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Big Changes Coming for Special Needs Plans

Big Changes Coming For Special Needs Plans

The Bipartisan Budget Act of 2018 created some major changes for Medicare Advantage Special Needs Plans (MA and SNP). While the implementation date is a few years out, plans will need to prepare now on how they will fulfill the new rules. Some laggard states, too, have a lot to think about.

As we have stated in the past, SNPs have gone through a very rocky road. At points, Congress and the Centers for Medicare and Medicaid Services (CMS) had lost faith in the program. SNPs were near death and survived in the past only through periodic temporary reauthorizations. However, CMS, recognizing the potential of SNPs to better coordinate Medicaid and Medicare funding (as well as acute and long-term care) overhauled their regulatory approach and demanded accountability. Gone are the days where SNPs were largely marketing vehicles for plans. Major CMS reforms included enhancing the audit rules and regime as well as requiring Models of Care to go through a thorough NCQA approval and reapproval process.

The 2018 budget act permanently reauthorizes SNPs as well as introduces further reforms aimed at cost-containment and improving quality. In the case of dual eligible or D-SNPs (those focused on enrolling individuals eligible for both Medicare and Medicaid), plans must meet specific integration requirements with states by 2021. Currently, an Integrated Denial Notice (IDN) is required for these plans. In this case, members are notified of their joint Medicare and Medicaid appeals rights. By April 2020, CMS will need to develop a strategy on uniform grievances and appeals procedures. These are aimed at streamlining and integrating the two cumbersome Medicaid and Medicare processes. These will have to be followed for the 2021 plan year. In an input solicitation notice, CMS indicates that the procedures will mimic what has been done for the Medicare-Medicaid Plans (MMPs).

We already have the MMP pilots under the Financial Alignment Initiative. About a dozen states participate in the MMPs and in a small number of them Medicaid long-term care services are included. In terms of D-SNPs, depending on the state, plans either (1) coordinate (the Medicare cost-sharing covered by Medicaid or Medicaid-specific benefit claims still flow through the state fee-for-service or other Medicaid plans) or (2) integrate (where plans are capitated by the state Medicaid system to cover Medicare cost-sharing covered by Medicaid and sometimes the Medicaid-specific benefits). About a dozen states (there is overlap) offer or require integration strategies for D-SNPs now. Today, most plans coordinate with states and have limited requirements as such.

The budget bill will require plans to effectively migrate from coordination to integration – or at least just short of it. Beginning in 2021, D-SNPs must do at least one of the following with their Medicaid regulators in each state or they face the inability to add new members.

  • Become a Fully Integrated Dual Eligible SNP noted above.
  • Provide LTSS or behavioral health services under a capitated arrangement with the state.
  • If the MA plan’s parent offers a Medicaid plan for LTSS or behavioral health in the state, the MA plan will need to assume all clinical and financial responsibility for Medicare and Medicaid benefits.
  • Coordinate LTSS and/or behavioral health based on requirements to be set by CMS’ dual coordination office. These could include notifying the state of ER use, hospital use or SNF use, PCP assignment, and data sharing.

The last item admittedly is short of full integration but plans likely will migrate to full integration as it may be easier overall to administer at that point.

Earlier this year, the CMS coordinating office issued a memo requesting feedback and had listed some very good questions regarding both the grievance and appeals streamlining and the exact requirements for integration. See that memo here.

There are over 2.5M members in various SNPs now. This number will only grow over time. Plans will need to adapt to these changes. Prepare now as providing proof of all this to CMS (unless pushed out) will be due in early 2020.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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