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Under the Medicare Modernization Act of 2003 (MMA), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. Special needs plans (SNPs) were allowed to target enrollment to one or more types of special needs individuals identified by Congress as: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions. Congress has since passed additional legislation affecting SNPs. For example, MMA Congressional SNP authority was first set to expire in December 2008. The "Medicare, Medicaid, and SCHIP extension Act of 2007" extended the SNP program from December 31, 2008 to December 31, 2009, but put in place a moratorium on the designation of new SNPs after January 1, 2008. Most recently, the "Medicare Improvements for Patients and Providers Act of 2008" (MIPPA), lifted the moratorium and extended the SNP program through December 31, 2010. The MIPPA extension, however, placed several new requirements on SNPs which are further explained in guidance on this web-page. Final SNP Guidance is in revision. The MIPPA statute required CMS to convene a panel of clinical advisers to identify the chronic conditions that met the MIPPA-clarified definition of "severe or disabling." CMS solicited public comments on the identification of SNP-specific chronic conditions through an Open Door Forum on September 10, 2008, and received 87 written comments through an electronic mailbox maintained from September 10 through October 1, 2008. The six Panelists included five physicians and a clinical pharmacist from three Federal agencies: the Agency for Healthcare Research and Quality, the Center for Disease Control and Prevention, and CMS. During their deliberations, the Panelists reviewed public comments, considered chronic conditions currently targeted by existing chronic condition SNPs, and applied their considerable experience in chronic disease management to derive recommendations for the Secretary. The Panel concluded its mission on October 16, 2008, and submitted fifteen (15) SNP-specific chronic conditions that met the MIPPA definition of severe or disabling to the Secretary. The fifteen SNP-specific chronic conditions approved for 2010 are: 1) Chronic alcohol and other drug dependence; 2) certain auto-immune disorders; 3) cancer (excluding pre-cancer conditions; 4) certain cardiovascular disorders; 5) chronic heart failure; 6) dementia; 7) diabetes mellitus; 8) end-stage liver disease; 9) end-stage renal disease requiring dialysis; 10) certain hematologic disorders; 11) HIV/AIDS; 12) certain chronic lung disorders; 13) certain mental health disorders; 14) certain neurologic disorders; and 15) stroke. All readers are cautioned that the fifteen SNP-specific chronic conditions have limited utility as a Medicare Advantage health plan product, and should not be generalized for any other purpose. Special Needs Plans Assessment Program Overview Background
Special Needs Plans (SNPs) were created by Congress in the Medicare Modernization Act (MMA) of 2003 as a new type of Medicare managed care plan focused on certain vulnerable groups of Medicare beneficiaries: the institutionalized, dual-eligibles and beneficiaries with severe or disabling chronic conditions. These beneficiaries are typically older, with multiple
comorbid conditions, and thus are more challenging and costly to treat. SNPs offer the opportunity to improve care for Medicare beneficiaries with special needs, primarily through improved coordination and continuity of care. Dual-eligible SNPs also offer the opportunity of enhanced benefits by combining those available through Medicare and Medicaid. SNPs can focus on monitoring health status, managing chronic diseases, avoiding inappropriate hospitalizations and helping beneficiaries move from high risk to lower risk on the care continuum. Specific legislative and regulatory provisions allow SNPs to focus on specific subsets of the Medicare population with the intent to improve care and control costs for these beneficiaries. Consistent, comparable measures that reflect the service delivery and outcomes important to these populations and that promote quality improvement and maturation of SNP products are necessary. In early 2008, the Centers for Medicare & Medicaid Services (CMS) contracted with the National Committee for Quality Assurance (NCQA) to develop a strategy to evaluate the quality of care provided by SNPs. This strategy relies on a phased approach, beginning with defining and assessing desirable structural characteristics and followed by assessing processes and, eventually, outcomes. The evaluation approach includes two types of assessment. • HEDIS measures
• Measures that evaluate structure and process requirements through submission of documentation (Structure & Process measures) CMS and NCQA are now publishing the second phase of reporting requirements. Phased Approach
The first phase of this effort focused on core SNP requirements—those that apply to all SNPs, regardless of type (i.e., dual eligible, chronic care, institutional)—using existing measures. The focus of the second and third phases is on measures that address the special needs of SNP populations and on more mature quality improvement efforts. Phase II includes two additional HEDIS measures, three new Structure & Process measures and two additional elements for the existing Structure & Process measures. HEDIS Measures
Specifications are contained in HEDIS 2009, Volume 2: Technical Specifications.
• Colorectal Cancer Screening (SNP benefit packages under PPO contracts do not have to report this measure because it relies on medical record review.)
• Glaucoma Screening in Older Adults
• Use of Spirometry Testing in the Assessment and Diagnosis of COPD
• Pharmacotherapy Management of COPD Exacerbation
• Controlling High Blood Pressure (SNP benefit packages under PPO contracts do not have to report this measure because it relies on medical record review.)
• Persistence of Beta-Blocker Treatment After a Heart Attack
• Osteoporosis Management in Older Women Who Had a Fracture
• Antidepressant Medication Management
• Follow-Up After Hospitalization for Mental Illness
• Annual Monitoring for Patients on Persistent Medications
• Potentially Harmful Drug-Disease Interactions in the Elderly
• Use of High Risk Medication in the Elderly
• Board Certification
• Care for Older Adults (Phase II measure, required for the first time in 2009.)
• Medication Reconciliation Post Discharge (Phase II measure, required for the first time in 2009.) Structure & Process Measures
• SNP 1: Complex Case Management
• SNP 2: Improving Member Satisfaction
• SNP 3: Clinical Quality Improvements
• SNP 4: Care Transitions (Phase II measure, required for the first time in 2009.)
• SNP 5: Institutional SNP Relationship With Facility (Phase II measure, required for the first time in 2009.)
• SNP 6: Coordination of Medicare and Medicaid Benefits (Phase II measure, required for the first time in 2009.) NCQA developed these measures under the direction of CMS and with guidance from NCQA's Geriatric Measurement Advisory Panel (GMAP). The development process included interviews with plans and stakeholders; field-tests; Public Comment; and oversight by the GMAP, which includes clinical, consumer, plan and purchaser representatives. Reporting Requirements
In 2009 NCQA will collect performance information on both Phase I and Phase II Structure & Process measures. SNP benefit packages that reported in 2008 will be required to submit the new elements in SNP 2 and 3 (Elements 2c and 3b), and all of SNP 4–6. SNP benefit packages reporting for the first time in 2009 will submit all measures except SNP 2C and 3B. Performance information for the Structure & Process measures will be collected via NCQA's Interactive Survey System (ISS). All SNPS must report all required HEDIS measures.
Page Last Modified: 03/27/2009 11:05:03 AM
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