MedicareMedicaid Integration through Special Needs Plans

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Medicare/Medicaid Integration through Special
Needs Plans

• September 7, 2006
• Mary Kennedy
• Vice President, State Public Affairs

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Overview

• Evercare Background
• Special Needs Plans Background
• Definition
• SNP Landscape
• Care Coordination
• Integrating Medicare and Medicaid through Special
  Needs Plans

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EvercareOrganizational Background

Our mission is to optimize the health and
well-being of aging, vulnerable and chronically
ill individuals

• Parent organization - UnitedHealth Group
• Diversified health and well-being organization
• Comprised of six business segments, each serving
  a unique population
• Part of Ovations, business segment focused on
  care for individuals over age 50
• Medicare Advantage plans serving over 1.5 million
  members
• Evercare serves 100K elderly and physically
  disabled members
• National PDP offering the AARP MedicareRx Plan,
  currently serving 4.5 million seniors nationwide
• Provide Medicare supplement to 3.5 million AARP
  members

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EvercareNational LTC Experience

• Serving 51,000 elderly and disabled Medicaid
  beneficiaries through 7 programs in 6 states
• Arizona Long Term Care System (ALTCS)
• Florida Long Term Care Programs
• Nursing Home Community Diversion Program
• Frail / Elderly Program
• Massachusetts Senior Care Options (SCO)
• Minnesota Senior Health Options (MSHO)
• Texas STARPLUS Program
• Washington Medicaid/Medicare Integration Program
• Serving 29,000 institutionalized Medicare
  beneficiaries in 25 states
• Offering Medicare Dual Special Needs Plans in 30
  states
• Currently serving 18,000 community-based Medicare
  beneficiaries

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Special Needs Plans (SNPs)

• New type of Medicare Advantage coordinated care
  plan focused on
• individuals with special needs created by Section
  231 of the MMA
• Institutionalized Beneficiaries
• Those who reside or are expected to reside
  continuously for 90 days or longer in Skilled
  Nursing Facility/Nursing Facility (SNF/NF)
• Those individuals living in the community but
  requiring a level of care equivalent to that of
  individuals in SNF/NF.
• Dually Eligible Beneficiaries
• Beneficiaries must have Medicaid coverage at the
  time of enrollment
• SNPs may enroll full and/or partial duals
  (Medicare Savings Program)
• Beneficiaries with Chronic Conditions
• To provide as much flexibility as the law allows
  and because this is a new untested type of MA
  Plan, CMS did not set forth in regulation a
  detailed definition of severe and disabling
  chronic conditions
• CMS will evaluate proposals on a case-by-case
  basis
• CMS will consider appropriateness of target
  population clinical programs and special
  expertise other unique features of the SNP
  serving the proposed target population.

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SNPs and Medicaid Long Term Care

• SNPs can manage care to prevent premature NH
  entry
• Better care can delay nursing home entry
• SNPs can enroll the partial duals states have
  struggled to find ways to assist these
  individuals
• Institutionalized beneficiaries are
  overwhelmingly dual eligibles
• The states are the primary purchaser of long term
  care a formal relationship is desirable.
• SNPs can work with states to improve care for
  those duals who are in the nursing home
• Overall quality in the nursing home
• Medication management
• Use of other services, especially transportation,
  ER, therapy, avoidable hospitalizations
• Assurance that short term stays remain short-stay
  
• Improve functioning to allow for lower case mix
  score or return to the community

SNPs can be a catalyst for the growth of
integrated long term care initiatives that
strengthen and rebalance the long term care
system.
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SNP Landscape

• CMS approved 276 SNPs for 2006, up from 125 SNPs
  in 2005
• While the vast majority of this year's SNPs cover
  dual eligibles, the total includes 37
  institutional plans as well as the 13 chronic
  care plans.
• 2007 Filings were due before much experience with
  SNPs expect more chronic care and
  disproportionate dual plans next year
• Congress must reauthorize SNPs, at the end of
  2008
• Mathematica has the CMS contract to evaluate SNP
  implementation that is due at the end of 2007

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States with SNPs in One or More Counties
Source CMS Special Needs Plan MapsUpdated
11-9-2005. http//www.cms.hhs.gov/healthplans/spec
ialneedsplans/default.asp
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SNPs What is Special?

• SNPs are a Medicare Product
• No requirement to coordinate with Medicaid
• States were very busy with Part D in 2006- new
  relationships with SNPs may not have been a
  priority
• Different Marketing and Enrollment rules than
  Medicare Advantage
• Able to target enrollment
• Able to accept new enrollees all year
• Same payment rules as MA-PDs
• Risk adjusted payment is the same
• Some demos have received a higher frailty
  factor
• Risk adjustment does not recognize frailty,
  dementia, or severity within a disease category
• The frailty factor helps pay appropriately for
  nursing home certifiable members residing in
  the community.

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States Can Influence the Special in Special
Needs Plans
SNPs provide great potential to improve care for
duals and people with chronic health conditions.
States can assure that it happens.

• State contracting for coordination of Medicare
  and Medicaid through SNPs can
• Promote care management approaches that improve
  care and support living in the community
• Assure adequate plan size to support care
  management infrastructure
• Develop infrastructure in rural or underserved
  urban areas
• Influence plans Medicare bids to best fit the
  states Medicaid program
• Chronic health conditions drive overall costs and
  lead to a cascade of medical events that drive
  premature or extended nursing home use

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Impact of Chronic Illness on Medicaid

• 87 of Medicare/Medicaid dual eligibles have 1 or
  more chronic conditions
• 63 of dual eligibles have 1 or more limitations
  in activity limitations

From Chronic Conditions Making the Case for
Ongoing Care, Johns Hopkins University for the
Robert Wood Johnson Foundation, December 2002
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Individuals with 2 Chronic Illnesses Account for
95 of Medicare Spending
From Chronic Conditions Making the Case for
Ongoing Care, Johns Hopkins University for the
Robert Wood Johnson Foundation, December 2002
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Multiple Chronic Conditions Lead to Increased
Unnecessary Hospitalizations
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Costs Double for People with Chronic Illness and
Activity Limitations
From Chronic Conditions Making the Case for
Ongoing Care, Johns Hopkins University for the
Robert Wood Johnson Foundation, December 2002
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Options for Medicare/Medicaid Integration

• Three Party Integration Model
• MSHO/MASS SCO/WI Partnership
• Plan Level Integration
• TX STARPLUS/ AZ ALTCS
• Capitated Wraparound Model
• NY Medicaid Advantage
• Buy-In Wraparound Model

Most Comprehensive

Least Comprehensive
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Potential Models for SNP and State Medicaid
Coordination

• Three party integrated model a three way
  contract between the State, CMS and the health
  plan.
• Prior to SNP option, used by MN,MA, WI as early
  innovators to design comprehensive programs
• Plan level integrated model
• Health plan pursues contracts with Medicaid for
  additional services such as OTC drugs, HCBS,
  nursing home
• Plan has to follow separate Medicaid and Medicare
  requirements for appeals, marketing, performance
  measurement, etc
• Capitated wrap-around contract with state for
  Medicare cost sharing only Example Alabama,
  Texas
• Default
• Medicaid State Plan services are provided by
  state state pays Medicare co-pays up to state
  plan level as a secondary payer to SNP
  enrollment no formal relationship with SNP.
• Or, state pays premium based plans on an
  individual by individual basis as cost
  effective" insurance

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Integrating LTC Services
Current System
Integrated LTC Program

• Medicaid
• Nursing Home Care
• Medicare Cost Sharing

Consumer with Care Coordination
Consumer
Medicare Part D
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State as Active Purchaser

• State crafts a Medicaid contract with a SNP with
  active leveraging of the Medicare benefit and
  contract requirements
• Special Needs Plan benefits because marketing,
  performance measurement, reporting, enrollment
  and other rules are consistent with the Medicare
  requirements.
• State and SNP benefit from sufficient enrollment
  to support care coordination infrastructure
• Beneficiary benefits from care coordination
  seamless benefit structure, enrollment in
  Medicare plan
• State can use to rebalance the long term care
  system
• Example New Yorks Medicaid Advantage (acute
  services)
• Idahos Optional Alternate Dual
  Benefit under DRA

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Federal Reforms Needed to Achieve Better Care
Coordination

• States should be given the option to integrate
  acute and long-term care benefits for dual
  eligibles through their state plans.
• Federal rules for Medicaid managed care and
  Medicare Advantage plans should be aligned in
  areas of marketing, grievances appeals,
  enrollment, and quality assurance.
• States should have increased tools to
  automatically enroll dual eligibles into
  integrated care management plans so long as these
  individuals have the ability to opt out.
• States should have the ability to share in
  savings achieved for Medicare through state care
  coordination initiatives.

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Contact Information

• Mary B. Kennedy
• Vice President, State Public Policy
• Evercare/Ovations
• MN008-W130
• 9900 Bren Road East
• Minnetonka, MN 55343
• 952-936-1382
• mary_b_kennedy_at_uhc.com