefits that provide added value. They referred to guidelines developed with support from the Robert Wood Johnson Foundation and provided by organizations around the country that have been providing care management for decades. They raised the need for the plan to be pro-active and contact the beneficiary, rather than wait for the beneficiary to contact the plan. The issue of problems for beneficiaries due to a delay in discharge planning was also raised. The caution was raised that benefits tend to be based on the medical model, not the social model, and that the more social benefits are harder to market. It was suggested that beneficiaries be given more control, and that attendant care be available. Several participants discussed the need for enrollment in SNPs to remain voluntary. The House-passed bill, H.R. 3162, would prevent auto-enrollment of dual eligibles into managed care. Advocates returned to the concept of coordination, both of benefits and of care. Though it is important, plans cannot market care coordination and they cannot bid on it (because it's an administrative cost). Nonetheless, since care coordination seems to be universally viewed as valuable, from the beneficiary perspective, there should be enforceable requirements that SNPs provide care coordination. A related and widely-held assumption is that care coordination saves money, but little evidence supports this view. The SNP business model seems to be constructed on the assumption that highly needy populations can be served cost-effectively by grouping them together and coordinating their care. What are the implications of this premise proving false? In response to a story about "care coordination" that seemed suspiciously like "cost management," a researcher raised the need to distinguish between the desirability of a particular aspect of care and whether the provider or payer performs the service well or effectively. CMS has the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to gauge the latter. We may not be able to define coordinated care in a generic sense; we should ask the patient if the care has been coordinated and attach money to that. There is no Pay-for-Performance program for managed care's performance; we can get at it without being over-regulatory. A propos the implications of care coordination being considered an administrative cost rather than a benefit, a CMS representative clarified that the MA bids include administrative costs. She also noted that the CMS definition of the health benefit affects how plans describe the plan benefits. And, in response to the suggestion that all plan enrollees should get care coordination without having to "qualify" for it, she stated that there is no service under health insurance that people should get at any time. Risk assessment means matching the availability of services and that is valuable. Managed care can do that well. CMS is working on a multi-year project with the National Committee for Quality Assurance (NCQA) to develop performance measures for SNPs. According to a researcher, whether care coordination is called an administrative cost or a benefit, the difference is whether you can use the savings from more efficiently delivering services under Parts A & B to do it. With SNPs, we should be looking for organizations that will be committed to doing something different that will give them a good reputation. Of the numerous plans now, some are just different benefit packages for the same organization, and some got in as placeholders. Over time, can you whittle it down to the organizations that are serious about the business, and how do you do that? Maybe make it more difficult to enter. State representatives discussed the barriers to states' willingness to coordinate with SNPs. One barrier is the standard summary of benefits that discusses only Medicare benefits and cannot say what Medicaid provides, which is not good for SNPs. MA plans, including SNPs, must follow MA rules, which require use of this summary of benefits. Some states try to push the envelope, but it may be more difficult for states that are just starting, that do not run one of the existing waiver programs. David Parrella, Director of Medical Care Administration with the Connecticut Department of Social Services (DSS), joined the conference by telephone to describe that state's experience. Connecticut does not have a Medicaid wrap-around contract for dual eligibles in Medicare Advantage plans. The Legislature authorized DSS to spend up to $25 million to contract with SNPs to provide wrap-around coverage, but DSS is not yet convinced of the value to the state. Ten years ago Connecticut entertained the development of an 1115 waiver for managed care for its long-term care population. Parrella described two problem areas. First, marketing to a population that includes individuals who are in home- and community-based waivers is problematic because the folks in those programs do not fully comprehend what is in the plan with its closed provider network. They sign and get complimentary gifts. Then, the homemaker companion whom they have seen for four years can't come and there is a disruption in the continuity with their home-care provider. That has occurred with some frequency. The state has had meetings with agencies that have home- and community-based service waivers and with SNPs to discuss the adequacy of their networks and to have more robust disclosure of who's in which network. It has gotten better, but it remains an issue. Second, he described Connecticut's successful program, over several decades, of getting Medicare coverage for dual eligibles for benefits such as home health and Skilled Nursing Facility (SNF) services. The state shifts these costs appropriately from the Medicaid program to the federal program. The modus operandi for SNPs is different from what the state is used to dealing with. It is good that they don't put people in an ambulance from a SNF and they may do more to treat a person in a SNF. But it doesn't align exactly with the skilled level of care that is recognized in fee-for-service Medicare. There is not much cooperation with SNPs for appealing a skilled level of care denial in Medicare. The larger issue for the State of Connecticut, according to Parrella, is fiscal impact. Whether contracting with Medicare managed care on a capitated basis will ultimately result in an advantage to the state or to the Medicare program has yet to be seen. The state has not completed its analysis because of the press of other issues. In response to a question concerning contracting with an Institutional SNP, Parrella stated that the dilemma is in determining the benefit to the state and whether the plans are shifting costs to the state or whether contracting with them would level the playing field. Parrella explained that SNPs are interested in having the ability to confirm Medicaid eligibility. They do so now by contacting case workers because they do not have access to the state's automatic eligibility system. SNPs are not providers with the state and do not have contracts with the state. In Connecticut, in the absence of being a Medicaid provider or having a contractual relationship with the state, the state cannot legally share protected health information. A CMS representative said that there is variation among states in the ability to share eligibility information. CMS is interested in facilitating state efforts to share that information, perhaps by going through the providers within a SNP's network. A researcher pointed out that a new system could be globally cost-effective and deliver better quality, but it could be more costly for each individual. Medicaid does not get any benefit if there is an avoided hospitalization. What are the components of what we're looking at to decide good policy? Are we looking in to whether this provides better health outcomes, even if it's break-even or costs Medicaid more? Participants discussed the impact on beneficiaries of cost-shifting between the two programs. Beneficiaries are more concerned about getting care than whether the wrong payer is paying. There is no general authority under Medicare or Medicaid to allow the two streams of funding to come together. Some states like Minnesota have done that, but others are concerned that the state will not benefit. The different Medicare and Medicaid payment rates may create disincentives at the provider level. The proposal was made that states should get some financial incentive from the bid process, some share with Medicare. V. Session IV - Working Lunch Moderator: Alfred J. Chiplin, Jr. A. Presentation "Medicare Advantage Special Needs Plans: Overview of Issues by Type of Plan" James Verdier, Senior Fellow at Mathematica Policy Research, described his research on SNP enrollment. Of the 1 million people enrolled in a Dual SNP, 250,000 are in Puerto Rico and 200,000 were passively enrolled. Another 50,000 are from Kaiser Permanente and about 100,000-plus were from the conversion of social HMOs in California and New York. The overwhelming majority of duals are autoenrolled in stand-alone Part D Plans. In aggregate, they are still in the plans into which they were autoenrolled. Duals are hard to identify and market to. And how does an individual know up front whether a plan is special or if the plan's networks and services will meet their needs? It is a hassle to disenroll and the next plan may not be better. This past year there has been a tremendous growth in Chronic SNPs led by UnitedHealth/Evercare (in 34 states) and Humana (in 24 states). Chronic SNPs have an enrollment of about 170,000 with 60,000 in Puerto Rico and 70,000 in Care Improvement Plus in 6 states. How do plans get the records of diagnosis from the year before because that's what drives payment? How do the plans change care patterns to keep people out of emergency rooms, hospitals, and SNFs? MA-PDs (MA plans combined with a Part D plan) have disease management programs, but is it better to have a plan providing an array of other services or some targeting? Half of the beneficiaries in Chronic SNPs are not dual eligibles. With respect to Institutional SNPs, most of the enrollment is in Evercare. How do they contract with and work with nursing facilities? The only claims data we have are about drug usage. Our other essential data tools are the CAHPS survey and the Healthcare Effectiveness Data and Information Set (HEDIS). Small enrollment may be a problem as plans need a critical mass to justify the special focus. B. Participant Discussion Alfred Chiplin, an attorney with the Center began by asking, "If enrollment is low, what is going on?" Jim Verdier said that it is easy to exaggerate the growth in numbers and in enrollment. At the same time, small enrollment may be a problem because these plans need some critical mass to justify their special focus. There are about half a dozen states contracting with plans and about six more working it out. Difficulties states are having in relationships with plans can be mitigated by looking at the experiences of other states. He thinks Institutional SNPs have potential but he does not know about Chronic SNPs. A plan representative said that the plan initially wanted a disease management waiver, but that morphed into a Chronic SNP that never caught on. It was difficult to market because what the plan was doing was too subtle and people could not see how what it was offering is better than Medicaid or traditional Medicare. Participants discussed that the marketing problems stem from a difficulty in describing the benefit. Beneficiaries look at the small gifts they get from the plans, but they do not see or understand what plans describe as the real value. A participant asked what data researchers need to understand what is going on. CAHPS and HEDIS have an impact but the problem is the small sample size for SNP data. It would be helpful if CMS could summarize the SNP models of care included in their application and make that information available. A researcher described the difficulties in getting the data. Data on patterns of disenrollment will never be public. CMS could generate analyses of their files, which would not violate confidentiality, and which would allow researchers to look at targeted disenrollment. CMS could also take the complaint data from advocates and convert that to some information. If the Medicare program is going to follow the model of more private plans, the fiduciary responsibility to Congress should be to require statistical reporting of patterns and trends to understand what is happening within states and among the different types of plans. The personal plan finder needs to be available earlier so researchers can look at the benefits being offered. A plan representative said that a group of Medicaid directors is looking at performance measurement in SNPs. One problem is that information systems are designed around systems they are trying to change, from a focus on where care is delivered to a focus on acute events. There are not ways of measuring continuity of care, multiple co-morbidities. There are not quality indicators for safe and effective transitions. The current HEDIS measures are mostly not appropriate. A CMS representative reminded participants of their timeline for NCQA to create a set of measures to be used in 2008. A beneficiary advocate stated that having the basic claims pattern data could help describe whether the beneficiary understands who is in the network, the benefit package and the role the SNP plays in helping enrollees get through the process. A researcher said that plans have the data but not in a standardized form. While Medicaid requires plans to report some data, it would burden CMS and the plans to determine what and how to report. A CMS representative explained that, although CMS was given authority for risk adjustment, which included plans having to report encounter data, they decided on diagnosis reporting rather than use of encounter data. In regard to Part D, CMS does not have the authority to use prescription claims information for any other purpose than payment. A plan representative stated that encounter data was not necessarily risk adjusted. A researcher said that claims have little effect because they are missing the clinical side. What specific data would be useful to monitor quality? It was pointed out that Wisconsin constructed HEDIS-like measures from selected encounter data. A beneficiary advocate pointed out that there has not been much discussion about the complexity posed to beneficiaries and their helpers trying to understand what the SNP is and how it differs from Medicare Advantage and traditional Medicare. Beneficiaries think MA plans are supplemental to their Medicare—that they have Medicare and something more (the advantage). People in the policy sphere underestimate the possibilities for confusion. A plan could be perfectly honest in its marketing, but the situation is too complex. The need for claims data is related to the issue of the failure of the beneficiary to understand the complexity of the plan's design. A researcher said that one advantage of MA, if it is done right, is the credentialing of providers. There is an important balance in how a plan builds its network. There are financial components and also quality components. NCQA drives the credentialing process for plans to build provider networks and that drives quality too. Having an open panel is valuable and having high quality providers is valuable. A poor-performing SNF (one with a high rate of hospitalization or a lot of deficiencies) can be shut out of a plan's network. An advocate for people with disabilities countered that existing surveys, including the CAHPS survey, are inadequate for people with complex needs. An instrument needs to be designed to ask questions that elicit beneficiary experiences and what is important to them. VI. Session V - The Beneficiary Experience Moderator: Brad Plebani A. Presentation "The Medicare Advantage Special Needs Plan Experience: Beneficiary Perspective from Pennsylvania" Alissa Halperin, Managing Attorney at the Pennsylvania Health Law Project, presented on problems faced by SNP enrollees. She reminded participants that this population has significant complex health needs, has low health literacy, and is often in a health care crisis. It is not possible for them to comprehend the marketing material or to read it. There is a lot of information out there and not all of it is accurate. Every beneficiary thinks the plan must be "special," which is the way the plans are presented and understood by consumers. Caseworkers often think that the Dual SNP is the only plan dual eligibles can have. Based on her work in Pennsylvania (over 3,500 calls per year from consumers statewide), she and other staff in her program have identified three key timeframes in which specific issues arise: initial enrollment, disenrollment, and the period of participation in the plan. Dual eligibles have historically been excluded from managed care and they do not understand the framework of managed care. They cannot understand a Summary of Benefits (SOB) and the SOB misstates their coverage because it does not include what is covered by Medicaid. A SNP in Pennsylvania sent a summary to the Medicaid agency. The agency asked the plan to make changes to the SOB because of misstatements. The plan refused and the CMS Regional Office said it had no authority to tell the plan to change its SOB. One plan was allowed to passively enroll beneficiaries without a network of providers. Throughout the period of enrollment, there are changes. What should the requirements be for SNPs? The plan should not be able to bury in its Annual Notice of Change (ANOC) that the only hospital in its network in a rural area has left the plan. Beneficiaries cannot wade through the ANOC. They do not get adequate information because written notice is often not adequate for this population. A possible requirement with regard to transitioning would be the provision of a 60-day window starting at enrollment for a beneficiary who enters a SNP that does not include her provider in its network. The 60-day window would allow her to find a new provider or to persuade her old provider to join the network, either of which would foster continuity of care. There should also be a transition period for benefit changes. The beneficiary should be permitted to keep using a hospital that is no longer in the network until she can change to a network hospital or switch plans. It is often hard to find out which providers are in a SNP's network and SNPs do not know which of their providers accept Medicaid's payment rate. There appear to be serious issues of network adequacy, especially as folded into Medicaid managed care because there are no network adequacy rules for SNPs. For example, under Mediciad law, urgent care must be available within a select number of minutes, miles, or days, but SNPs serving a wider area than the city of Philadelphia had no services outside the city. One SNP for dual eligibles refused to let a passively-enrolled beneficiary have the full subsidy for Part D, even though dual eligibles are automatically eligible for the subsidy. There are also coverage problems. SNPs decline to coordinate benefits and SNPs do not take an active role in knowing which of the services that the SNP does not cover are covered by Medicaid. SNPs are not required to know what Medicaid covers. SNPs are not required to give a modified denial, in the event the denied service is covered by Medicaid or other insurance. For example, a SNP for dual eligibles does not cover benzodiazepine drugs but does not know that the state Medicaid plan does cover benzodiazepines. Regarding institutional SNPs, the Nursing Home Reform Law imposes requirements on facilities. How do those requirements align with the SNPs requirements? Where does any conflict between the two sets of requirements get resolved? And, with respect to home- and community-based services, there may be issues of network adequacy. The financial incentive on the plan does not provide the protection for beneficiaries and their advocates that is provided by regulations against which advocates can hold plans accountable. B. Participant Discussion Brad Plebani, Deputy Director of the Center for Medicare Advocacy, moderated the discussion. 1. Would structural changes to the requirements for SNPs improve beneficiary experience? If so, what are those structural changes? Are they legislative or regulatory? Participants began by discussing the need for a legislative change to share some of the savings achieved, possibly half of the 25% rebate received by MA plans, with state Medicaid programs. It was unclear if such a proposal would address the beneficiary problems raised in the presentation. Participants from states with successful waiver programs were asked to describe how they handle the coordination of Medicare and Medicaid, in particular with regard to provider networks. The suggestion was made that CMS consult with the leading states to identify best practices and to develop standards for provider access for SNPs that serve dual eligibles. In Minnesota, all SNP plans are also Medicaid plans and they have contracts for Medicaid so the network is the same. The transition issue is built into the state's contract with the plans. If a service is authorized for a period prior to joining the SNP, the SNP must provide it and provide for continuity of care. They do not distinguish between Medicare and Medicaid covered services. SNPs have Medicaid contracts and they have to be non-profit to operate in Minnesota as a risk-based plan. Massachusetts uses a three-way contract among the state, the plan, and CMS; all the requirements are in a single agreement. Addressing the adequacy of an integrated network is challenging. The state allowed for a provisional start-up period and the networks were not full blown in 2004. Massachusetts plans have the flexibility to be creative. They can help people when an aspect of their housing is an issue, such as needing a wheelchair ramp. They can do things outside the box and that works. A Massachusetts advocate said that quality care comes down to what providers are willing to accept and that often depends on what the plan will pay. Good providers are not part of the network because they will not accept what is paid. 2. What are the minimal and optimal elements of SNP coordination with Medicaid? Participants discussed a suggested recommendation that SNPs must have a contract with the state Medicaid agency to some degree and conduct aggressive care coordination. They raised questions about what the contract would say and require, and whether the issues could be addressed without a contract. Some expressed concern that a contract does not solve problems, but recognized that the state needs to be on board in some way or else the SNP does not add value. A researcher suggested adoption of a common Medicaid managed care protection which provides a transition period for people entering and leaving a plan. A contract with the state would alleviate the problem of the SNP not knowing the diagnostic history of a new enrollee. He said there are positive ways of approaching cross-over claims (claims going from Medicare to Medicaid for payment of the Medicare cost-sharing), which is different from diagnostic data for risk adjustment. Another participant noted that years of planning went into the programs in Massachusetts, Minnesota, and Wisconsin, which is why they have not been replicated in the recent proliferation of SNPs. The requirements need to go beyond that a SNP needs an arrangement with the state. Such an arrangement only works if the state wants to put in the time to develop a program. A plan representative supported having a relationship with states and noted her efforts to get states interested. Beyond information sharing, she said the minimum relationship should have some coordination of non-Part D drugs. She said the attention of Medicaid directors is focused on other areas, including the uninsured, and expressed the need to develop some incentive to get states interested. Mr. Plebani asked for a clarification of the term "placeholder plan" and whether such plans lend themselves to the problems identified in the presentation. A researcher described a placeholder as a plan that is not actively marketing and enrolling. A sponsor wanted to enter the market and see what it is like. It is easy for plans to enter and they were not sure how things would shake out in 2006 so they did not spend much time developing anything. The researcher had not reviewed the data to know if such plans are causing problems. One question is whether it makes sense to allow these plans to continue to exist if they do not have a certain enrollment after a certain number of years. An advocate pointed out that the discussion has focused on good relationships with full integration. There are a lot of SNPs and we cannot make every state do what Massachusetts, Minnesota, and Wisconsin have done. But the absolute minimal requirements should be that the plan has staff members who know the state Medicaid program and a designated place to call to find out what the Medicaid benefits are, and that there be a regulatory requirement to that effect that is enforceable. These requirements should be independent of plan and state involvement. A researcher suggested that it might be difficult for a SNP to help enrollees navigate the Medicaid system if the enrollee is in Medicaid managed care. Advocates disagreed. They raised the issue of providing information about where to get assistance. They also expressed the concern that no one in an MA plan who is dually eligible should get fewer benefits than are offered by both programs. Medicare Advantage should have the same level of coordinated care that we require of SNPs. The purpose of SNPs should not be to migrate people to private plans. People in traditional Medicare should have the same coordinated services (medical, not administrative) and these services should be enforceable. Care coordination should become an expected and coverable service in traditional Medicare prescribed in the statute or in the regulations so that it is enforceable CMS policy. A plan representative agreed that it is appropriate for SNPs to be required to provide comprehensive complex care management. All SNPs should assist dually eligible beneficiaries in accessing and coordinating Medicare and Medicaid. He agreed that contracting with the state may be good, but said some states do not want anything to do with a SNP. He referred to some concerns about the wording of H.R. 3162, the bill passed by the House of Representatives in 2007, with regard to contracts with states, including that the language says nothing about either care coordination or fiscal coordination between Medicare and Medicaid. Several advocates pointed out that there is no right to a SNP, and asked why dual eligible SNPs should be allowed to participate in a state that does not want to cooperate. It was pointed out that some states, such as Arizona, believe they have no authority to place any requirements on SNPs. A state representative said that CMS helped the state with its Evidence of Coverage to add SNP language. There are other things CMS could do administratively to help things along. In 2006, there was a major reprogramming when Part D started and CMS took over the drug benefits. Minnesota had an integrated program and CMS gave the pharmacy benefit managers software to help them. CMS could produce materials for Dual SNPs to promote better communication. A CMS representative said that it is difficult for the state to provide the information. Preemption relates to licensure. What can the state require before it licenses a plan? States can't require a SNP to behave in a certain way that is contrary to Medicare rules, but they can put specific terms in the contract. A beneficiary representative queried the need for SNPs. Another returned to the lack of federal oversight, regulation, and enforcement, and said that states should not have to pay SNPs to do what they should already be doing. States are not the bad guys. A researcher reminded participants that the idea for SNPs came out of a long series of initiatives that responded to a perceived need of these special populations. Otherwise, there was just managed care that deals with healthy people. Plans, states, and CMS should work together. Plans also have an incentive to coordinate with states otherwise to validate their product. CMS needs to regulate at some point and decide what it wants to demand. From the beneficiary's perspective, it should not matter to the beneficiary if the plan is a SNP or a Medicaid plan. It should depend on what the plan offers. A plan representative said there also needs to be an opportunity for dialogue about integration. The value to beneficiaries is undeniable if it would result in integration between the two programs. It is no small investment for states to get into this and it is no small investment for the plans. The plans are accountable for delivering services and there are good reasons for accountability. Plans think the quality measures under development are an excellent idea, but do not want requirements to be set in stone so that good plans have difficulty. Another plan representative said there is an obvious need for integration because the Medicare benefit package does not respond to chronic care needs. If you want to be a SNP, you must have integration as a goal, not just the Medicare benefit, but be really interested in serving the dual-eligible population. He asked how plans relate to the beneficiaries they are trying to serve. How do we begin to understand the true needs of beneficiaries so they can see the value in a particular service delivery system? Educating dual eligibles about their choices is very difficult because there are basic issues of literacy. How can we get Medicare to work with other groups in our community that have relationships with enrollees? Medicare's focus on containing acute care costs makes addressing chronic care needs difficult. 3. What should SNPs be required to demonstrate? What are the essential elements of the contract between CMS and SNPs? A researcher reminded participants of CMS's initiatives related to people with chronic conditions in the traditional Medicare program. People with chronic illnesses are served well neither by traditional Medicare nor by MA. The entire Medicare program needs to move in the direction of serving this population better, but it may be easier in managed care. Making SNPs special is the whole purpose of this day. We can either say CMS must make sure these SNPs are special and serve the needs of enrollees, or tell Congress what tools CMS should be given to be able to do that. A beneficiary advocate said CMS needs legislative authority to make SNPs more special. They need more of a mandate to integrate Medicare and Medicaid and more specific requirements to protect beneficiaries. A researcher suggested that when a SNP submits its bid to CMS, it should describe its relationship with its host state (a formal relationship, data sharing, benefit coordination, or some other connection). CMS has not had a mandate or the resources to oversee plans. There are bad marketing abuses, including misleading marketing information. If there is a market failure here (the plan is not delivering on the promise in all places), how is the market failure addressed? Is disenrollment a sufficient protection? If not, what are the statutory and regulatory protections to deal with the market failure? The MMA language is premised on the notion that consumers would bail out if there were a market failure. Given the size and format of the meeting, participants found it difficult to identify with great specificity requirements for SNPs. It was noted that some different requirements might be needed for each type of SNP. On a larger scale, they should have to show what makes them special. It was suggested that CMS, in consultation with all of the interests, should come up with requirements that all SNPs have to meet. Perhaps CMS should be required to monitor disenrollment, complaints, and beneficiary reports from the field. Where there is a pattern, CMS should look at the particular plans. VII. Session VI – Recommendations Moderator: Nancy Coleman Because it was not possible in the time allotted to develop consensus recommendations, the recommendations are presented as those of the Center for Medicare Advocacy, based on the conference experience and related papers. The recommendations can be found here. [1] Erb v. McClellan, No. 2:05-vc-6201 (E.D. Pas. Filed Nov. 30, 2005). [2] Alissa Eden Halperin, et al., "What's so Special about Medicare Advantage Special Needs Plans? Assessing Medicare Special Needs Plans for ‘Dual Eligibles.'" 8 Marquette Elder's Advisor 215 (Spring 2007); Alissa Eden Halperin, et al., "Medicare Advantage Special Needs Plans for ‘Institutionalized Individuals:' What Advantage to Enrollment?" St. Louis Journal of Health Policy (in press). [3] There are three types of SNPs, SNPs for dual eligibles, which we will refer to as ‘Dual SNPs;' SNPs for individuals with severe or disabling chronic conditions, which we will refer to as ‘Chronic SNPs;' and SNPs for institutionalized individuals, which we will refer to as ‘Institutional SNPs.' [4] After the conference, Congress passed the Medicare, Medicaid, and SCHIP Extension Act of 2007 which extended SNP authorization through January 1, 2010, created a moratorium on the Secretary's ability to designate existing MA plans as SNPs, and a moratorium on enrollment in new SNPs through December 31, 2009. Pub. L. No. 110-173.
Copyright 2007 Center for Medicare Advocacy
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