Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.
By James Gutman, Managing Editor
January 31, 2013 Volume 19 Issue 2
The Medicare Payment Advisory Commission (MedPAC) on Jan. 10 unanimously adopted four recommendations regarding Medicare Advantage Special Needs Plans, including one specifying that no new chronic care SNPs should be approved beginning Jan. 1, 2014. And while current C-SNPs could keep operating during a transition period running through 2016, and some highly specialized ones could continue beyond that, the MedPAC proposal could have the vast majority of C-SNPs integrated into regular MA plans, which would be empowered to offer enhanced separate benefit packages for chronically ill members.
The separate-benefits provision and the three-year transition period are among several changes MedPAC incorporated since the original recommendations of Chairman Glenn Hackbarth were released (MAN 12/6/12, p. 1) that make the proposals more palatable to industry groups. So does a provision that would allow C-SNPs for end-stage renal disease (ESRD), HIV/AIDS and “chronic and disabling mental health conditions” to continue. But the overall suggestions, which will go to Congress as part of MedPAC’s report in March, still could cause disruption in some aspects of current SNP markets.
The law that created MedPAC in 1997 specifies that its recommendations are made to Congress, which is not required to accept them and often doesn’t. Moreover, Congress in this month’s “fiscal cliff” law reauthorized all SNPs for one year.
The most controversial recommendations clearly are the ones on C-SNPs. They stem in part from MedPAC’s finding that C-SNPs perform no better and often worse than regular MA plans. That finding, however, like the star-rating system it largely is based on, does not take into account the difficulties in caring for a population that is largely rural, very poor and often disabled, says Rich Bringewatt, co-chair of the SNP Alliance trade group. Bringewatt, speaking only for himself since the group hasn’t yet taken positions on the final recommendations, also noted there are some smaller SNPs that have very strong (e.g., 4.5 stars) quality ratings from CMS.
The other three SNP recommendations adopted by MedPAC are that:
(1) Institutional SNPs (I-SNPs) get permanent reauthorization;
(2) All integrated Medicare-Medicaid dual-eligible SNPs get permanently reauthorized, but authority for other D-SNPs would be allowed to expire; and
(3) HHS be directed to allow D-SNPs to market Medicare and Medicaid benefits “as a combined benefit package,” permit use of a single enrollment card for Medicare and Medicaid benefits, and develop a model D-SNP contract that states could use.
The recommendations for D-SNPs, which now account for about 10% of MA enrollees, were particularly detailed and attracted substantial comment from both MedPAC staffers and commissioners during the more than an hour and a half of discussion preceding the vote.
Analyst Christine Aguiar noted during her introductory comments that most D-SNPs are not integrated and that only about 25% of D-SNP enrollment is in integrated models. Moreover, she said, there are separate processes for appeals and grievances for Medicare versus Medicaid in D-SNPs that pose an administrative problem. But she recommended permanent reauthorization for D-SNPs if they’re redefined “as an integrated product,” and said directing HHS to develop the model D-SNP contract should help states in achieving this.
MedPAC Adjusted Initial D-SNP Proposals
The model state contract, says Bringewatt, wouldn’t do much in itself to foster this integration. But he tells MAN the other D-SNP changes show that MedPAC heard the SNP Alliance and made adjustments in its initial recommendations in an effort to eliminate “misalignment” in duals programs both within and outside the massive CMS-funded duals demonstration that is slated to start this year (MAN 12/20/12, p. 1).
The other SNP Alliance co-chair, Valerie Wilbur, also speaking just for herself, contends it is significant that MedPAC is seeking “permanent” authorization for dual SNPs and that MedPAC’s concept of integrated D-SNPs is “much more flexible” than is the concept of fully integrated dual eligible (FIDE) SNPs, which federal policymakers have pushed before.
For example, Bringewatt explains, MedPAC would allow either “some or all” of long-term care and behavioral health benefits to be included, and would permit a separate Medicaid contract.
“We didn’t get all of what we wanted, but there’s a lot of good news, and they didn’t say that if you don’t have this now, [D-SNPs] must go away,” he asserts. Bringewatt adds that “one of the most important things MedPAC is saying is that D-SNPs can be a platform for integration both inside and outside the [CMS duals office’s] demo.”
More good news from MedPAC, he says, lies in the recommendation of permanent reauthorization for I-SNPs, which have significant numbers of enrollees.
It would be harder to find good news for SNPs in the C-SNP recommendations, but Bringewatt says there is some in the form of the transition of C-SNPs back into regular MA taking place over three years. While this is less than the five years the SNP Alliance had recommended, he acknowledges, it is a lot better than the initial MedPAC chairman’s recommendation to let the authorization for C-SNPs expire at the end of 2013.
Furthermore, the commission in its final recommendations is saying that “specialty care is a good idea” and that it should be made available to all of an MA plan’s population, partly via specialty medical benefits, he maintains. Although alliance members have some questions about how this would be done and want to have discussions with Congress, adds Wilbur, the transition itself is good news.
But she also says there is a “disadvantage” in the recommendations if C-SNPs, by going back into regular MA, lose the ability to enroll beneficiaries year-round as they can now. Currently, Wilbur notes, a C-SNP-eligible beneficiary needing care can enroll immediately one time in a C-SNP, and Congress could decide to let this continue. It could be “a matter of life and death” if such a severely ill beneficiary would have to wait 11 months to enroll for this kind of specialty care, she contends.
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