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Chronic Care Special Needs Plan Changes Coming

Chronic Care Special Needs Plan Changes Coming

We have spent a great deal of time telling you about the Centers for Medicare and Medicaid Services (CMS) refined approach to Special Needs Plans (SNPs) and the Model of Care (MOC) regulations over the last few years. In general, CMS has enhanced their regulatory oversight and audits of SNPs over the past many years, including requiring submission and approval/reapproval of MOCs.

A huge sea of change will occur for Dual-eligible SNPs (D-SNPs) in 2021 when Medicare Advantage plans will have to abandon coordination and essentially become integrated SNPs and forge a strong relationship with state Medicaid agencies.

Now, CMS is looking at enhancing their approaches to Chronic Care SNPs (C-SNPs). This is courtesy of yet another element of the Bipartisan Budget Act of 2018. Beginning in 2020, all C-SNP plans will be required to submit their MOC annually for approval by the National Committee for Quality Assurance (NCQA) which has become one of the de factor arms of CMS for all things quality in the Medicare Advantage world. All C-SNPs will need to submit their MOC in 2019 whether they already have a 1, 2 or 3 year approval in place. This requirement does not apply to D-SNPs or Institutional SNPs (I-SNPs).

Beginning in 2021, CMS will require a minimum scoring benchmark for each element of the C-SNP’s MOC and permit approval of a MOC only if each element of the MOC meets the applicable minimum benchmark. While not required by the budget act, CMS will pursue rulemaking to adopt the new scoring benchmarks across all three SNP types. The scoring benchmarks will be key and aimed at ensuring that all C-SNPs are meeting the intent of such plans – enhancing the care and quality outcomes of people in the Medicare Advantage program that have underlying co-morbidities. Before the scoring is in place, the current NCQA element by element review will continue to apply.

While I-SNPs do not have as much focus, we note that several Medicare-Medicaid Plan (MMP) pilots are in place that are testing integration of acute and long-term care in both programs. This will serve as a basis to improve I-SNP outcomes as well.

Why is CMS going down this road? Simple: the agency sees the looming problem of high costs and poor quality as America ages and more and more qualify for both Medicare and Medicaid services. CMS is determined to lay out a rational path now.

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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