Recommendations OF THE CENTER FOR MEDICARE ADVOCACY

Based on the proceedings of a full-day working conference of experts from various disciplines, on the papers prepared for that conference, and on related articles and reports, the Center for Medicare Advocacy makes the following recommendations concerning legislative and administrative action that would promote the viability of Special Needs Plans (SNPs) as a useful alternative to currently available health care delivery systems.

 

Recommendations are made within the context of the American health care system’s nearly thirty years of experience striving to identify the best ways to deliver high-quality specialized care to special needs populations through, among others, On Lok, the Program of All Inclusive Care for the Elderly (PACE), and the dual eligible integration demonstrations. Congress and the Centers for Medicare & Medicaid Services (CMS) should use the fruits of that experience to develop standards of care and protocols for Medicare Advantage Special Needs Plans.

Beneficiary Protections and Standards for Care and Coverage

 

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

 

Access to Care for all SNP Enrollees

• Special enrollment periods (SEPs) must be available to allow all SNP enrollees to disenroll at any time and return to traditional Medicare.
   

• SNPs must review the health care providers and services currently used or desired by a potential enrollee and before enrolling the individual, disclose to the potential enrollee whether those providers are in the plan’s network and how the services will be covered.
   

• SNPs must ensure that their provider networks meet the specific needs of their enrollees with respect to specialists, geographic spread, transportation needs, language and cultural access and access for people with disabilities.   The networks of SNPs serving dual eligibles must comprise health care providers who accept Medicaid.
   

• SNPs must ensure that all network hospitals have at least one network doctor and provider affiliated with the hospital to provide diagnostic and other ancillary services and that those providers deliver the ancillary services to enrollees.
   

• SNPs enrolling dually-eligible beneficiaries must ensure that their network providers bill Medicaid for any beneficiary cost-sharing for a dually eligible enrollee or forgo cost-sharing for that enrollee. Cost-sharing could only be charged to the beneficiary to the extent that the state imposes cost-sharing under Medicaid on that beneficiary.

       Benefit Design

• SNPs must design their benefit package to offer supplemental health benefits that include care planning, care coordination, and benefit coordination.  Additional supplemental health services must be relevant to the target population.
   

• Supplemental health services offered to dual eligibles must augment and not frustrate access to services already covered through their Medicaid program.

Continuity of Care/Transitions for all SNP Enrollees
 

• SNPs must provide for continuity of care, including allowing for transition coverage of non-network providers, services and prescriptions for new enrollees and for enrollees entering a new plan year when a previous network provider is no longer in the network or when a previously covered service or prescription the enrollee requires has been removed from the benefit package.

 

• Transition coverage must be provided for either six months or two visits to any given provider after the effective date of coverage, or the time necessary to complete a specific course of treatment.
   

Initial Assessment and Development of a Care Plan
 

• SNPs must, within a short period after the individual’s enrollment, conduct an initial assessment of the individual’s medical and social service needs and develop a care plan.  If the individual does not want such an assessment, the SNP must document efforts it made to discuss same with the individual. 

 

• Copies of the assessment and care plan should be provided to the enrollee and to her primary care physician.  The care plan is updated as needed and always after a change in the enrollee’s situation.

 

Coordination of Care

 

Care coordination must be an essential element of all SNPs for all SNP beneficiaries and should be readily available upon enrollee’s request or a determination by another source of the need for same.  Care coordination must be a prerequisite for CMS approval to operate as a SNP.

 

• SNPs must coordinate the care of enrollees in accordance with the care plans developed for each consumer or the evolving needs of the enrollee as presented to the SNP.  Denials of care coordination must be appealable.

 

Coordination of Benefits

 

SNPs serving dual eligibles, regardless of whether they are Dual Eligible SNPs, must demonstrate the capacity to deliver or coordinate the SNP benefits with Medicaid services and with related social services, as the latter term is defined in regulations promulgated by CMS.  Such capacity can be demonstrated (for Medicaid services) through a contract with the state to deliver Medicaid services or (for all services) through identifying core competencies, staff expertise and dedicated resources to coordinate all the health needs of their enrollees.  CMS must identify specific areas in which the plan must demonstrate competence. Beneficiary-oriented plan materials must include clear and accurate information about the benefits available under the state’s Medicaid program.

• SNP marketing materials, summary of benefits and evidence of coverage must state explicitly how the SNP benefits coordinate with and supplement Medicaid, including a list of all SNP supplemental benefits and how they differ from those offered by Medicaid.  They must articulate the costs to consumers, taking into account the Medicaid coverage available for some of the costs.  Materials must be state-specific.  Enrollment brokers or sales agents must be trained accordingly.
   

• All enrollees of Dual SNPs and those enrollees of Institutional and Chronic SNPs who provide evidence of Medicaid at the time of enrollment must be treated by the plan as eligible for the full Part D low-income subsidy.  The SNP must initiate action to correct CMS’s records, if needed.
   

• Enrollees of Dual SNPs who lose Medicaid eligibility during the year must be permitted to remain in the SNP through the end of the calendar year. The SNP must inform them of additional costs they will bear as a result of losing Medicaid coverage. Exclusively Dual SNPs must be prohibited from enrolling medically needy individuals.
   

• SNPs with Medicaid Managed Care contracts for dual eligibles must present to each enrollee, in an understandable format, clear information about their appeal rights under both Medicare and Medicaid.
   

• SNP staff must know what the state Medicaid program covers and how to access it.  SNPs must assist enrollees in accessing Medicaid coverage when their care plan indicates they cannot do so independently.
   

• SNPs must coordinate benefits of enrollees with multiple forms of coverage, such that provider claims submitted to the SNP for amounts covered by other coverage get seamlessly transferred to Medicaid or the other insurance program.

Enforcement

 

The protections and standards outlined above must be enforced and we recommend that the Congress:

• require that all SNPs serving dual eligibles demonstrate the capacity to deliver or coordinate Medicaid services and related social services; 
   

• adopt a minimum definition of and minimum standards for “care coordination” that are required to be offered to all enrollees of SNPs;
   

• require periodic reviews by the Government Accountability Office and/or the Office of Inspector General at the Department of Health and Human Services of CMS’s oversight and enforcement of plan compliance; and
   

• Provide an enhanced federal matching rate for states for data-sharing activities described below.

We further recommend that CMS should increase its audits and other compliance reviews of SNPs. Further, CMS should, by regulation: 

• incorporate and elaborate on the legislative requirements for coordination with Medicaid and for care coordination;
   

• define “severe or disabling chronic condition;” and
   

• adopt the specific beneficiary protections enumerated above and should incorporate these requirements into contracts with SNPs.

Research/Data

Data must be collected, analyzed and made available to researchers.  Analyses must be disseminated to the public to promote better understanding of whether and how SNPs are meeting the special needs of their enrollees.

 

Use/availability of Currently Collected Data

 

     We recommend that CMS:

• release downloadable Personal Plan Finder for each new plan year when the information becomes available to the public in October of each year;
   

• coordinate public data file and release MA and SNP data to allow analysts to better understand SNPs in overall MA context;
   

• conduct objective analyses and publicly report targeted disenrollment rates nationally and by state and plan sponsor (e.g., early disenrollments, type of transition, voluntary vs. involuntary) on a regular basis annually and/or quarterly;
   

• refine the Medicare Plan Finder Tool to better illustrate for beneficiaries any unique feature of SNPs; and 
   

• monitor complaints and grievances by type and plan type with public reporting.

New Data Requirements

 

     We recommend that CMS:

 

• identify data needed to review actual success of SNPs, in terms of beneficiary satisfaction and quality, require plans to collect it and report it to CMS, and make it available to the public;

 

• require uniform data reporting to CMS that would include:

  • claims/encounter data from SNPs (out-of-network coverage, etc.),

  • data related to cultural competency and language access of the plan and the providers, and

  • data related to physical accessibility to and within the medical office of providers in a plan’s network;

 

• develop mechanisms, using CAHPS and other survey sources that solicit beneficiary feedback specific to SNPs and make findings publicly available;
   

• require that SNPs serving dual eligibles share utilization, encounter, diagnostic and key health events data of each dual enrollee with the state Medicaid program in the state in which the enrollee resides, and that state Medicaid agencies similarly share data with SNPs; and
   

• provide an enhanced federal matching rate for states for data sharing activities described above.