1. Special Needs Plans (SNPs), Expanded Benefits, Part B Step Therapy in Medicare Advantage Plans
Presenter: Vicki Buchholz
Board on Aging & Long Term Care
Medigap Helpline Services
October 2019

2. Special Needs Plans What is a Special Needs Plan?
A special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals.  
A SNP may be any type of MA CCP, including either a local or regional preferred provider organization (i.e., LPPO or RPPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan.  There are three different types of SNPs:
Chronic Condition SNP (C-SNP) - targeted for individuals with a severe or disabling chronic condition specified by CMS.
Dual Eligible SNP (D-SNP) - for dual eligible individuals, either on full/partial Medicaid.
Institutional SNP (I-SNP) – for institutionalized individuals.
Oct 2019

3. Special Needs Plans
SNPs are expected to follow existing MA program rules, as modified by guidance, with regard to Medicare-covered services and Prescription Drug Benefit program rules.  
All SNPs must provide Part D prescription drug coverage because special needs individuals must have access to prescription drugs to manage and control their special health care needs.  
SNPs should assume that, if no modification is contained in guidance, existing Part C and D rules apply.  
Oct 2019

4. Chronic Condition Special Needs Plans C-SNPs
C-SNPs restrict enrollment to special needs individuals with specific severe or disabling chronic conditions.  Approximately two-thirds of Medicare enrollees have multiple chronic conditions requiring coordination of care among primary providers, medical and mental health specialists, inpatient and outpatient facilities, and extensive ancillary services related to diagnostic testing and therapeutic management.
MAOs may apply to offer a C-SNP that targets any one of the following:
1. Single CMS-approved chronic condition
2. CMS-approved co-morbid, clinically linked conditions
3. MAO-customized group of multiple chronic conditions
Oct 2019

5. Chronic Condition Special Needs Plans C-SNPs
15 SNP-Specific Chronic Conditions
Chronic Alcohol/Drug dependence End-stage Renal Disease (dialysis)
Autoimmune disorders Hematologic disorders
Cancer (not pre-cancer conditions) HIV/AIDS
Cardiovascular disorders Chronic Lung disorders
Chronic Heart Failure Chronic/Disabling Mental Health
Dementia Neurologic disorders
Diabetes Mellitus Stroke
End Stage Liver Disease
Oct 2019

6. Dual Eligible Special Needs Plans D-SNPs
Dual Eligible Special Needs Plans (D-SNPs) enroll individuals who are entitled to both Medicare (title XVIII) and medical assistance from a state plan under Medicaid (title XIX).  States cover some Medicare costs, depending on the state and the individual’s eligibility.
Medicaid Eligibility Categories:
Full Medicaid only
Qualified Medicare Beneficiary (only)
Specified Low-Income Medicare Beneficiary (only)
Qualifying Individual (QI-1 in Wisconsin: SLMB+) (only)
Qualified Disabled and Working Individual (QDWI) 
Oct 2019

7. Dual Eligible Special Needs Plans D-SNPs
Dual Eligible Special Needs Plan (D-SNP) Look Alikes
Not subject to regulations governing D-SNPs therefore no responsibility to coordinate Medicare and Medicaid benefits.
2019: 80+ plans in 35 states pulling Duals away from coordinated plans leaving duals to navigate thru two programs: Medicare and Medicaid.
Are not contracting with state Medicaid offices
CMS approved as ordinary Medicare Advantage plan however, being marketed to duals.
Charge premiums/high OOP limits
Marketing violations, plans are prohibited from claiming their plan is designed for duals, not cannot use a name that has language implying they have a relationship with Medicaid
Oct 2019

8. Dual Eligible Special Needs Plans D-SNPs
The Bipartisan Budget Act of 2018 (2018 BBA) permanently authorized D- SNPs and directed the Medicare-Medicaid Coordination Office at CMS to adopt regulations that set minimum D-SNP requirements to integrate Medicare and Medicaid benefits.
Key elements of the final D-SNP regulations applying to plan year 2021:
Minimum responsibilities to coordinate Medicaid benefits (D-SNP’s must have contracts with state Medicaid offices re: responsibilities to coordinate.)
Integrate Medicare and Medicaid appeals (Highly Integrated D-SNP or HIDE-SNP vs Fully Integrated D-SNP or FIDE-SNP)
Notify state Medicaid programs of hospital admissions (states identifying at least one high risk group for this notification)
Enrollment of partial duals in D-SNPs (CMS questioning value for enrolling Medicare Savings Program individuals)
Enforcement options for CMS (allows CMS to impose intermediate sanctions)
Oct 2019

9. Institutional Special Needs Plans I-SNPs
Institutional Special Needs Plans (I-SNPs) are SNPs that restrict enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility.  
CMS may allow an I-SNP that operates either single or multiple facilities to establish a county-based service area as long as it has at least one long-term care facility that can accept enrollment and is accessible to the county residents.  
Oct 2019

10. Medicare Advantage Plan Updates
An “all-in-one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D.
May have lower out-of-pocket costs than Original Medicare.
Plans may offer extra benefits that Original Medicare doesn’t cover—like vision, hearing, dental, and more.
Include Private Fee for Service (PFFS), Preferred Provider (PPO), Health Maintenance Organization (HMO), Special Needs Plans (SNPs), and Medicare and Medical Savings Accounts (MSAs)
Oct 2019

11. NEW Expanded Health Related Extra Benefits
In 2019, the Centers for Medicare & Medicaid Services (CMS) expanded the definition of “primarily health related” to consider an item or service as primarily health related if it is used to:
Diagnose
Compensate for physical impairments
Improve the functional/psychological impact of injuries or health conditions
Reduce avoidable emergency and health care use
Benefit must focus on enrollee’s health care needs and be recommended by a licensed medical professional as part of a care plan, if not provided by one
Beginning in calendar year 2019, the Centers for Medicare & Medicaid Services (CMS) expanded the definition of “primarily health related” to consider an item or service as primarily health related if it’s used to diagnose, compensate for physical impairments, acts to ameliorate (improve) the functional/psychological impact of injuries or health conditions, or reduces avoidable emergency and health care utilization. A supplemental benefit is not primarily health related under the previous or new definition if it’s an item or service that’s solely or primarily used for cosmetic, comfort, general use, or social determinant purposes.
For CMS to approve a supplemental benefit, the benefit must focus directly on an enrollee’s health care needs and be recommended by a licensed medical professional as part of a care plan, if not directly provided by one.
NOTE: CMS calls these “Extra benefits” rather than “Supplemental benefits” in consumer materials, to clearly distinguish from supplement insurance (Medigap).
Oct 2019

12. NEW Expanded Health Related Extra Benefits (continued)
In 2019, 12 parent organizations with 160 plans are providing enrollees with access to expanded health related supplemental benefits
More than 778,000 projected enrollees will have access to these benefits, with in-home support and support for caregivers being the most popular
Adult-day care services
Home-based palliative care
In-home support services
Support for caregivers of enrollees
Therapeutic massage
Stand-alone memory fitness benefit
Home & bathroom safety devices & Modifications
Non-emergency Transportation
Over-the-counter (OTC) benefits
For more information about the expansion of health related supplemental benefits, visit CMS.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate-announcement-and-call-letter.
There are 20 states that have plans offering expanded health related supplemental benefits: AR, AZ, CT, GA, IL, IN, KY, MO, MS, NC, NJ, OR, RI, SC, TN, TX, VA, WA, WI and WV
Oct 2019

13. NEW Reduced Cost-Sharing and Additional Benefits for Enrollees with Certain Health Conditions
In 2019 plans could offer benefits to a specific disease or illness and can now provide benefits they were previously not allowed to offer.
Reduced cost sharing for specific benefits (e.g., lower copay for specialist or acupuncture)
Tailored supplemental benefit offerings tied to one or more disease state (e.g., therapeutic massage)
MA plans may require enrollees to participate in a care management program or use high value providers as a condition of reduced cost sharing or additional benefits
Wisconsin had no plans participating in 2019.
CMS has also determined that MA Plans can offer targeted cost-sharing and supplemental benefits for specific enrollee populations based on health status or disease state in a manner that ensures that similarly situated individuals are treated uniformly. This flexibility helps MA Plans better manage health care services.
For more information Uniformity Flexibility information, visit CMS.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate-announcement-and-call-letter.
Oct 2019

14. Special Supplemental Benefits for the Chronically Ill (SSBCI)
Beginning 2020 MA plans can offer Special Supplemental Benefits for the Chronically Ill for certain chronically ill enrollees.
MA plans can choose to only offer these benefits for one or more specific chronic condition
Reduced cost sharing for specific benefits (e.g., lower copay for specialist or acupuncture)
Standard supplemental benefits offered only to the chronically ill enrollees (e.g., therapeutic massage)
Non-health related supplemental benefits (e.g., transportation for non-medical needs, food and produce)
Oct 2019

15. Special Supplemental Benefits for the Chronically Ill (SSBCI) (cont.)
New laws define a chronically ill enrollee as an individual who:
Has one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee;
Has a high risk of hospitalization or other adverse health outcomes; and
Requires intensive care coordination
Listing for the Chronic Conditions same as for C-SNPs
MA plans may offer a benefit (even if not primarily health related) to a chronically ill enrollee if it has a reasonable expectation of improving or maintaining their health or overall function
Oct 2019

16. Special Supplemental Benefits for the Chronically Ill (SSBCI) (cont.)
“Non-primarily health related” item or service examples that may meet the criteria if the statue requirements are met:
Home-delivered meals
Non-medical Transportation
Pest control
Indoor air quality equipment
Social needs benefits
Complementary therapies
Services supporting self- direction
Structural home modifications
General supports for living
Oct 2019

17. Part B Drugs and Step Therapy
MA plans may use step therapy for Part B drugs as a recognized utilization management tool and must disclose that Part B drugs may be subject to step therapy requirements in the plan’s Annual Notice of Change and Evidence of Coverage documents
MA plans must cover all medically necessary Part B drugs;
Beneficiaries can request a coverage decision (“organization determination”) if they need direct access to a drug that would otherwise only be available after trying an alternative drug
Shorter adjudication timeframes for organization determinations and appeals: 72 hours for standard requests, 24 hours for expedited requests
Step therapy requirements only apply to new starts of medication (not taken within the past 365 days) and must be reviewed and approved by the plan’s pharmacy and therapeutics committee
The beneficiary can appeal the plan’s decision
Oct 2019

18. NEW 2020 Non-Opiod Pain Management Extra Benefits
CMS encourages MA Plans to consider extra benefits that address medically-approved non-opiod pain management and complementary and integrative treatments.
Peer Support Services to facilitate recovery and assist in navigating health care resources as part of pain management treatment.
Psychosocial services/cognitive behavioral therapy can be included in counseling services
Non-Medicare covered chiropractic services
Acupuncture
Therapeutic massage
Oct 2019

19. Medicare Supplements (Medigap) Updates, Cost Policies, Suitability
Presenter: Vicki Buchholz
Board on Aging & Long Term Care
Medigap Helpline Services
October 2019

20. 2020 Medigap Changes Federal Law (MACRA)
MACRA enacted in 2015 (effective 2020)
Medicare Access and CHIP Reauthorization Act
Prohibited sale of benefit for Medicare Part B deductible to newly eligible for Medicare Part A on or after 1/1/20
NAIC (National Association for Insurance Commissioners) adopted changes to the NAIC Model Medigap Regulation
Subsequently incorporated into federal law
States must enact changes to continue authority to regulate Medigap insurance
Oct 2019

21. Beginning January 1, 2020 Anyone “newly eligible” for Medicare Part A
Can’t be sold or issued any benefit for Medicare Part B deductible
Part B Deductible Rider, High-Deductible, Cost-sharing policies
Needs “Skin in the Game”
“Newly eligible” means:
65th birthday occurred on or after 1/1/20, or
Deemed eligible for Part A
Due to disability or ESRD effective on or after January 1, 2020
Date of eligibility for Part A by age or disability determines which Medigap policies a beneficiary can buy in 2020
Oct 2019

22. Part A Entitlement Eligible for Part A before January 1, 2020
By age (65), disability, or ESRD
Even if didn’t apply for Medicare at the time
Even if didn’t sign up for Part B
Can still buy Part B Deductible Rider/coverage after January 1, 2020
Note: Effective date of Medicare A or B shown on Medicare card may not be date of entitlement
Delayed or retroactive enrollment
Drivers license or other legal source includes birthdate
Effective date of Medicare Part A may not be the date of an individual’s 65th birthday or the date of eligibility. There can be a time lag between the actual date of eligibility and the effective date of coverage.
Oct 2019

23. Medigap Policies Innovative Benefits
Option as part of original standardization of Medigap policies
Congressional intent:
State’s can experiment to develop future modification of standard benefits
Managed care and cost control features
INS 3.39 (17) New or Innovative Benefits.  An issuer may offer policies or certificates with new or innovative benefits .... The new or innovative benefits may include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available and are cost-effective. New or innovative benefits may not include an outpatient prescription drug benefit. New or innovative benefits may not be used to change or reduce benefits, including a change of any cost-sharing provision.
Oct 2019

24. Medigap Policies Innovative Benefits (cont.)
Innovative benefits can’t:
Be a vendor discount or discounted cost
“Benefits such as discounts for eyeglasses or frames, discounts for hearing aids, membership in health clubs, or other types of ancillary services or programs should not be considered new or innovative benefits.” (NAIC Compliance Manual)
Must show separate premium cost
Extra benefits without a premium are not innovative benefits
Nurse line, Silver Sneakers, etc.
Oct 2019

25. Medigap Policies Innovative Benefits (cont.)
Examples:
Dental, vision, hearing benefits (filed as innovative benefit)
Disappearing high-deductible Policy
Converts to full coverage policy after 3 years with same premium (filed as innovative benefit)
Part A deductible waiver
$100 premium deduction for use of preferred hospital waives Part A deductible (filing status unknown)
Oct 2019

26. Medigap Cost Policies
Another type of Medicare health plan which provides health care coverage
Still part of Medicare
Some provide Part A and Part B coverage
Some provide only Part B coverage (none in Wisconsin)
Some provide Medicare prescription drug coverage (Part D)
Share some of the same rules/regulations as MA Plans
Each type has special rules and exceptions
Oct 2019

27. Medigap Cost Policies (cont.)
Defined in Section 1876 of the Social Security Act, and Title 42, Part 417 of the Code of Federal Regulations
May offer Part D or non-qualified prescription coverage but not both
Available in limited areas
No new Cost Plans accepted by the Centers for Medicare & Medicaid Services (CMS)
Ins. 3.39(7)(a) A Medicare cost policy or certificate issued by an issuer that has a cost contract with CMS for Medicare benefits shall meet the standards and requirements of sub. (4) and shall contain all of the following required coverages, to be referred to as “Basic Medicare cost coverage" for a policy or certificate issued after January 1, 2005.
Oct 2019

28. Medigap Cost Policies (cont.)
People with Medicare enrolled in a Cost Plans
Aren’t restricted to the Health Maintenance Organization (HMO) network to get covered Medicare Part A and Part B services
May use non-HMO plan sources and are reimbursed separately by Original Medicare
Don’t have to take the Cost Plan’s Part D or non-qualified prescription drug coverage, and can enroll in the Part D Plan of their choice
Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created a competition clause which banned Medicare cost plans from operating in areas where they faced substantial competition from MA Plans. Implementation was delayed, but MACRA 2015 required the competition to be implemented as of 2019.
Oct 2019

29. Medigap Cost Policies (cont.)
The competition requirements provide that CMS non-renew cost plans beginning contract year (CY) 2016 in service areas where two or more competing local or regional Medicare Advantage (MA) coordinated care plans meet minimum enrollment requirements over the course of the entire prior contract year.
Implementation has affected plans non-renewed at the end of CY 2016.
MACRA :
delays the non-renewal requirement for cost plans affected by the competition requirements by two years to CY 2019 and revises how enrollment of competing MA plans is calculated for the purpose of meeting the competition requirements;
permits cost plans to transition to MA by CY 2019; and
allows organizations to deem their cost enrollees into successor affiliated MA plans meeting specific conditions.
Oct 2019

30. How to choose: Medicare Advantage vs. Medigap?
Steps in Understanding which option to select:
Differences between how a Medigap policy covers vs a Medicare Advantage plan. (ie. Medigap = premium with no copays vs. Advantage = lower premium with copay Max Out-Of-Pocket)
Select the “type” of coverage wanted.
Compare premium/copay costs; Choice vs Network options
Suitability Issues: Cost risks, health concerns, enrollment/purchase eligibility
Purchase the Medigap Policy or Enroll into the Medicare Advantage plan
Oct 2019

31. Medicare Beneficiaries in Wisconsin
Beneficiary and Family Centered Quality Improvement Organization (BFCC-QIO)
Livanta replaces KEPRO. Their website is
Medicare Beneficiaries in Wisconsin
Medicare Helpline: ; (TTY)
Have a Quality of Health Care Complaint?
Are You Being Discharged Too Soon?
You have rights under Medicare!
Provide the following when calling:
Medicare card & number
Date of birth
Address and phone number
Dates of service
Provider contact info
Monday - Friday: 9:00 a.m. - 5:00 p.m.
24 hour voic service is available
Translation Available
Oct 2019

32. We look forward to hearing from you!
Call: (Medigap Helpline)
Call: (Prescription Helpline serving 60 and over)
Write: Board on Aging & Long Term Care
1402 Pankratz St Suite 111
Madison, WI
Website:
BOALTC 9/2019