Medicare Advantage Special Needs Plans: A National and California Perspective
June 6, 2007 Webcast Q & A Session
Center for Medicare Advocacy, Inc.
California Health Advocates
National Senior Citizens Law Center
The following is a list of answers to questions submitted during the California Medicare Coalition webcast on June 6, 2007 entitled “Medicare Advantage Special Needs Plans: A National & California Perspective.” Note that some of the language of the submitted questions has been altered for purposes of clarity and duplicate/similar questions have been consolidated. The webcast is available online.
Q1: Start to finish, how long does it take for a Special Needs Plan (SNP) to be approved?
A: It is our understanding that it takes the same amount of time for CMS to approve a SNP plan as any other Medicare Advantage plan offered by a sponsor that wishes to contract with the Medicare program. See, generally, CMS’s 2008 Call Letter available at: http://www.cms.hhs.gov/….pdf
As discussed during the webcast, there are some additional requirements in the application a Special Needs Plan must answer for 2008. See 2008 Special Needs Plan (SNP) requirements are at: http://www.cms.hhs.gov/….asp (Click on “Application for Coordinated Care Plans.”)
Q2: Are Special Needs Plans the “whole healthcare” for individuals, even those with chronic conditions? If so, a person with a plan like Brand New Day for the seriously mentally ill, who goes to a doctor for an unrelated treatment, will be showing a health insurance card, which is quite revealing; meaning in other words, that he or she is mentally ill. That is quite a stigma and quite revealing. Is that appropriate? Is that a HIPAA violation?”
A: With respect to the first question, are SNPs the “whole healthcare for individuals, even those with chronic conditions,” the short answer is, it depends. It depends on what other health coverage that person might have, it depends on the particular services that that individual is trying to obtain and whether they are covered by the plan. For dual eligibles in California, for example, specialty mental health services under Medicaid are carved out and are administered on a county basis, and there have been some questions and concerns about how those different mental health plans coordinate, if at all, with Special Needs Plans. Even if a SNP enrollee does not have other coverage, the SNP plan is still required to cover all Medicare services under Part A, Part B, and Part D. So a SNP enrollee is entitled to the full Medicare package, even if the SNP’s particular emphasis is on a chronic condition, such as mental health.
We believe the question raises an important point concerning whether a SNP plan’s name and/or focus creates any stigma, or inappropriate disclosure of protected health information. We can’t really speak, though, to whether such disclosure is a violation of HIPAA privacy protections.
Q3: Is a Special Needs Plan paid by Medicare and Medi-Cal (Medicaid)? Is the primary care provider to bill the Special Needs Plan and Medi-Cal?
A: A SNP could be paid by both Medicare and Medi-Cal, for its dually eligible enrollees, if the SNP had either a contract with Medi-Cal or some other agreed upon process to pay Medicare cost-sharing. For example, even without a SNP contract with Medi-Cal, Medi-Cal might make a monthly payment to the SNP to cover its cost-sharing obligations on behalf of Qualified Medicare Beneficiaries.(*) Other factors that would bear on whether there are payments from both Medicare and Medi-Cal, include what service the individual is trying to get covered and whether that service is covered by Medicare and/or Medi-Cal, and whether the provider accepts both Medicare and Medi-Cal. It is sometimes hard to remember that a Special Needs Plan is a Medicare plan, since what they are looking to provide, or what the law and guidance says about the population they’re serving, has a lot of Medicaid elements to it. But in terms of the plan itself, the payment it would be getting is a Medicare payment. And, as referenced above, if there is also a Medi-Cal plan with the same sponsor, then there would also be a Medi-Cal payment.
Q4: How many SNPs for dual eligibles are truly “integrated” as far as Medicare and Medicaid benefits and revenue streams? I understand that some Medicare Advantage SNPs might offer Medicaid-like benefits (e.g. transportation), but do not actually integrate/coordinate with Medicaid.
A: This is an excellent question, but there is no national yardstick for measuring whether SNPs are truly integrated. In many respects, it is tough to measure true integration, because it really involves looking at both the particular plan itself and the experiences of beneficiaries on the ground and not just whether the plan checks a box that says that they’re integrating. We likely have a long way to go to before we are able to figure out the exact answer. The Special Needs Plan applications for 2008 do require plan sponsors to indicate whether or not they have some type of relationship with the state Medicaid program, but we do not yet know how that information will be used. There are several states that are looking to require (or may already require) their dual eligibles to be in a Medicaid managed care plan that would coordinate with a Medicare Advantage SNP (see, e.g., slides 42-44); in those few states where they’ve been working with integrated systems for a while, there are probably a lot higher number that already are integrated.
In California, some of the Medi-Cal County Organized Health System (COHS) plans that became Special Needs Plans, in theory, integrate Medicare and Medi-Cal funding. And under the state’s business plan with respect to the other types of Medi-Cal managed care models (the Two-Plan and Geographic Plan models), in theory, dual eligibles who are in a SNP plan offered by a sponsor that also contracts (or subcontracts) as a Medi-Cal managed care plan will have access to some type of integrated care (see slides 49-50).
In the opinion of one webcast participant, “Integration of Medicare and Medicaid services are hard to define and hard to understand at the plan level. I believe that PACE is the only program that integrates all Medicare, Medicaid and LTC services. Even if a SNP says that they integrate Medicare and Medicaid, it is probably not integrating most of the LTC services under Medicaid. Unfortunately, PACE is very difficult to scale up.”
Q5: When you were talking about Kaiser passively enrolling dual eligibles into their Special Needs Plan (slide 47), our experience is that sometimes what should have happened did not always happen. What should dual eligible Kaiser enrollees do if they weren’t passively enrolled into the Kaiser SNP in California?
A: According to Kaiser plan representatives, Kaiser has structured their Special Needs Plan benefits so that dual eligibles enrolled in Kaiser’s SNP do not have to pay certain expenses that dual eligibles in their standard HMO must pay (any applicable Medicare Advantage premium and cost sharing for Part A and B services; see (*) at Question 3). Our suggestion would be to get in touch with Kaiser and request that that dual eligible individual be enrolled in their Special Needs Plan (if that’s what they want to do, assuming they want to stay in Kaiser). Depending upon that particular individual’s situation, you might be able to request a retroactive enrollment into the SNP if the person has been paying a lot out of pocket, and depending upon whether or not the person received adequate notice about their options. If they don’t want to stay in Kaiser, then of course, as a dual eligible, they have an ongoing Special Enrollment Period (SEP) right to change plans on a monthly basis.
Dual eligibles enrolled in Kaiser’s Medi-Cal managed care plan who were not also enrolled in Kaiser’s Medicare Advantage HMO were not passively enrolled into the Kaiser SNP. This caused confusion for some in 2007, when Kaiser stopped covering most prescription drug medications for its Medi-Cal-only dual eligible enrollees (in 2006, Kaiser apparently continued to cover medications for these individuals despite the introduction of Medicare Part D).
In addition, in a few instances, dual eligibles enrolled in the Kaiser SNP have been (erroneously) auto-enrolled by CMS into a different Part D plan, causing them to be disenrolled from the Kaiser SNP. In those situations, Kaiser automatically sends the member a letter telling him or her of the disenrollment, and advising the member to contact Kaiser in case the disenrollment was in error. The beneficiary then must take affirmative action and contact Kaiser if he or she wishes to re-enroll.
Q6: To what extent does Medicare alone cover long-term care services?
A: The short answer is that Medicare generally doesn’t cover long-term care services. Medicare Part A covers acute care services in the hospital and in a skilled nursing facility, as long as certain conditions are met, namely that an individual requires skilled care on a daily basis (with some additional caveats). Medicare’s coverage of skilled care in a nursing facility is generally limited by duration. You can get home health care services under Part A and Part B, and there is no duration, but there is the requirement that you need a skilled service, and with that might come some unskilled care. And the fact that that is true is what makes the whole institutional SNP kind of a curiosity.
Q7: Are Special Needs Plans allowed to discriminate against sicker members of the target population?
A: No. A chronic care SNP can take an individual’s health condition into account if they only accept individuals with a particular illness, but a SNP cannot restrict enrollment based upon severity of illness. If it’s a chronic condition SNP serving HIV positive individuals, for example, they can’t say they will enroll you “Only if you need a certain level of care,” or “Only if your disease is managed in a particular way.” CMS is responsible for making sure that, on a case-by-case basis, Special Needs Plans aren’t structured in a way that they discriminate against people based on the seriousness of their condition.
Q8: Please give some examples of the "extra" benefits a SNP may offer.
A: A SNP, like any other Medicare Advantage plan, can offer benefits in addition to those that are available through the Original Medicare program (Parts A and B). Some SNPs also provide additional benefits that might be tailored towards their particular target population, such as providing transportation services for low-income individuals. Other examples include: a chronic care SNP focusing on mental health might offer group therapy sessions; a chronic care SNP focused on individuals with chronic obstructive pulmonary disease might cover oxygen without imposing any cost-sharing; an institutional SNP might provide supportive services in the home to people who would otherwise require an institutional level of care.
Q9: On slide 7 it indicates that SNPs can serve duals or a subset of duals; what does a subset of duals mean?
A: Dual eligibles are individuals who are entitled to Medicare and also eligible for some level of Medicaid (Medi-Cal) benefit. “Full” dual eligibles qualify for full Medicaid benefits, whereas “partial” dual eligibles do not qualify for full Medicaid benefits, but for some type of assistance with Medicare cost-sharing through the Medicare Savings Programs (QMB, SLMB, QI) (see, e.g., http://www.cms.hhs.gov/DualEligible/). Within the context of SNPs, some plans cover “all” duals, including individuals only eligible for a Medicare Savings Program, and others cover only “full” duals. In addition, CMS may, on a case by case basis, allow some SNPs to target certain other subsets of full or partial duals based on an attempt to coordinate with state Medicaid agencies for service to that sub-population.
Q10: During the webcast, it was mentioned that in one geographic area, CMS approved a SNP where no providers are accepting the plan – could you clarify this?
A: It is our understanding that, according to advocates in Pennsylvania, CMS approved a plan that did not have any providers in it who accepted Medicaid, and yet it was approved to be a Special Needs Plan for dual eligibles.
