2021 special needs plans - aetna€¦ · a “special needs individual” is eligible for medicare...

Y0114_21_123151_I_C 06/08/2020This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.

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Special Needs Plans

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Introduction

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Agents wishing to sell SNP plans must take both the SNP and Part D modules as part of their certification, as well as the HMO and/or PPO module, depending on

the type of SNP plan available to market in their area.

Welcome to the Special Needs Plans (SNP) course. The overall goal of this course is to teach you about the different types of SNPs, their characteristics and associated election periods.

A course is considered completed with a passing score of 90% or higher on the product certification test for this module. Once you have successfully completed this module, you will see a completion checkmark on your online training list.

This module may also be used for agent re-education if necessary in the event of a sales inquiry. Note: You may return to this module at any time for a refresher on SNP product training.

This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.

Learning Objectives

• Identify the types of SNPs and their characteristics

• List the SNP Model of Care (MOC) objectives

• Recognize specific enrollment and disenrollment opportunities

• Dual Special Needs Plans (DSNP)

• Chronic Special Needs Plans (CSNP)

• Institutional Special Needs Plans (ISNP)


What is a Special Needs Plan (SNP)?

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There are three types of Special Needs Plans:

1. Dual Special Needs Plans (DSNP)

2. Chronic Special Needs Plans (CSNP)

3. Institutional Special Needs Plans (ISNP)

Special Needs Plans are either HMO or PPO plans which means all plans,

regardless of type, include a contracted network of providers.


What is a Special Needs Plan (SNP)?

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These plans are intended to provide targeted care to beneficiaries with special

needs. A “special needs individual” is eligible for Medicare Parts A and B, and:

1. Receives assistance from Medicaid, or

2. Has a specific severe or disabling chronic condition (as specified by CMS), or

3. Who, for 90 days or longer, has had or is expected to need the level of

services provided in a long-term care (LTC) skilled nursing facility (SNF).


Model of Care

Each SNP is required to develop a Model of Care (MOC). The MOC has specific goals and objectives for the population it will serve, including:

• Measurement

• Training

• Staffing

• Health Risk Assessments (HRAs)

• Interdisciplinary Care Team (ICT)

• Communication

• Clinical Practice Guidelines

• Results

• Evaluation


Dual Special Needs Plans (DSNP)

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In order to qualify to enroll in a DSNP, beneficiaries must be entitled to both (1) Medicare, and (2) Medical Assistance from a State Plan (commonly referred to as Medicaid).

Each state generally determines Medicaid eligibility criteria. The Medicaid eligibility categories, for the purposes of DSNP eligibility, include all levels of Medicaid eligibility, including those referred to as Medicare Savings Programs.


Dual/LIS Special Election Period (SEP)

This SEP begins the month the beneficiary becomes eligible for Low Income Subsidy (LIS) or receives any type of assistance from Medicaid. It is available one time-per-calendar-quarter during the first nine months of the year; or:

• January – March

• April – June

• July – September

The SEP is considered “used” based on the month the beneficiary makes the election (application date). The effective date of an enrollment request made using this SEP is the first of the month following receipt of an enrollment request.


Chronic Special Needs Plans (CSNP)

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Approximately two-thirds of Medicare beneficiaries have multiple chronic conditions requiring coordination of care among primary providers.

Chronic SNPs (CSNPs) are SNPs that restrict enrollment to special needs individuals with specific severe or disabling chronic conditions. There are 15 conditions currently approved for CSNPs.

Source: https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/C-SNPs.html


CSNP – Conditions & Groups

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Autoimmune disorders limited to:• Polyarteritis nodosa,• Polymyalgia rheumatica,• Polymyositis,• Rheumatoid arthritis, and• Systemic lupus erythematosus.

Cardiovascular disorders limited to:• Cardiac arrhythmias, • Coronary artery disease, • Peripheral vascular disease, and• Chronic venous thromboembolic disorder;

Chronic alcohol and other drug dependence.

Cancer, excluding pre-cancer conditions or in-situ status.

Chronic heart failure.

Chronic Lung disorders limited to:• Asthma, • Chronic bronchitis, • Emphysema, • Pulmonary fibrosis, and • Pulmonary hypertension.

Severe hematologic disorders limited to:• Aplastic anemia, • Hemophilia, • Immune thrombocytopenic purpura, • Myelodysplatic syndrome, • Sickle-cell disease (excluding sickle-cell trait), and • Chronic venous thromboembolic disorder.



CSNP – Conditions & Groups (cont.)

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Dementia Diabetes mellitus End-stage liver disease

Chronic and disabling mental health conditions limited to:• Bipolar disorders, • Major depressive disorders, • Paranoid disorder, • Schizophrenia, and • Schizoaffective disorder.

Neurologic disorders limited to:• Amyotrophic lateral sclerosis (ALS), • Epilepsy, • Extensive paralysis (i.e., hemiplegia, quadriplegia,

paraplegia, monoplegia), • Huntington’s disease, • Multiple sclerosis, • Parkinson’s disease, • Polyneuropathy, • Spinal stenosis, and • Stroke-related neurologic deficit.

HIV/AIDSEnd-state renal disease requiring dialysis.

Stroke



Eligibility & Enrollment

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To determine eligibility for a special needs individual to enroll in a CSNP, CMS requires the CSNP to contact the applicant's existing provider or provider's office to verify the enrollee has the targeted condition.

If the qualifying condition cannot be confirmed by the CSNP before the end of the first month of enrollment, the beneficiary will be mailed a notice of disenrollment for not having the qualifying condition.

CSNPs must reconfirm a beneficiary’s eligibility at least annually.


Special Election Periods (SEP) – CSNP

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SEP for Enrollment Into a Chronic Care SNP

CMS provides a one-time SEP for those individuals with severe or disabling

chronic conditions to enroll in a CSNP designed to serve individuals with

those conditions.

This SEP will apply as long as the individual has the qualifying condition

and ends once he or she enrolls in a CSNP. Once the SEP ends, that

individual may only make plan changes during applicable election periods.


Institutional Special Needs Plans (ISNP)

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ISNPs restrict enrollment to beneficiaries who, for 90 days or longer, have had or are expected to require an institutional level of care, or an institutional equivalent level of care.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c16b.pdf (page 25)


Enrollment – OEPI

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The Open Enrollment Period (Institutional), or OEPI, is continuous for eligible beneficiaries. For purposes of enrollment under the OEPI election period, an institutionalized beneficiary is defined as one who moves into, resides in, or moves out of an institution.

The OEPI ends two months after the month the beneficiary moves out of the institution.


SNP Assessment

An assessment will be given to test your knowledge on the information presented. A score of 90% or above on the assessment is required to successfully pass this module. If a score of 90% is not obtained, the assessment can be attempted again immediately.

Please click the “Certification Portal” link at the upper left portion of the screen to return to your home page to access the assessment.

After completing the assessment for this course, refer to your online training summary for your certification progress.


2021 special needs plans - aetna€¦ · a “special needs individual” is eligible for medicare...

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