SNP Surveyor Update Training
June 19, 2012
Objectives of SNP SUT Training
• Review NCQA’s year-to-year approach to
the project and reporting requirements for
SNPs
• Describe the changes in the S&P measures
for the 2012 SNP Assessment
• Explain how to assess performance with
individual elements in the S&P Measures
SNP: Surveyor Update Training
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Objectives of SNP Assessment Program
• Develop a robust and comprehensive
assessment strategy
• Evaluate the quality of care SNPs provide
• Evaluate how SNPs address the special
needs of their beneficiaries
• Provide data to CMS to allow plan-plan
and year-year comparisons
SNP: Surveyor Update Training
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SNP Assessment: How did we get here?
• Existing contract with CMS to develop measures
focusing on vulnerable elderly
• Revised contract to address SNP assessment
2008 - rapid turnaround, adapted existing NCQA
measures and processes from Accreditation
programs
2009 - focused on SNP-specific measures
2010 - refined existing measures
2011 - clarified requirements in SNP 1 thru 6
2012 - added elements/factors, removed factors, refined
measures and documentation requirements
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Who Reports
• HEDIS measures
– All SNP plan benefit packages with 30+
members as of February 2011 Comprehensive
Report (CMS website)
• S&P measures
– All SNP plan benefit packages
– Plans with zero enrollment as of April 2012
Comprehensive Report are exempt for certain
elements
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SNP Reporting
• Returning SNPs— all SNPs that were
operational as of January 1, 2011 AND
renewed for 2012 AND have previously
submitted.
– SNP 1 A-B and I-K, SNP 2C, SNP 3-6
• New SNPs — all SNPs operational as of
January 1, 2011 AND renewed for 2012
AND are reporting for the first time.
– SNP 1 A-H, SNP 2, SNP 4-6
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Project Time Line – 2012-2013
• June 2012 through September 2012- Training for
SNPs
• June 2012 - Release ISS Data Collection Tool for
S&P Measures
• October 15, 2012 - S&P Measure submissions
due to NCQA
• October 15, 2012 to April 30, 2013 – S&P reviews
conducted by NCQA and surveyors
• September 28, 2013 - NCQA delivers SNP
Assessment Report to CMS
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Structure and Process Measures
SNP 1: Complex Case Management
SNP 1- Complex Case Mgmt.
Changes since 2011
• Look-back period–6 months (all Elements)
• Added 2 new factors (Element A)
• Clarified requirements and language for auto
enrolling all members in CM (Elements A, B, D &
E factor 2)
• Revised factor 5 (Element B)
• Deleted language excluding frail members or
those near the end of life from guideline
application (Element C)
SNP: Surveyor Update Training
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SNP 1- Complex Case Mgmt.
Changes continued
• Removed:
– factor 1 – right to decline CM participation
– factor 6 – life planning activities (Element F)
• Split existing element into 2 separate elements
(Elements F and G)
• Added three new elements for reporting by
returning SNPs (Elements I, J and K)
• See Surveyor Resource Guide for additional
changes in data sources
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SNP 1 Element A
Definition of Complex case mgmt (CM):
– the coordination of care and services provided
to members who have experienced a critical
event or diagnosis requiring the extensive use of
resources and who need help navigating the
system to facilitate appropriate delivery of care
and services.
Goal of the CM program:
• to help members regain their health & help
them improve their functional capability
–
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SNP 1 Element A
• SNP must provide actual reports
(documented process no longer
acceptable) showing it uses 6-7 types of
data (not referrals) to identify members for
CM
1)
2)
3)
4)
5)
claims or encounter data
hospital discharge data
pharmacy data
laboratory results
UM data (if it conducts UM activities)
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SNP 1 Element A
6) data provided by member or caregiver
– may include self-reported data provided in
risk assessments
– Caregivers consist of family members or
other individuals who support members and
on whom the member depends for help
coping with a serious condition or disability
7) data provided by practitioners
– e.g., through electronic health records
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SNP 1 Element A
• Auto enrollment in CM – A SNP can also
meet this element (and Elements B, D,
factor 2 of E) by showing that it enrolls and
maintains all members in CCM and as part
of the program does the following:
– comprehensive assessment of member’s
condition
– determination of available benefits/resources
– development/implementation of individualized
CM plan with performance goals
– CM plan monitoring and follow-up
SNP: Surveyor Update Training
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SNP 1 Element B
• A SNP’s documentation must show it uses 5
to 7 types of referrals to consider members
for CM
1)
2)
3)
4)
5)
6)
7)
Health information line referral
Disease Management program referral
Discharge planner referral
UM referral, if applicable
Member or caregiver referral
Practitioner referral
Other (documentation defines source)
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SNP 1 Element B
• A SNP that has a Health Information Line
must accept referrals from it to receive
credit for factor 1.
– If the documentation does not mention health
information lines, enter the issue on the OIF
requesting evidence or clarification
• Alternatively, score factor 1 “NA” for a SNP
that shows it does not have a Health
Information Line.
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SNP 1 Element C
CM Systems
• The SNP’s documentation for member assessment
and management in the CM system must show it:
1) incorporates evidence-based clinical
guidelines or other clinical evidence into
decision trees/algorithms;
2) automatically documents staff member
identification and the date/time of action on
the case or interaction with the member;
3) receives automatic prompts for follow-up as
CM plan requires
•
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SNP 1 Element C
For factor 1 a SNP’s documented process or training
manual must:
• reference the specific clinical guidelines and
describe how it uses them for assessment and
mgmt of members
• show guidelines are embedded in system logic
Factors 2 and 3 require SNP’s screenshots (rpts) to:
• show automation of user actions, dates/times and
prompts or reminders for follow-up
SNP: Surveyor Update Training
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SNP 1 Element D
Frequency of Member Identification
• A SNP must submit reports for Element D
showing it systematically identifies
members who qualify for CM services
monthly.
• Since clinical data may be dynamic, the
intent is for the SNP to demonstrate it
reviews these data frequently to pinpoint
members that would benefit from
enrollment in CM.
SNP: Surveyor Update Training
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SNP 1 Element E
Providing Members With Information
• A SNP must submit materials that show it
supplies written and verbal information to
members eligible for CM on how:
1) to use the services
2) members become eligible to participate
3) to opt in opt out
SNP: Surveyor Update Training
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SNP 1 Element E
• Factors 1 thru 3 require the SNP to submit:
– call scripts or detailed outlines for in-person or
telephone contact
– materials such as letters, member handbook
excerpts for written communication
– materials to show how members informed
about how to opt in/out
• Factor 3: Score NA if state/others require
SNP to provide all members w/CM
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SNP 1 Element F
CM Assessment Process
• Includes all info for SNP to assess members’
needs and develop interventions for them
• A SNP’s written procedures must address all
8 factors
• It may submit assessment tools or
screenshots as evidence, if these
documents demonstrate the system has all
required functionality
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SNP 1 Element F
SNP’s evidence must include:
• Documentation of clinical history and meds
– e.g., disease onset, inpatient stays, treatment
history
• Initial assessment of:
– health status & comorbidities
– activities of daily living
– mental health status and cognitive function
• both aspects are required
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SNP 1 Element F
• Evaluation of:
– cultural and linguistic needs
•review of language needs meets factor 5
– visual & hearing needs, preferences/limitations
– caregiver resources
• e.g., family involvement in decision making
– available benefits
• covered by SNP, carved out, for supplemental
services such community behavioral health or
national and community resources
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SNP 1 Element G
Individualized Care Plan
• SNP uses info from assessment process to
develop a comprehensive care plan
• CM plan includes descriptions of actions and
their duration to address members’ medical, BH,
functional and support needs, along with:
– prioritized goals that reflect member’s or
caregiver’s preferences and involvement
– self-management plan
– schedule for follow-up/identify barriers
– process to assess member progress
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SNP 1 Element G
• Based on the member’s specific needs
the care plan also identifies:
– resources to be utilized and appropriate level
of care
• CMs often facilitate referrals to other providers as
part of member’s benefits
– planning for coordination of care including
transitions and transfers
• identifying how and when CMs follow up with a
member after referral to a health resource
– collaborative approaches to be used
SNP: Surveyor Update Training
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SNP 1 Element H
Informing and Educating Practitioners
• Element H requires the SNP to supply
materials that show:
1) Instructions on CCM and how to use services
2) Information on how the organization works
with a practitioner’s patients in the program
SNP: Surveyor Update Training
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SNP 1 Element H
• A SNP’s documentation for each factor:
– Must include the actual materials it uses
•e.g., a provider manual, website, newsletter
or brochure to inform practitioners about
CCM services, explaining how the services
would benefit members and how to refer
them
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SNP 1 Element I
Satisfaction with Case Mgmt
Intent is for SNP to obtain feedback on its
CM program from a broad sample of
members, not just those that contacted it
• SNP must submit a report showing it
performed an evaluation of satisfaction
by:
1) Obtaining feedback from members
2) Analyzing member complaints and inquiries
SNP: Surveyor Update Training
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SNP 1 Element I
Factors 1 and 2 require SNPs to use:
• focus groups or satisfaction surveys that
are specific to CM programs
– e.g., assess satisfaction with--program staff,
the usefulness of info received, member’s
ability to adhere to recommendations.
• analysis of complaint and inquiry data to
identify patterns or trends
– quantitative and qualitative
SNP: Surveyor Update Training
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SNP 1 Element I
• Reports with data obtained from CAHPS or
general surveys will not meet the intent
• Results from satisfaction surveys
administered across multiple SNPs must
be stratified at individual plan level for
analysis
• Score factors 1 and 2 NA for SNPs that did
not have any members at the start of the
look-back period. Use the CMS April 2012
Comprehensive Report to confirm this.
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SNP 1 Element J
Analyzing Effectiveness/Identifying
Opportunities
• The SNP measures the effectiveness of its case
management program using three measures. For
each measure, it:
1)
2)
3)
4)
5)
6)
Identifies a relevant process or outcome
Uses valid methods that provide quantitative results
Sets a performance goal
Clearly identifies measure specifications
Analyzes results
Identifies opportunities for improvement, if applicable
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SNP 1 Element J
SNP’s report must contain appropriate measures
Likely to have significant and demonstrable
bearing on all or a subset of CM members
– Outcomes based
– Relevant to target population
– Valid methodology
• Contains info on sampling (if used) and sample size
calculation
• Measurement periods reflect the effects of
seasonality
– Denominator specific to CM population
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SNP 1 Element J
Report shows appropriate analysis – goes beyond
simple reporting or data display
– Comparison to goal or benchmark
– Quantitative and qualitative
– Opportunities for improvement
• SNP can use 3 patient experience measures
• e.g., improved quality of life, pain
management and health status
• May only use 1 satisfaction measure with CM
program operations
• Scoring is based on an average for all 3 measures
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SNP 1 Element J
• Score factor 6 NA if your assessment of
the SNP’s documentation confirms it does
not have any opportunities for
improvement
• Score factors 1 thru 6 NA for SNPs that did
not have any members at the start of the
look-back period. Use the CMS April 2012
Comprehensive Report to confirm this.
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SNP 1 Element J
• Examples of measures
– HEDIS measures of effectiveness for chronic
conditions
• e.g., controlling high blood pressure, persistence
of beta blocker treatment after a heart attack
– SF-36 or SF-12 results
– Use of service measures for which consensus
indicates improvement – e.g., ED visits
– Readmission rates
– Ambulatory-care sensitive admissions
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SNP 1 Element K
Implementing Interventions and Follow-up
Evaluation
• Based on the results of its measurement
and analysis of case management
effectiveness, the organization:
1) Implements at least one intervention for the
three opportunities identified in Element J to
improve performance
2) Develops a plan for evaluation of the
intervention and re-measurement
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SNP 1 Element K
• Scoring is based on an average for all 3
measures
• A SNP’s documentation must show that it
developed a plan to evaluate the
effectiveness of its interventions; this
evaluation includes re-measurement
using methods consistent with initial
measurement.
SNP: Surveyor Update Training
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SNP 1 Element K
• Factor 1 may be NA if no opportunities
• Factor 2, re-measurement, must be
completed whether there are
opportunities or not.
• Score factors 1 and 2 NA for SNPs that did
not have any members at the start of the
look-back period. Use the CMS April 2012
Comprehensive Report to confirm this.
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SNP 2: Improving Member Satisfaction
Summary of Changes for 2012
• Look-back period – all elements – 6 months
• SNP 2 Element A
– Modified factors 1-3 to make it clear that plans must
provide both a qualitative and quantitative analysis
– Added documented processes as a required data
source
• SNP 2 Element B
– Added documented processes as a required data
source
• SNP 2 Element C (New!)
– SNP must show implementation of interventions based
on results from 2A and 2B
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SNP 2: Overview
• Who reports?
– Initial SNPs are responsible for reporting all of
SNP 2. This includes Elements A, B and C.
– Returning plans are required to report the new
Element C
•must use results from 2A and 2B; may use
new data/opportunities from analysis, if
appropriate.
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SNP 2 Element A
Assessment of Member Satisfaction
• a SNP must supply a documented process and a
report explaining how it performs the assessment
and an analysis of member satisfaction data that
shows it:
– identified the appropriate population
– selected appropriate samples from the affected
population, (if used)
– conducted an quantitative and qualitative
analysis annually
• Score factor 2 “yes” if the SNP collected data on
its entire SNP population
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SNP 2 Element A
• A SNP’s complaint and appeal data must relate to at
least the four major categories
– Quality of Care
– Access
– Attitude and Service
– Billing and Financial
• It must submit a report that shows the data collected,
sampling methodology, quantitative and qualitative
analyses.
• Complaint, grievance and appeal data or satisfaction
survey data collected 12 months prior to the start of the
look-back period--(4/15/11) will not meet the intent
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SNP 2 Element A
• All SNP complaint/appeal data must be at
the PBP level. If not,
– Score 50% for data only identified as
“Medicare”
– Score 0% if data source is not specified at all
• Score 100% for SNP that performed its own
analysis (did not just attach vendor’s
report) of CAHPS data, which may be at
contract level
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SNP 2 Element A
• If the SNP has no complaints, appeals or
grievances, it must still show a table,
spreadsheet or other documentation that
demonstrates it collected appropriate
data for an analysis
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SNP 2 Element A
• The analysis must be SNP-specific; plans
must break out the data at the PBP level for
an aggregate analysis of complaints and
appeals across multiple benefit plans
• If a SNP has no members as of the start of
look-back period, score the factors 1-3
“NA”.
– Confirm with CMS April 2012 SNP
Comprehensive Report.
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SNP 2 Element B
Opportunities for Improvement
• Element B requires a SNP to show:
– How it identifies opportunities for improvement of
member satisfaction (documented processes)
– At least 2 opportunities for improvements based on its
data and analysis for SNP 2A (reports).
• Analysis should indicate reasons for opportunities
identified
– May be lesser priorities
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SNP 2 Element B
• Score Element B NA if:
– a SNP does not identify any opportunities for
improvement
– analysis does not result in the identification of
one or more opportunities for improvement.
• Reasons for no improvement opportunities
may include:
– no or very low enrollment;
– no trendable data available
– very low number of complaints/appeals.
SNP: Surveyor Update Training
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SNP 2 Element B
• If a SNP has no members as of the start of
look-back period, score the element
“NA”.
– Confirm with CMS April 2012 SNP
Comprehensive Report.
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SNP 2 Element C
Improving Satisfaction
• Element C requires a SNP to show that it is actively
working on implementing interventions and measuring
their effectiveness.
– Plans must provide BOTH Documented Processes and
Reports
• The interventions must relate to those opportunities
identified in SNP 2B, or from other opportunities identified
from the analysis of member satisfaction data in SNP 2A
• Do not have to show improvement on interventions, but
do have to show SNP measured the effectiveness of
them.
SNP: Surveyor Update Training
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SNP 2 Element C
• Score factor 2 NA if SNP 2B is scored NA.
– SNP must still provide a documented process
explaining how it implements interventions
and monitors them for effectiveness.
• If a SNP has no members as of the start of
look-back period, score the element
“NA”.
– Confirm with CMS April 2012 SNP
Comprehensive Report.
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SNP 3: Clinical Quality Improvement
SNP 3 Element A (New!)
• Plan no longer provides 3 relevant clinical
measures
• If a SNP has achieved three statistically
significant improvements in its Effectiveness of
Care measures, it receives a 100% score for the
element.
• NCQA uses the previous year’s HEDIS results as
the baseline and compares them to results for
current year
– i.e., 2012 HEDIS results are compared to 2011 results
– If previous year’s data is unavailable the plan will
receive a score of NA
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SNP 3 Element A
• Which SNPs must demonstrate clinical
improvement?
– Returning SNPs will be scored
– Initial SNPs and plans with <30 members (as of
2/11 CMS Comp. Report) are exempt
• Surveyors are not responsible for reviewing SNP
3 Element A. NCQA staff will score it at ER
stage.
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Activity
Activity Instructions
• Surveyors are divided up into 4 groups
• Each table is given documentation to review
and an OIF to write as a group
• After 10 minutes each table will exchange OIFs
• The groups are given 10 more minutes to act as
an Executive Reviewer and determine whether
or not they agree with the other table’s OIF.
• Groups will then come together and we will
review the documents as a whole.
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SNP 2, Element C - SUT Exercise
Deficiencies:
Factor 1
1.
New opportunity for improvement identified; however,

2.
Documentation demonstrating analysis of member satisfaction data to identify
opportunity, as outlined in Element A and B, is missing
Documented process lacks a detailed methodology outlining process to
implement the intervention and measure effectiveness.
Factor 2
1.
Data used for analysis is not appropriate member satisfaction data or CAHPS
data. It does not follow data collection requirements
Note:
Analysis of member satisfaction data in Element C shows a decline in performance,
this is not a deficiency.
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SNP 4: Care Transitions
What’s Changed?
• No major content, documentation or scoring
changes
• Look-back period—6 months
• Clarified explanations of planned and
unplanned transitions (Elements A & B)
• Defined number of examples needed to meet
intent (Elements A, B & D)
• Defines sampling universe (Elements C & E)
• Member coordination/education must target atrisk members from Element E (Element F)
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SNP 4 Element A: Managing Transitions
• Managing & coordinating
planned/unplanned transitions from one
care setting to another
– Factor 1 focuses on planned transitions to and
from a hospital
• Requires SNP to show it is aware that a transition is
about to take place—before it happens and
provide support throughout the transition process,
not just after discharge
• A preauthorization policy included in
documentation must show how it triggers clinical
action. Cannot solely pertain to a coverage or
payment decision.
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SNP 4 Element A
• Factor 2 specifies requirements for planned and
unplanned transitions to and from a hospital
• Sending setting must share care plan with
receiving setting within 1 business day of
transition notification
– Care plan consists of patient info that facilitates
communication, collaboration and continuity of care
across settings
– Org determines what info care plan includes
– Must specify practitioner to receive care plan for
planned transitions to hospital—must show evidence
SNP shared care plan with practitioner w/in specified
timeframe
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SNP 4 Element A
• Factor 3: Notifying member’s usual
practitioner of transition
– planned and unplanned transitions to and
from all care settings
– must specify a timeframe for completion of
transition activities, e.g.,
• 24-48 hours prior to member movement to
receiving setting
• within 1 business day of member’s discharge
• at least 2 calendar days before the scheduled
procedure
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SNP 4 Element B
Supporting Members Through Transitions
• Communications with members/
caregivers within specified timeframes
regarding:
– the transition process and what to expect
– changes in health status and their care plan
– who will support them through the process
• Factors 1 thru 3 pertain to planned and
unplanned transitions to and from all care
settings
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SNP 4 Element B
• A SNP’s documented process for factors 1
thru 3 must specify a timeframe for
completion of required transition activities
– The following do not qualify as timeframes
•during the encounter ….
•upon identification of transition needs ….
•regular contact and review ….
•on an ongoing basis ….
•during discharge ….
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SNP 4 Element C
• An aggregate analysis of transitions should
contain:
– Measures that directly assess the frequency a
SNP performs the functions assessed in factors
1-3 of Elements A & B
– A description of:
• how the SNP collects the data
• who performs the functions assessed
• the timeframe for the analysis
• Universe of planned & unplanned transitions
included and care settings involved
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SNP 4 Element C
• The intent of the aggregate analysis for this
element is for plans to assess how well they are
managing transition activities.
• Factors 1 and 3 need to show:
– data collected;
– a quantitative and qualitative analysis; and
– the opportunities for improvement
• Factors 2 and 4 must describe:
– the universe of members in the sample
– sampling methodology
– how the SNP drew at least 3 months of data
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SNP 4 Element C
What is an Analysis?
• An evaluation of aggregate performance that
includes:
– quantitative data – number of transitions in the
denominator for a factor and the number of transitions
where the SNP performed the activity specified by the
factor within any pertinent timeframes
– qualitative data – notations on results, trends,
anomalies, assessment of causes/reasons for findings
» identification of opportunities and
recommendations for further action
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SNP 4 Element D
Identifying Unplanned Transitions
• A SNP must show that it:
– has a documented process and reviews
reports of hospital admissions within 1
business day of the admission
• Must show at least 3 admissions
– reviews reports of long-term care facility
admissions within 1 business day of the
admission
• Must show at least 3 admissions
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SNP 4 Element E
•
Focus of element is on minimizing unplanned
transitions and keeping patients in least
restrictive setting
•
Factor 1 requires an analysis of patient-specific
data to identify those at risk
−
•
E.g., claims, UM or provider reports, predictive
modeling
A SNP can also analyze the same data for
factor 1 that it uses to identify members
eligible for case management (SNP 1:A, B
and D)
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SNP 4 Element E
• A SNP’s documentation for factor 1 needs
to show:
– data collected—must monitor all members
– members targeted
– areas where it acts to minimize the risk of
unplanned transitions and keep members in
the least restrictive setting
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SNP 4 Element E
Factor 2 requires SNPs to analyze data and identify
areas where avoidable, unplanned transitions can
be reduced
• Analyze member admissions to all hospitals
and ED visits
– Population focus (aggregate data)
– Actual analysis to identify areas for
improvement
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SNP 4 Element E
• SNP’s documentation for factor 2 must
show:
1) data collected
2) quantitative and qualitative analysis
3) opportunities for improvement.
• SNP must include in-network and out of
network facilities and EDs in this analysis
for factor 2. If it only includes in-network
facilities, it does not receive full credit for
this factor (cannot score >50%).
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SNP 4 Element E
• SNP must provide evidence of 1 analysis
performed w/in the look-back period (April
1-October 15, 2012).
– Data for analysis can go back to April 2011.
• Analyses must be SNP-specific;
organizations that perform an aggregate
analysis of multiple benefit plans must
break out the data for each individual plan
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SNP 4 Element F
Reducing Transitions
Factors 1 and 2 require a SNP’s documentation to
show that it:
• Coordinates services for at-risk members
•
Educates these members or their caregivers
on how to prevent unplanned transitions
Actions must relate to findings from
monthly analyses in SNP 4:E, factor 1
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SNP 4 Element F
• Factor 1—Care Coordination may be
done through Case Mgmt; SNP must
maintain special procedures if all
members are not in CM
• A SNP can assign functions for factors 1
and 2 to providers and practitioners but it
is responsible for meeting these factors
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SNP 5: Institutional SNP Relationship with
Facility
Summary of Changes for 2012
• All Elements
 Added language to explicitly extend SNP 5 requirements to Assisted
Living Facilities (ALFs)
 Look back period- 6 months
• SNP 5 Element A
 Changed the time frame for monitoring health status changes
from quarterly to monthly
• SNP 5 Element B
 Revised the scoring to better reflect the intent that the SNPs
must address all 4 factors to receive a score of 100%
 Specified which 3 of the 4 factors must be met to receive a
score of 50%
• SNP 5 Element C
 No change
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SNP 5 Element A
Monitoring Members’ Health Status
• Institutional SNPs only
– Focus is on communications with facilities to monitor
member needs and services provided
– Facilities include contracted nursing facilities and
assisted living facilities
• The SNP must show that it monitors information on
members’ health status at least monthly
– Communication should include information that may
indicate a change in health status or no change
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SNP 5 Element A
• Scoring changes from 2011 to 2012
– Element is no longer all or nothing
•100% or full credit
– Institutional SNPs who monitor at least
monthly
•50% or partial credit
– Institutional SNPs who monitor at least
quarterly
•0% or no credit
– Institutional SNPs who monitor less often
than quarterly
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SNP 5 Element A
• Monitoring methods a SNP can use:
– data derived from MDS or other reports on member
health status it requires from the institutional facility
– reports from its staff who visit members in facilities
– data on members’ health status it collects through
case management on a monthly basis
• Status reports may include:
–
–
–
–
Functional status assessments
Medication regimen
Self-reported health status
Reports on falls, socialization and depression
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SNP 5 Element A
• Documentation
– a SNP must provide evidence in the required
data source (documented processes) and
one additional data source or it does not
receive full credit for this element
• Element is NA for:
– An Institutional SNP that shows it does not have
contracts with nursing facilities or assisted living
facilities
 all members reside in the community
• Dual Eligible and Chronic Care SNPs are exempt
– Score all elements in this measure “NA”
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Question
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SNP 5 Element A
An Institutional SNP that shows it does not
have contracts with nursing facilities or
assisted living facilities is exempt from
reporting
a. True
b. False
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SNP 5 Element B
Monitoring Changes in Members’ Health Status
•
Organization monitors and responds to triggering
events and changes by:
1.
2.
3.
4.
Setting parameters for the types of changes and
triggering events contracted facilities must report within
48 hours, 3 calendar days and 4 to 7 calendar days
Identifying who will act on that information and should
be contacted
Identifying how the member’s care will be coordinated
with appropriate clinicians or the clinical care plan
Identifying one monitoring or data collection method it
uses to assess changes in all members’ health status
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Factor 1 Details
• An organization must submit evidence that shows it has
identified specific conditions or early warning signs and
symptoms that facilities must report within a minimum of:
 48 hours
 3 calendar days
 4-7 days
• The SNP must submit a policy and reports or materials
showing how and when facility staff must report a list of
triggers such as:
 changes in vital signs
 changes in the member’s behavior
 changes in their functional status
 complaints of pain
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SNP 5 Element B
• Scoring changes from 2011 to 2012
•100% or full credit
– The organization meets all 4 factors
•50% or partial credit
– The organization meets 3 factors including
factors 1 through 3 (critical factors)
•0% or no credit
– The organization meets 0-2 factors or does
not meet factors 1, 2 or 3
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SNP 5 Element B
• The SNP must demonstrate it monitors
members through one of the following
methods:
– Reports from facilities to the organization such as
Minimum Data Set (MDS)
– Reports from organization staff who visit the
members
– Oversight of facility monitoring and reporting
changes to treating practitioners rather than to the
organization
– A combination of the processes above
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SNP 5 Element C
Maintaining Members’ Health Status
• Organizations use the information from SNP 5
Elements A&B to identify at-risk members and
work with facilities/practitioners to arrange
for necessary care and adjust care plans as
needed to prevent declines in member
health status
• Scoring is 100% or 0% (all or nothing element)
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SNP 5 Element C
Methods of providing care:
• SNPs may have differing models of relationships
with facilities to address these monitoring
functions
– Facility oversight: relies on facilities to
modify/carry out care plans
– Staff practitioners: SNP staff practitioners visit
facilities and order care plan modifications
– Other models of care: SNPs may use a
combination of above models or different
one
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SNP 5 Element C
Documentation
• A SNP must submit:
– Documented Processes; AND
• Policies describing increases in frequency of visits to
member by the organization’s nurse managers to
assess, revise the care plan and monitor his or her
condition after a health status decline and resulting
inpatient stay
– Reports
• Screenshots from the organization’s care
management system documenting monitoring visits,
assessments and care plan changes the nurse
managers discussed with the member’s treating
practitioner and notes confirming the practitioner’s
agreement
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SNP 6: Coordination of Medicare and
Medicaid Coverage
What’s Changed?
• Look-back period – 6 months
• Element A: Eliminated previous factors 1-3
• Elements A & B: Added reports/materials to the
required data sources.
• Eliminated Element C: Relationship with State
Medicaid Agency for Dual-Eligible SNPs
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What’s Changed?
• Old Element D: Coordination for Chronic and
Institutional Benefit Packages: Now Element C
– Added reports/materials to the required data
sources.
– Revised the language regarding billing and copayments for dual-eligible members.
• Element E: Service Coordination Now Element D
• Element F: Network Adequacy Assessment: Now
Element E
– Added requirements for a SNP to establish
geographic and numeric standards for practitioners
and providers and analyze its performance against
those standards
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SNP 6 Element A
Not Applicable for C-SNPs & I-SNPs
Coordination of Benefits for Dual-Eligible Members
Dual-eligible SNPs coordinate Medicare & Medicaid
benefits/services for their members by:
• Giving members access to staff knowledgeable about
both programs
• Providing clear explanations of rights to pursue
grievances/appeals under both programs
• Providing clear explanations of benefits and any
communications they receive re: claims, cost sharing
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SNP 6 Element A
• Documentation - SNPs must provide
reports and may include documented
processes or materials to supplement
them
– Reports:
• Evidence of Coverage (EOC) documentation
– Documented processes:
• Job descriptions for staff who help members with
coordination of both sets of benefits
– Materials:
• Job descriptions, scripts or guidelines for staff who
help members with eligibility, benefits and claims
for both Medicare and Medicaid (Factors 1 & 2)
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SNP 6 Element A
• For all factors — SNP must provide
information to members for Medicare
AND Medicaid per the requirements of
the element. The SNP cannot receive
credit for any factor where it provides the
required information for only Medicare
without a report demonstrating resources
for information on Medicaid. Evidence of
implementation is required.
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SNP 6 Element A
• Documentation must show:
– SNP’s materials cover the details of members’
specific benefit plans
– It gives members information on staff who
can answer questions regarding both
programs in lieu of written documents
– SNP’s staff can answer questions about
Medicare benefits and the state’s payment
cost-sharing as well as Medicaid eligibility
and cost-sharing for services where the
member is liable.
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SNP 6 Element B
Not Applicable for C-SNPs & I-SNPs
Administrative Coordination of Dual-Eligible
Benefit Packages
A dual-eligible SNP coordinates Medicare
and Medicaid benefits for its members by:
•Identifying changes in members’
Medicaid eligibility
•Coordinating adjudication of Medicare/
Medicaid claims for which it is
contractually responsible
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SNP 6 Element B
• SNPs must demonstrate that they monitor
instances where members are losing Medicaid
eligibility and regaining Medicaid eligibility to
receive credit for factor 1.
• Score factor 2 “Yes” if a SNP that is not
contractually responsible for the adjudication of
Medicaid claims submits documentation
showing that it helps members understand the
state’s adjudication of claims submitted by
providers.
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SNP 6 Element B
Documentation
• SNPs must provide (1) documented processes
and (2) reports OR materials
– Documented processes:
• Procedures used to determine changes in
Medicaid eligibility
• Procedures used to coordinate adjudication of
Medicare and Medicaid claims
– Materials:
• Instructions on where to reapply for Medicaid
– Reports:
• Redacted reports on Medicaid eligibility used by
organization
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SNP 6 Element C
Not Applicable for D-SNPs
Administrative Coordination for Chronic and
Institutional Benefit Packages
• SNP shows it coordinates Medicare/Medicaid
benefits for C-SNP& I-SNP members by:
– Using a process to identify changes in members’
Medicaid eligibility
– Informing members about maintaining Medicaid
eligibility
– Giving members information about benefits they are
eligible to receive under both programs
– Giving members access to staff who can advise them
on using both programs
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SNP 6 Element C
• Factors 1, 3 and 4—SNP must supply
documentation that shows it provides
information to members for Medicare
AND Medicaid per the requirements of
the element. The SNP cannot receive
credit for factors 1, 3 and 4 if the SNP
provides the required information only for
Medicare without a documented process
directing the member to a resource for
information on Medicaid.
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SNP 6 Element C
• To receive credit for factor 2:
– I-SNPs’ documentation must address
changes where members gain Medicaid
eligibility;
– C-SNPs’ documentation must show that they
monitor instances where members are
gaining and losing Medicaid eligibility.
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SNP 6 Element C
• SNP’s materials cover the details of members’ specific
benefit plans
• SNP’s staff can answer questions about Medicare
benefits and the state’s payment cost-sharing as well as
Medicaid eligibility and cost-sharing for services where
the member is liable.
• Documentation - SNPs must provide
– Documented processes; AND
• Procedures used to verify changes in Medicaid
eligibility
– Reports or Materials
• Sample benefit summaries provided to members
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SNP 6 Element C
• C-SNPs and I-SNPs are exempt from this
element if less than 5% of the members in
their SNP population are dual eligibles as
of the start of the look-back period
(April 15, 2012).
• Score each factor “NA” if they meet this
requirement.
– Surveyors should verify this information using
the SNP Plans by Type list provided in the
Surveyor Resource Guide.
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SNP 6 Element D
Applicable for all SNPs*
Service Coordination
• Organization coordinates delivery of services
covered by Medicare/Medicaid through the
following:
– Helping members access network providers
that participate in both programs or accept
Medicaid patients
– Educating providers about coordinating
benefits for which members are eligible and
about members’ special needs
– Helping members obtain services funded by
either program when needed
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SNP 6 Element D
• Helping dual-eligible members obtain
services covered by Medicare &
Medicaid
– The SNP must require that its network
physicians do not bill dual-eligible members
for more than the copayment amount which
the state pays for individuals in that category
of Medicaid eligibility.
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SNP 6 Element D
For factor 1
• SNP must publish a directory that shows:
– providers that participate in both programs
or
– providers that accept Medicare for services
covered by Medicare
and
– providers that accept Medicaid for dualeligible members
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SNP 6 Element D
Factor 2 requires SNPs to educate network
practitioners and providers about their role
coordinating Medicare/Medicaid benefits
and members’ special needs. A SNP can:
– Alert their providers to the range of benefits
or services for which members are eligible, as
well as responsibility for cost-sharing, if any,
and their right to reimbursement
– Inform providers who is responsible for
coordinating services for both programs
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SNP 6 Element D
Factor 3 requires SNPs to help members
obtain services funded by either program
when assistance is needed. The SNP can:
– Arrange services by contracting with
providers, working with facilities, referring
members, or by assisting members and
providing services directly
– Help its members obtain services and detail
how they can obtain non-emergency
transportation
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SNP 6 Element D
• C-SNPs and I-SNPs are exempt from this
element if less than 5% of the members in
their SNP population are dual eligibles as
of the start of the look-back period
(April 15, 2012).
• Score each factor “NA” if they meet this
requirement.
– Surveyors should verify this information using
the SNP Plans by Type list provided in the
Surveyor Resource Guide.
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SNP 6 Element D
• Documentation - SNPs must provide:
– Documented processes; AND
•Policies and procedures for arranging
services for members
– Reports or Materials
•Reports detailing how members were
assisted in obtaining services from
Medicaid when needed.
•Materials such as the provider directory or
provider manuals.
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SNP 6 Element E
Applicable for all SNPs*
Network Adequacy Assessment
• Organization assesses the adequacy of the
network for member access to practitioners and
provider by:
- Establishing standards of the number and geographic
distribution of each type of practitioner and provider
- Conducting an annual analysis of performance against
said standards
* Element is NA for C-SNPs and I-SNPs w/less than 5% dual
eligible members and D-SNPs with no enrollment at the
start of the look-back period.
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SNP 6 Element E
• The SNP’s documentation must include
the geographical and numeric standards
for practitioners and providers and a
description of its methodology used to
perform the analysis.
• Review the organization’s documented
process for factors 1 and 2 and reviews
reports for factors 3 and 4.
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SNP 6 Element E
• A SNP’s analysis must include a network access
indicator (ratio of member to practitioner
availability based a number of miles/minutes). A
plan that uses:
1) Access data (appointment availability)
2) Data on members’ cultural or linguistic needs
or
3) Satisfaction data (surveys, complaints and
appeals)
must supplement its assessment with another
network access indicator
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SNP 6 Element E
• Organization must determine adequate
access for members for the following types
of providers
– Primary care practitioners (e.g. general
practitioners, internal medicine specialist)
– High volume specialist (e.g. cardiologist,
neurologist, gynecologists, psychiatrists)
– Providers (e.g. hospitals, skilled nursing facilities)
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SNP 6 Element E
• GEO Access analysis for a SNP’s Medicare
practitioner network only is insufficient to meet
this element. The GEO Access or other analysis
must include practitioners and providers that
accept coverage for services paid for by
Medicare and Medicaid.
• GEO Access maps must be accompanied by
an assessment of quantitative data
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SNP 6 Element E
• The SNP’s methodology must include: direct
measurement of results against standards,
info about sampling (if used), and analysis
of causes of any deficiencies, if SNP did not
identify any gaps/deficiencies, determine
whether this conclusion is reasonable.
• Analyses must be SNP-specific;
organizations that perform an aggregate
analysis of multiple benefit plans must
break out the data for each individual plan.
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SNP 6 Element E
• SNPs must provide the following
documentation:
– Documented processes; AND
• P&Ps for assessing network adequacy
– Reports
• Reports on accessibility of Medicare and
Medicaid practitioners and providers
• Reports on access indicators such as percentage
of in-network and out-of-network use; rate of ED
use compared to norms in area; or member
surveys of satisfaction with access
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Activity
Activity Instructions
• Surveyors are divided up into 4 groups
• Each table is given documentation to review
and an OIF to write as a group
• After 10 minutes each table will exchange OIFs
• The groups are given 10 more minutes to act as
an Executive Reviewer and determine whether
or not they agree with the other table’s OIF.
• Groups will then come together and we will
review the documents as a whole.
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4C Activity Answer Slide
Factor 1: Conducting an analysis of all
transitions
• The SNPs P&Ps indicate that it collects and
analyzes planned and unplanned transitions
data. The analysis shows data for planned
transitions only; did not include an analysis of its
unplanned transitions performance.
• While the SNP stratifies all members into three
categories, (low, medium and high-risk) only
high-risk members are assigned a case
manager. The SNP does not consistently capture
transition episodes for low and medium risk
members from home to hospital.
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4C Activity Answer Slide
Factor 1
• The analysis shows data for planned
transitions only; did not include an analysis
of its unplanned transitions performance.
Factors 2 and 4: Drawing an appropriate
sample (if sample used)
• SNP submitted data for the month of June.
Does not meet the requirement – if the SNP
uses a sampling of its data, it must draw a
minimum of three month’s worth of data.
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4C Activity Answer Slide
Factor 3: Communicating with
member and/or responsible party
• SNP provided discharge planning and does
not following members throughout the care
transitions process.
• This factor requires the SNP to support its
members through the entire transition
process to include planning for the transition
as well as follow-up care needs posttransition.
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Questions?
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Contacts
Brett Kay
Director, SNP Assessment
202-955-1722
kay@ncqa.org
Casandra Monroe
Assistant Director, SNP Assessment
202-955-5136
monroe@ncqa.org
Sandra Jones
Assistant Director, SNP Assessment
202-955-5189
jones@ncqa.org
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Contacts
Nidhi Dalwadi
Accreditation Manager, SNP Assessment
202-955-3585
dalwadi@ncqa.org
Anthony Davis
Accreditation Manager, SNP Assessment
202 –955-1713
ahdavis@ncqa.org
Priyanka Oberoi
Analyst, SNP Assessment
202-955-5130
oberoi@ncqa.org
Delia Ponce
Coordinator, SNP Assessment
202-955-1742
ponce@ncqa.org
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Please visit the
SNP Surveyor Website:
www.NCQA.org/SNPSurveyor
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