Special Needs Plans (SNP) Frequently Asked Questions (FAQs)

1 Special Needs Plans (SNP) Frequently Asked Questions (FAQs) SNP FAQ DRAFT 1 Table of Contents I. 2 II. General SNP Questions .. 2 III. SNP Application Process .. 3 IV. Chronic Condition SNPs .. 6 V. Dual Eligible SNPs .. 8 VI. Institutional SNPs .. 13 Special Needs Plans (SNP) Frequently Asked Questions (FAQs) SNP FAQ DRAFT 2 I. PURPOSE This document addresses Questions regarding Special Needs Plans (SNPs). Questions are categorized into four sections: 1) General SNP Questions ; 2) Chronic Condition SNPs; 3) Dual Eligible SNPs; and 4) Institutional SNPs. II. GENERAL SNP Questions Question: What is a Special Needs Plan? Answer: A Special Needs Plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) designed to provide targeted care and services to individuals with unique " Special Needs individuals" have been defined as: 1) institutionalized beneficiaries; 2) Medicare-Medicaid enrollees; and/or, 3) individuals with severe or disabling chronic conditions, as specified by the Centers for Medicare and Medicaid Services (CMS).

2 2 Question: What are the payment procedures for SNPs? Answer: Payment procedures for SNPs mirror the procedures that CMS uses to make payments to non-SNP MA Plans . CMS makes advance monthly payments, or capitated payments, to an MA organization for each enrollee for coverage of original Medicare benefits in an MA payment Question: Do SNPs have to offer benefits in addition to those offered in non-SNP MA Plans ? Answer: SNP-specific Plan Benefit Packages (PBPs) should incorporate some or all benefits that exceed the basic requirement of Medicare A and B benefits offered by other MA products available in the same service area, such as: No or lower beneficiary cost sharing; Longer benefit coverage periods for inpatient services; Longer benefit coverage periods for specialty medical services; Parity between medical and mental health benefits and services; Additional preventive health benefits ( , dental screening, vision screening, hearing screening, age-appropriate cancer screening, risk-based cardiac screening); Social services ( , connection to community resources for economic assistance) and transportation services; and, Wellness programs to prevent the progression of chronic Question: Do SNPs have the same quality improvement requirements as non-SNP MA Plans ?

3 Answer: SNPs have the same quality improvement requirements as other MA Plans ; however, such requirements are tailored to the Special Needs individuals that the SNP serves. SNPs must conduct 1 SNPs were established by the Medicare Modernization Act of 2003 (MMA) 2 CMS, Medicare Managed Care Manual (MMCM), chap. 16b, and see 42 Code of Federal Regulations (CFR) which defines Special Needs individuals and specialized MA Plans for Special Needs individuals 3 MMCM, chap. 8 4 Ibid, chap. 16b, Special Needs Plans (SNP) Frequently Asked Questions (FAQs) SNP FAQ DRAFT 3 both a Chronic Care Improvement Program (CCIP) and a Quality Improvement Project (QIP) targeting the Special Needs population that it has selected to Question: What is the SNP enrollment process and how does it differ from the enrollment of non-SNP MA Plans ? Answer: SNPs may only enroll individuals who meet the plan s specific eligibility criteria and enrollment All SNPs are required to verify the applicant s Special Needs status.

4 SNPs must include elements on the enrollment request mechanism that correspond to the Special Needs focus of the particular Although MA organizations must accept enrollment through the Online Enrollment Center (OEC), SNPs may choose whether or not to enroll beneficiaries through the Question: What happens if a beneficiary loses his/her Special Needs status? Answer: CMS provides a Special Enrollment Period (SEP) for individuals enrolled in an SNP, but are no longer eligible because they no longer meet the specific Special Needs SNPs must send the appropriate notice to the beneficiary explaining their Question: Are there Special marketing requirements for SNPs? Answer: As with any MA organization, SNPs must market to all individuals eligible to enroll in the Certain marketing provisions are in place, specifically regarding the disclaimer SNPs must place on enrollment eligibility marketing materials targeting potential enrollees and the information SNPs can include related to their National Committee for Quality Assurance (NCQA) SNP Please refer to Section V (Question 9) for Special marketing requirements specific to Dual Eligible SNPs.

5 III. SNP APPLICATION PROCESS Question: How can an MA apply to offer an SNP? Answer: Every Medicare Advantage (MA) applicant seeking to offer a Special Needs Plan (SNP) must obtain approval as a Medicare Advantage Prescription Drug (MA-PD) plan. Applicants with a CMS approved MA-PD contract in place only need to complete the SNP portion of the MA application. The SNP application contains a list of Questions and attestations requiring a yes or no response and requires the applicant to upload documentation in support of responses to the Questions and attestations, including the Model of Care (MOC) matrix upload SNP applicants can obtain the MA and SNP application for the current contract year at 5 MMCM, chap. 16b, 90, chap. 5 , and 42 CFR (c)-(d) 6 Ibid., chap. 16b, and Section 1859(f) of the Social Security Act (the Act) 7 See chap.

6 2 for more information on enrollment requirements 8 MMCM, chap. 16b, 9 Individuals enrolled in a D-SNP always qualify for a SEP. See IV. Dual Eligible SNPs, Question 4 10 MMCM, chap. 16b, and also see chap. 2, for more information on SEPs 11 Ibid., chap. 16b, 70 12 Ibid., chap. 3, 13 Ibid., chap. 16b, Special Needs Plans (SNP) Frequently Asked Questions (FAQs) SNP FAQ DRAFT 4 All SNP applications must be submitted electronically through the Health Plan Management System (HPMS). Question: When are SNP applications due? Answer: The deadline for submitting applications is available in the application package for the current contract All SNP applications must be submitted electronically through HPMS by the MA application due date. CMS will not review applications received after the due date and after the due date applicants access to the HPMS application fields will be Question: What criteria should be included in an SNP s MOC?

7 Answer: CMS is currently revising the existing MOC criteria. Question: What is the National Committee for Quality Assurance SNP MOC approval process? Answer: As of January 2012, all SNPs MOCs must be approved by the The NCQA is a non-profit organization that accredits and certifies health care organizations to ensure adherence to health care quality. The NCQA SNP approval process is based on scoring each of the eleven clinical and non-clinical elements of the MOC in the SNP application. The scoring methodology consists of three parts: Standard: In order to operate, an SNP must achieve a score of 70 percent or greater on the MOC based on the scoring methodology as described below. Element: The MOC has 11 clinical and non-clinical elements. Each element will have a score that will be totaled and used to determine the final overall score. The 11 MOC elements are listed below: o Description of the SNP-specific Target Population; o Measurable Goals; o Staff Structure and Care Management Goals; o Interdisciplinary Care Team; o Provider Network having Specialized Expertise and Use of Clinical Practice Guidelines and Protocols; o MOC Training for Personnel and Provider Network; o Health Risk Assessment; o Individualized Care Plan; o Integrated Communication Network; o Care Management for the Most Vulnerable Subpopulations; and, o Performance and Health Outcomes Measurement.

8 Factors: Each element is comprised of multiple factors that NCQA evaluates and scores on a scale of 0 to 4, where 4 is the highest score. Plans are required to provide a response that addresses every applicable factor within each of the eleven elements. Responses should be detailed and include multiple examples and/or case studies. The scores for each factor 14 Both the MA and the SNP application for the current contract year are available at 15 MMCM, chap. 16b, 16 Ibid., and Section 1859(f)(7) of the Act Special Needs Plans (SNP) Frequently Asked Questions (FAQs) SNP FAQ DRAFT 5 within a specific element are totaled to provide the overall score for that particular element. There is a total of 160 possible points that can be achieved across the 11 elements based on 40 factors. A passing score is 70 Question: What if an SNP applicant receives a score below the standard of 70 on their MOC? Answer: SNPs with an MOC score below the standard of 70 will have one opportunity to resubmit their MOC and achieve a score of 70 or greater.

9 This one-time opportunity is called a cure. To ensure that SNPs submit high quality MOCs, CMS has limited the cure opportunity to just one with only a one-year approval to Question: Are there different categories of NCQA approval for SNPs? Answer: SNPs are granted NCQA approval to operate for a certain number of years based on their MOC score. The categories of approval are as follows: Three-year approval: SNPs that receive a score of 85 or higher on their initial MOC submission will not have to submit a new MOC until the end of the third year of operating. Two-year approval: SNPs that receive a score between 75 and 84 on their initial MOC submission will not have to submit a new MOC until the end of the second year of operating. One-year approval: SNPs that receive a score between 70 and 74 on their initial MOC submission, OR SNPs that score less than 70 on their initial MOC submission and subsequently achieve a score of 70 or higher after they have had one opportunity to cure, will submit a new MOC at the end of the first year of operating.

10 This approval process provides incentive for SNPs to develop and submit comprehensive MOCs by rewarding a longer term of approval to SNPs with high-quality Question: When does an MA organization have to submit a new SNP application and MOC? Answer: An MA organization must submit a new SNP application20 and MOC under the following circumstances: The MA organization seeks to offer a new SNP The MA organization seeks to expand its existing service area21 The MA organization operating a D-SNP expects to change its approved dual eligible subset22 When approval periods for MA organizations with existing SNPs expire, SNPs must submit new MOCs but are not required to submit SNP 17 The scoring methodology is currently being revised and will reside in MMCM, chap. 5 once complete. 18 MMCM, chap. 16b, 19 Ibid. 20 The SNP portion of the MA application 21 In this circumstance, the MA organization must submit both the SNP portion and SAE portions of the MA application 22 See Section IV.