Medicare AdvantageMedicare Advantage

Other Medicare Plans

September, 2015

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SNPs may be any type of Medicare Advantage Coordinated Care Plan, including local or regional preferred provider organization (PPO) plan. 3 common types of SNPs:• Chronic Condition SNPs (C-SNPs) • Dual Eligible SNPs (D-SNPs) • Institutional SNPs (I-SNPs)

Types of SNPsTypes of SNPs

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• Longstanding barrier to coordinating care for Medicare-Medicaid enrollees has been financial misalignment between Medicare and Medicaid.

• Qualifying states have an option to pursue one or both of the capitated or the FFS financial alignment models. In states with approved demonstrations, CMS will test these models over the next several years.

• CMS is also working with some states to pursue demonstrations outside the capitated and FFS financial alignment models.

Financial Alignment: Medicare and Medicaid

Financial Alignment: Medicare and Medicaid

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• Capitated Model:– State, CMS, and a health plan enter into a three-

way contract– Plan receives a prospective blended payment to

provide comprehensive, coordinated care.

• Managed Fee-for-Service (FFS) Model: – State and CMS enter into an agreement by which

the state would be eligible to benefit from a portion of savings from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid.

Two ModelsTwo Models

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• Restricts enrollment to special needs individuals with specific severe or disabling chronic conditions.

• Approximately two-thirds of Medicare beneficiaries have multiple chronic conditions requiring coordination of care among primary providers, medical and mental health specialists, inpatient and outpatient facilities, and extensive ancillary services related to diagnostic testing and therapeutic management.

Chronic Condition SNPs (C-SNPs) Chronic Condition SNPs (C-SNPs)

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• D-SNPs enroll beneficiaries who are entitled to both Medicare (Title XVIII) and Medical Assistance from a State Plan under Title XIX (Medicaid)

• 5 CMS-approved enrollment categories for D-SNPs: o All-Dual D-SNPs; o Full-Benefit D-SNPs; o Medicare Zero-Cost-sharing D-SNPs; o FIDE SNPs; and o Dual eligible subset D-SNPs.

Dual Eligible SNPs (D-SNPs) Dual Eligible SNPs (D-SNPs)

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• Restrict enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for the mentally retarded (ICF/MR), or an inpatient psychiatric facility.

Institutional SNPs (I-SNPs) Institutional SNPs (I-SNPs)

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1. Description of the SNP-specific target population2. Measurable Goals3. Staff Structure & Care Management Roles4. Interdisciplinary Care Team5. Provider Network having Specialized Expertise &

Use of Clinical Practice Guidelines6. Model of Care Training for Personnel and Provider

Network7. Health Risk Assessment Tool 8. Individualized Care Plan Communication Network9. Care Management for the Most Vulnerable Sub-

populations

Models of Care ElementsModels of Care Elements

1. (HRAT)

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• HRA: Health Risk Assessment• ICP: Individualized Care Plan• ICT: Interdisciplinary Care Team• C-SNP: Chronic Condition Special Needs

Plan• D-SNP: Dual Eligible Special Needs Plan• I-SNP: Institutionalized Special Needs

Plan• MOC: Model of Care• SNP: Special Needs Plan

SNP AcronymsSNP Acronyms

• Medicare OR Medicaid• Team of health professionals– May need to use PACE-preferred

doctor

• Services delivered in the home, community, or PACE center

Program of All-Inclusive Care for the Elderly

Program of All-Inclusive Care for the Elderly

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• 55 or older• Live in PACE service area• Need nursing-home level of care – As certified by State– But only 7% live in nursing home

• Can live safely in community with help of PACE

PACE EligibilityPACE Eligibility

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• May include services Medicare or Medicaid doesn’t cover

• Adult day primary care• Dentistry• Emergency services• Home care• Prescription drugs• Transportation if medically necessary

Services includedServices included

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• Depends on financial situation– If you have Medicaid, no monthly

premium for long-term care • Otherwise, pay for long-term care portion of

PACE benefit and Part D premium

–No deductible or copay for any drug, service, or care approved by your health care team

– If no Medicare or Medicaid, can pay for PACE privately

What You PayWhat You Pay

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Alaska, Arizona, Connecticut, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Kentucky, Maine, Minnesota, Mississippi, Montana, Nevada, New Hampshire, South Dakota, Utah, Vermont, West Virginia

States without a PACE ProgramStates without a PACE Program