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Creating Partnerships to Improve Support for Vulnerable Groups-Cheryl Phillips, SNP Alliance, Inc.

Presentation delivered by Cheryl Phillips, MD, President and Chief Executive Officer, SNP Alliance, Inc. at the marcus evans Long-Term Care & Senior Living CXO Summit 2019 held in Orlando, FL.
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  • 1. SPECIALIZED MANAGED CARE – INTEGRATING LTC Cheryl Phillips, M.D. President and CEO Special Needs Plan Alliance, Washington, D.C.
  • 2. MULTIPLE FORCES PUSHING SPECIALIZED MANAGED CARE: WHAT IS THE IMPACT ON LTC? Growth of Medicare Advantage Overall States moving to managed LTSS (long term services and supports) Focus on increasing integration for high risk populations Flexibility of Supplemental Benefits
  • 3. OVER 1/3 OF MEDICARE BENEFICIARIES ARE ENROLLED IN MEDICARE ADVANTAGE (MA)
  • 4. Functional impairment refers to the need for non-medical supports and services that help with basic activities of daily living like bathing, dressing, and eating. It is highly associated with being age 80 and older and having multiple chronic conditions. MEDICARE ADVANTAGE NOW MIRRORS FEE-FOR-SERVICE COMPLEX CARE POPULATION Medicare Advantage Medicare Fee-for-Service Age 75 and Older1 38.2% 34.5% Moderate – Severe Functional Impairment 12% 12% Cognitive Impairment 7% 7% Diagnosed with 3+ Chronic Conditions 47% 45% Percentage of Population with Complex Needs (2015) Source: Anne Tumlinson Innovations analysis of the 2015 Medicare Current Beneficiary Survey. Note: Data is limited to fee-for- service Medicare beneficiaries living in the community and excludes long-stay nursing home residents. 1. America’s Health Insurance Plans. Medicare Advantage Demographics Report, 2015. June 2018. Accessed at: https://www.ahip.org/wpcontent/uploads/2018/06/MADemographics_IssueBrief.pdf.
  • 5. NEW TYPES OF TARGETED MANAGED CARE Special Needs Plans ▪ Are a type of managed Medicare (MA) plans - > 2.7 million enrollees ▪ Just received permanency – January, 2018 – Bipartisan Budget Act ▪ 3 types (with 1 important sub-type) ▪ Chronic Condition – serving those with serious and potential life-threatening chronic conditions. (C-SNPs) ▪ Dually-eligible – serving those with both Medicare and Medicaid enrolled in managed care (may be aligned or not aligned). (D-SNPs) ▪ Fully Integrated Dual Eligible SNPs – eligible in certain states, function as a single Medicare-Medicaid plan, additional benefit flexibility, eligible for PACE frailty factor if they enroll a high % of “frail” members based on acuity scores – similar to PACE programs ▪ New definition in recent proposed rule: HIDE SNP – when parent organization has financial risk for both D SNP (MA) and MLTSS (further clarification still needed) ▪ Institutional – serving those who are at the state definition of “institutional level of care” for at least 90 days. Most are in NHs, but not all. (I-SNPs)
  • 6. ENROLLMENT IN SPECIAL NEEDS AND INTEGRATED DEMONSTRATION PLANS - JAN, 2019 ▪ D SNPs ▪ Medicare-Medicaid Plans ▪ C SNPs ▪ I SNPS Plan Type National Enrollment # of Plans D- SNPs 2,442,708 480 MMPs 383,047 54 C SNPs 351,002 (down from 2018) 129 I SNPS 83,597 125 Sources: Jan 2019 CMS SNP Comprehensive Report and MCRAdv/Part D Monthly Enrollment Data
  • 7. THE SPECTRUM AND ALPHABET SOUP OF INTEGRATION FOR MEDICARE AND MEDICAID Medicare Parts A&B Original (FFS) Original (FFS) Medicare Advantage (managed care) MA-PD Special Needs Plan Dual-SNP (Fully Integrated Dually Eligible) FIDE-SNP Medicare- Medicaid Plan (demonstration) And PACE Examples of one aligned plan Medicare Part D (PDP) Part D Plan PDP PDP Medicaid FFS Different Medicaid Managed Care Organization (MCO) Different Medicaid MCO Different Medicaid MCO Different Medicaid MCO Aligned MCO (same plan sponsor) Aligned MCO Medicaid managed LTSS (MLTSS) and/or BH FFS FFS FFS FFS FFS or Different MCO FFS or Different MCO INCREASING INTEGRATION
  • 8. WHAT MAKES SNPS DIFFERENT? ▪ Specific eligibility requirements ▪ Be enrolled in Medicare Part A and Part B. ▪ Live in the service area of the Special Needs Plan. ▪ Meet the eligibility requirements that the Special Needs Plan targets (i.e., live in an institution; have Medicare and Medicaid; or have the chronic conditions(s) that the plan targets). ▪ Model of Care requirement (MOC) ▪ Individualized care plan and care coordination ▪ MIPPA Contracts *(for D SNPs) ▪ Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 to improve the by requiring D-SNPs to obtain contracts with State Medicaid Agencies. Contracts must document each entity’s roles and responsibilities with regard to dual eligible individuals and contain, at a minimum, the following eight elements (42 CFR 422.108(c)): ▪ The MA organization’s responsibilities, including financial obligations, to provide or arrange for Medicaid benefits; ▪ The category or categories of eligibility for dual eligible beneficiaries to be enrolled under the SNP, including the targeting of specific subsets; ▪ The Medicaid benefits covered under the SNP; ▪ The cost-sharing protections covered under the SNP; ▪ The identification and sharing of information on Medicaid provider participation; ▪ The verification process of an enrollee’s eligibility for both Medicare and Medicaid; ▪ The service area covered under the SNP; and ▪ The contracting period.
  • 9. ELEMENTS OF THE MODEL OF CARE (MOC) ▪ Define specific targeted population in the SNP ▪ Measurable goals ▪ Staff structure and care management role ▪ Interdisciplinary care team ▪ Provider network with expertise and use of clinical practice guidelines ▪ Model of Care training for provider network ▪ Health risk assessment ▪ Individualized care plan ▪ Communications network ▪ Care Management for most vulnerable ▪ Performance and measurable outcomes
  • 10. INSTITUTIONAL SNPS ▪ These types of MA plans are rapidly expanding in NHs. ▪ NH and senior living owners are actually coming together a co-owners of these plans. ▪ Since the plan now assumes risk for all Medicare costs – it requires new thinking and strategies… ▪ LTC residents are Medicare’s last FFS cohort – and I SNPs target only this population ▪ Are facing some resistance from States – as they may have conflicting interested re: rebalancing / keeping members in the community – not in long stay NH care ▪ I SNPs now targeting senior-living communities
  • 11. INTEGRATED MEDICARE ADVANTAGE AND MANAGED LTC – NEW EXPECTATIONS ▪ Nursing homes contracting with integrated MA plans may be required to provide additional types of data – due to the MLTC (Medicaid) requirements from the state. ▪ The State will likely set capitation rates for long-stay NH residents for the LTC benefits ▪ The State will also likely wish to implement transition protocols and rebalancing strategies (returning individuals to the community for the LTC needs) ▪ NH will likely have to interface with new providers and services (home and community-base providers, care managers, etc.) that are beyond the typical Medicare services.
  • 12. MEDICARE ADVANTAGE TO COVER (SOME) HCBS! CMS expands “supplemental benefits – include “primarily health related” such as (but not limited to) ▪ ADL assistance ▪ Nutrition support ▪ Adult day care ▪ Caregiver support ▪ Home and bathroom modification
  • 13. CMS ANNOUNCES NEW VBID – OPTIONS FOR BENEFIT FLEXIBILITY ▪ New Flexibility for benefits under VBID model ▪ Changes to Part D with increased risk sharing ▪ Pilots for Hospice benefits in MA plans ▪ Applications to be released …
  • 14. SUPPLEMENTAL BENEFITS FLEXIBILITY • Allowed for benefits not covered by original Medicare • “Primarily health related” • Limited to D SNPs with 3- yr MOC approval, quality star ratings and < 2 negative points on previous performance review •“Health care benefits” now defined as Must DX, prevent or treat an illness or injury; or Compensate for physical impairment and/or fxnl/psychological impact; or Reduce avoidable emergency and health care utilization • Must focus on health care needs • Must be medically appropriate and recommended by a licensed provider • Shall not be used solely to induce enrollment • Examples included: Adult day services, personal care, respite, home safety mod, NEMT, OTC benefits • Can tailor benefit designs to subpopulations of enrollees who meet specific medical criteria New Flexibilities for all MA Plans Additional Flexibility for Chronically Ill (relaxed definition of “uniformity” • Starting in 2020 bid submission • Will not need to be applied to ALL chronically ill enrollees and can vary based on the individual’s specific medical condition – therefore does not need to be granted if it is unlikely to improve a specific health condition • Do not need to be primarily health related, but must • Have a reasonable expectation of improving or maintaining the heath or over all function” • Guidance is expected in early 2019
  • 15. MORE THINKING How will the shift to managed care impact even private pay providers? How will the push to move LTC services to the community impact NH? Senior living? Are LTC providers prepared to address changes in data requirements of both MA and Managed LTC (Medicaid) How will Senior Living and LTC providers differentiate marketing messaging in future years? Will LTC providers move beyond I SNPs and consider offering D SNPs? How will LTC providers integrate community-based services (such as behavioral health?) HOW DO CONSUMERS KNOW HOW TO NAVIGATE THIS MAZE OF SERVICES AND PAYORS?
  • 16. SOME RESOURCES ▪ CMS Guide to Special Needs Plans: www.medicare.gov/pubs/p[df/11302.pdf ▪ Summary of Chronic Care Act: https://www.thescanfoundation.org/chronic- care-act-2018-advancing-care-adults-complex-needs ▪ LTQA overview of Supplemental Benefits: http://www.ltqa.org/wp- content/themes/ltqaMain/custom/images/LTQA-Report-on-MA-Flexible- Supplemental-Benefits-FINAL-11-9-18.pdf ▪ Kaiser Family Foundation Medicare Advantage 2016 Spotlight: www.kff.org/report-section/medicare-advantage-2016-spotlight-enrollment- market-update-appendices/ ▪ Integrated Care Resource Center: https://www.integratedcareresourcecenter.com/PDFs/ICRC_Growing_Enrollme nt_in_Integrated_Managed_Care_Plans_FINAL_6-01-17.pdf ▪ Special Needs Plan Alliance: www.snpalliance.org ▪ Contact me: Cheryl Phillips, M.D., cphillips@snpalliance.org
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