CMS 2012 Medicare Advantage &
Prescription Drug Plan Spring Conference
Special Needs Plans Update
April 12, 2012
LaVern W. Baty, M.H.S.
Susan Radke, MSW; LCSW-C
Medicare Drug and Health Plan Contract Administration Group
1
Overview
• Legislative Overview – MIPPA & the Affordable Care Act
(ACA)
• State Medicaid Agency Contracts
• MIPPA Contract Elements
• D-SNP Types
• Subcontracting Arrangements
• FIDE-SNP Definition and Determination
• Questions & Answers
2
Legislative Overview – MIPPA & ACA
• The Medicare Improvements for Patients and Providers Act
of 2008 (MIPPA) requires a contract between a D-SNP and
the State Medicaid agency
• MIPPA’s goal is to strengthen integration and coordination of
Medicare & Medicaid benefits through D-SNPs
• MAO’s offering D-SNPs were required to have a contract with
the State Medicaid Agency if the D-SNP was changing its DSNP type, expanding the service area or applying for an initial
D-SNP
• The Affordable Care Act of 2010 (ACA) extended
deadline/effective date of the MIPPA contract provision, and;
• Requires All MAOs offering D-SNPs to have a State contract
beginning 1/1/13
• Defines fully integrated dual eligible SNPs (FIDE-SNPs)
3
State Medicaid Agency Contracts
The State Medicaid Agency Contract submittal and review
process is now automated in HPMS. All D-SNPs are:
• Required to submit the “State Medicaid Agency Upload
Document” that provides CMS with status of the State
Medicaid Agency contract negotiations by February 21, 2012
• Required to submit a signed and executed 2013 State
Medicaid Agency Contract with a corresponding 2013 D-SNP
State Medicaid Agency Contract Matrix Upload Document for
each State by July 1, 2012
4
State Medicaid Agency Contracts
State Responsibilities for D-SNP Contracting:
• Not mandated to contract with all D-SNP applicants or cover
all service areas
• Have the option to selectively contract with D-SNPs
• Other than coordination and integration of Medicare &
Medicaid benefits, MIPPA did not mandate any specific
Medicaid benefit package
• Contract may cover certain category(ies) or target a subset,
e.g., frail elderly
5
State Medicaid Agency Contracts
D-SNP Responsibilities for D-SNP State Contracting
• Communicate frequently with the State in which you seek to
offer your D-SNP
• Ensure that the D-SNP type category matches the
categories of eligibility listed in the State Medicaid Agency
Contract
• Ensure that the D-SNP type category that matches the
eligibility criteria listed in the State Medicaid Agency
Contract also matches your Plan Bid
• Ensure that the State Medicaid Agency Contract meets all 8
MIPPA elements
• Submission of State Medicaid agency contract does not
relieve MA applicant of pre-existing requirement to secure
license from State Dept. of Insurance
6
MIPPA Contract Elements at 42 CFR 422.107
1. MAO’s responsibilities, including financial obligations, to provide
or arrange for Medicaid benefits
2. Category(ies) of eligibility for dual eligibles to be enrolled under
the SNP
3. Medicaid benefits covered under the SNP
4. Cost sharing protections covered under the SNP
5. The identification and sharing of information on Medicaid
provider participation
6. Enrollee eligibility verification process for both Medicare and
Medicaid
7. Service area covered by the SNP
8. The contract period for the SNP (e.g. Effective January 1, 2012 –
December 31, 2012; January 1, 2012 – December 31, 2015 or
January 1, 2012 – December 31, 2012 and renews yearly.)
7
D-SNP Types
• All-Dual - Must enroll all types of dual eligibles
• Full-Benefit - Limits enrollment to individuals eligible for full
Medicaid benefits
• Medicare Zero-Cost-share - Limits enrollment to QMBs-only and
QMB+
• Dual eligible subset – Zero Cost-share
• Select when subset enrolls individuals other than just QMB and
QMB+ for whom the State pays Medicare cost-sharing
• Dual eligible subset
• Select when subset enrolls individuals who pay some part of the
Medicare cost-share
• A dual eligible subset and dual eligible subset zero cost-share enrolls
any category or combination of Medicaid eligibility categories, as
long as CMS approves the subset and the D-SNP’s enrollment
limitations parallel the structure and care delivery patterns of the
State Medicaid program in the State in which the D-SNP operates
8
D-SNP Types
D-SNP
Sub-Type
QMB
QMB+
SLMB
SLMB+
QI
QDWI
FBDE
All-Dual
Yes
Yes
Yes
Yes
Yes
Yes
Yes
FullBenefit
Medicare
Zero
CostSharing
No
Yes
No
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Dual
Eligible
Subset($
0 & non$0)
9
Correct D-SNP Type
Example D-SNP Type Listed in HPMS
Contract ID
Contract Name
SNP Type
SNP Detail
Z 0001
Health Care for All
Dual Eligible
All Dual
__________________________________________________________________________
All Dual Contract
State Medicaid Agency Contract
10
Incorrect D-SNP Type
Example D-SNP Type Listed in HPMS
Contract ID
Z 4444
Contract Name
Health Care for Some
SNP Type
Dual Eligible
SNP Detail
Medicare
$ 0 Cost Share
___________________________________________________________________________
All Dual Contract
State Medicaid Agency Contract
This D-SNP type is incorrect because only QMB and QMB + can be enrolled in a Medicare $0 Cost
Share. The SMA Contract includes other types of dual eligibles.
11
D-SNP Types
REMINDERS
• When selecting D-SNP sub-types: if you needed to convert your
D-SNP sub-type in order to correctly match the State eligibility
categories in the State Medicaid Agency Contract, you needed to
apply as a new D-SNP
• For bids: the type of D-SNP sub-type entered in HPMS, and
identified in the State contract, must conform to the bid submitted
• Contact CMS via the CMS SNP mailbox at:
[email protected] and your RO Account Manager if the
State in which you seek to offer your D-SNP for CY 2013 has
changed is eligibility category and/or your D-SNP type does not
match the State Contract
• The subject line in the e-mail should state: “D-SNP Type”
12
Subcontracting Arrangements
• Allows equivalent subcontracting arrangements in limited
circumstances provided that:
• The subcontract meets all 8 MIPPA elements
• The D-SNP subcontracts with a State approved Medicaid
MCO for all Medicaid services under the SMA Contract (i.e.,
not a carve-out for a single service)
• The D-SNP submits a letter from the State indicating its
approval of subcontracting arrangement
13
Subcontracting Arrangements
14
Subcontracting Arrangements
15
Subcontracting Arrangements
16
Fully Integrated Dual Eligible SNPs
• Section 1853(a)(1)(B)(iv) of the Social Security Act
authorizes CMS to make frailty payments to D-SNPs that
are “fully integrated with capitated contracts with States for
Medicaid benefits, including long-term care and that have
similar average levels of frailty . . . as the PACE program”
•
In order for a SNP to be eligible to receive frailty payments
pursuant to section 1853 of the Act, the SNP must: (1)
satisfy the FIDE-SNP definition under 42 C.F.R. §422.2;
and (2) have similar average levels of frailty as PACE
organizations
17
Fully Integrated Dual Eligible SNPs
A FIDE-SNP:
• Provides dual eligible beneficiaries access to Medicare and
Medicaid benefits under a single managed care organization;
• Has a capitated contract with a State Medicaid Agency that
includes coverage of specified primary, acute and long-term care
benefits and services, consistent with State policy;
• Coordinates the delivery of covered Medicare and Medicaid
health and long-term care services using aligned care
management and specialty care network methods for high-risk
beneficiaries; and
• Employs policies and procedures approved by CMS and the
State to coordinate or integrate member materials, enrollment,
communications, grievance and appeals and quality improvement
18
Fully Integrated Dual Eligible SNPs
In further determining whether a D-SNP meets the FIDE-SNP
definition, CMS will only allow Long Term Care benefit carveouts or exclusions if the plan can demonstrate that it meets the
following criteria:
The Health Plan:
1. Must be at risk for substantially all of the services under the
capitated rate; and
2. Must be at risk for nursing facility services for at least six months
(or one-hundred and eighty days) of the year; and
3. Must not disenroll individuals as a result of exhausting the
service covered under the capitated rate; and
4. Must remain responsible for managing all benefits, including any
carved-out or excluded services or benefits, notwithstanding the
method of payment (e.g., fee-for-service, separate capitated
rate) received by the plan
19
FIDE-SNP Determination
• No option in HPMS to self-identify as a FIDE SNP
CMS will:
• Review the State Medicaid Agency Contract to determine
whether a D-SNP qualifies as a FIDE-SNP according to
statutory and regulatory definitions
• Share information with other components in CMS
responsible for administering the Health Outcome Survey
• Notifies health plan if plan receives similar levels of PACE
frailty for additional payment
• FIDE-SNPs and certain other D-SNPs may qualify for
additional supplemental benefit flexibilities, this is discussed
in the next presentation
20
Questions
Any Questions?
• For questions or further clarification, you may contact your
Regional Office Account Manager and/or
• Contact the CMS SNP mailbox at: [email protected]
Please make sure you also “cc” your RO Account Manager
21
CMS 2012 Medicare Advantage &
Prescription Drug Plan Spring
Conference
Special Needs Plan Update:
New Benefit Flexibility for Certain Dual Eligible
SNPs
Jaya Ghildiyal, MPH
Medicare Drug and Health Plan Contract Administration
Group
22
New Benefit Flexibility for
Certain Dual Eligible Special Needs Plans
23
Background
• Both the Parts C&D Final Rule and Final Call Letter for MA
organizations addressed CMS’s policy for new supplemental
benefit flexibility for certain D-SNPs beginning CY 2013
24
Benefit Flexibility for Certain Dual Eligible SNPs
• Gives certain D-SNPs that meet integration, contract design,
performance and quality-based standards flexibility to offer
additional Medicare supplemental benefits beyond those
that CMS currently allows for other MA plans
• These D-SNPs may offer supplemental benefits that may
prevent health status decline and reduce the quantity & cost
of health care needs
25
Benefit Flexibility for Certain D-SNPs (cont.)
• CY 2013 Final Call Letter describes categories of
supplemental benefits that D-SNPs may offer:
•
•
•
•
•
Personal care services in the home
Non-skilled nursing activities in the home
Respite care for caregivers
In-home food delivery
Adult daycare services
• D-SNPs must describe these benefits as part of their plan
benefit packages (PBPs) at the time of bid submission
26
Criteria to Qualify for Benefit Flexibility
• Contract Design Requirements
• Operational in CY 2012 and CY 2013
• Capitate coverage of specified primary, acute and long-term
care benefits and services, to the extent that State policy
permits the SNP to capitate these services
• Coordinate delivery of covered Medicare and Medicaid
primary, acute and long-term care services throughout its
entire service area
• Other requirements outlined in the Final Call Letter
27
Criteria to Qualify for Benefit Flexibility (cont.)
• Performance Standards
• Based on CY 2013 Past Performance Methodology for MA
and Part D contracts (performance analysis from January 1,
2011 to February 8, 2012)
• Quality-based Criteria
• 3-year approval on their CY 2012 model of care (MOC), and
• Part of at minimum a 3-Star contract, or
• Score of 75% or above on 5 of 7 SNP-specific CY 2011 HEDIS
measures (for D-SNPs in contracts without star ratings)
28
Additional Requirements
• D-SNPs that choose to offer additional supplemental
benefits must provide these to the beneficiary at zero cost
• D-SNPs that participate in this benefit flexibility initiative to
submit an additional mandatory quality improvement project
(QIP)
• D-SNPs will be able to choose this QIP topic from a list of
broadly-defined topics designed to assess beneficiary
outcomes related to the provision of new supplemental
benefits
• Additional supplemental benefits must not inappropriately
duplicate existing Medicare, Medicaid or locally available
benefits
29
Notification for Qualified D-SNPs
• CMS will determine whether a D-SNP qualifies to participate
in this initiative based on the contract design and qualifying
criteria outlined in the CY 2013 Final Call Letter
• All applicable D-SNPs that meet the stated contract design
and qualifying criteria, will receive written notification at the
end of April/early May
30
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