Medicare Advantage. Financial Alignment: Medicare and Medicaid 08/19/2015. Types of SNPs

Size: px

Start display at page:

Download "Medicare Advantage. Financial Alignment: Medicare and Medicaid 08/19/2015. Types of SNPs"

Elaine Kennedy
6 years ago
Views:

Medicare Advantage Other Medicare Plans September, 2015 Types of SNPs SNPs may be any type of Medicare Advantage Coordinated Care Plan, including local or regional preferred provider organization

1 Medicare Advantage Other Medicare Plans September, 2015 Types of SNPs 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) 2 Financial Alignment: Medicare and Medicaid 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. 3 1

2 Two Models Capitated Model: State, CMS, and a health plan enter into a threeway 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. 4 Chronic Condition SNPs (C-SNPs) 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. 5 Dual Eligible SNPs (D-SNPs) 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. 6 2

3 Institutional SNPs (I-SNPs) 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. 7 Models of Care Elements 1. Description of the SNP-specific target population 2. Measurable Goals 3. Staff Structure & Care Management Roles 4. Interdisciplinary Care Team 5. Provider Network having 1. (HRAT) Specialized Expertise & Use of Clinical Practice Guidelines 6. Model of Care Training for Personnel and Provider Network 7. Health Risk Assessment Tool 8. Individualized Care Plan Communication Network 9. Care Management for the Most Vulnerable Subpopulations 8 SNP Acronyms 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 9 3

4 Program of All-Inclusive Care for the Elderly Medicare OR Medicaid Team of health professionals May need to use PACE-preferred doctor Services delivered in the home, community, or PACE center PACE Eligibility 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 11 Services included May include services Medicare or Medicaid doesn t cover Adult day primary care Dentistry Emergency services Home care Prescription drugs Transportation if medically necessary 12 4

5 What You Pay 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 13 States without a PACE Program Alaska, Arizona, Connecticut, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Kentucky, Maine, Minnesota, Mississippi, Montana, Nevada, New Hampshire, South Dakota, Utah, Vermont, West Virginia 14 5

CIGNA Medicare Select Dual Special Needs Plan (D-SNP)

A CIGNA Medicare Select Dual Special Needs Plan (D-SNP) Model of Care Training for Contracted Health Care Professionals Prepared: October 2010 CIGNA Medicare Services," "CIGNA Medicare Select Plus Rx"