Special Needs Plans SNP

1. Special Needs Plans (SNP)

2. Overview MA-PD Puerto Rico Landscape SNP Breakdown in Puerto Rico The Affordable Care Act and SNPs Dual SNP Contracting 2

3. MA-PD Puerto Rico Landscape 57 total Plan Benefit Package offerings in Puerto Rico including: 21 MA-PDs (non-SNPs) 17 PDPs (drug plans) 13 SNPs (all types) 6 MA only plans 3

4. Puerto Rico SNP Breakdown 4

5. 2011 Puerto Rico SNP Type Breakdown 5

6. The Affordable Care Act and SNPs Overview of SNP Specific Provisions: Extension of SNP Authority State Medicaid Contract Requirements Fully Integrated Dual Eligible SNPs Frailty Adjustment Payments C-SNP Risk Score Methodology NCQA Approval 6

7. Extension of SNP Authority § 3205 of the Affordable Care Act Extends the authority for SNPs to restrict enrollment to special needs individuals Permits SNPs to continue to limit enrollment to special needs individuals through 2013 Exception: DE-SNPs without State Medicaid contracts only through 2012 7

8. State Medicaid Contract Requirements for D-SNPs Section 164 of MIPPA required that new and expanding D-SNPs contract with the State Medicaid Agencies in the jurisdictions in which they operate. Under MIPPA, existing, non-expanding D-SNPs were authorized to operate without a contract through the end of 2010. Section 3205 of the Affordable Care Act extended the provision in section 164 of MIPPA such that: Certain SNPs may now operate without a contract through December 31, 2012; D-SNPs that were new or expanded after MIPPA must have a contract with the State Medicaid Agencies in the States in which their plans operate; and All D-SNPs will need contracts for CY 2013. 8

9. 8 Minimum State Medicaid Contract Elements at 42 CFR 422.107 1. MAO’s responsibilities, including financial, to provide/arrange for Medicaid benefits 2. Category(ies) of eligibility covered 3. Medicaid benefits covered 4. Cost sharing protections 5. Medicare/Medicaid provider participation 6. Enrollee eligibility verification process 7. Service area 8. Contracting period 9

10. Definition of Fully Integrated Dual Eligible SNPs Section 3205 of the Affordable Care Act defines for the first time Fully Integrated Dual Eligible SNPs (FIDE-SNPs) – This is not applicable to the Medicare Platino structure Under CMS’ definition, a FIDE-SNP: Enrolls special needs individuals entitled to Medicaid; Provides dually-eligible beneficiaries Medicare and Medicaid benefits under a single MCO; Has a capitated contract with the State Medicaid Agency for primary, acute, and long term care; Coordinates care though an aligned care management and specialty networks; and Coordinates & Integrates Member Materials. 10

11. Frailty Payment for FIDE-SNPs § 3205 of the Affordable Care Act; 42 CFR § 422.308 Allows for the Program of All Inclusive Care for the Elderly(PACE) frailty payment to be applied to SNPs that: (Not Applicable for PR) Meet FIDE-SNP requirements Have similar average levels of frailty to PACE organizations This methodology was specified in the Advance Notice & Rate Announcement 11

12. Improved Risk Scores to Reflect C-SNPEnrollees’ Chronic Health Conditions § 3205 of the Affordable Care Act; 42 CFR § 422.308 Effective 2011, revised risk adjustment methodology for C-SNPs to account for known underlying risk profile and chronic health status, including: Higher medical and care coordination costs associated with frailty; multiple co morbidities, chronic conditions; and individuals with diagnosed mental illness Higher costs associated with high concentrations of these conditions This revised risk score is to be used instead of the default MA score 12

13. National Committee for Quality Assurance (NCQA) Approval § 3205 of the Affordable Care Act; 42 CFR § 422.4; 42 CFR § 422.101; 42 CFR § 422.152 Effective January 1, 2012 all SNPs must be approved by the NCQA All new and existing SNPs submitted their Quality Improvement (QI)Program description and Models of Care (MOC) as part of the application process to operate in 2012 13

14. NCQA Approval (Continued) CMS implemented a 1 – 3 year approval based on SNPs’ scores: Higher scores would be granted a longer approval period Guidance on scoring issued in an HPMS memo entitled “Special Needs Plan Approval Process Scoring Criteria for Contract Year 2012” dated April 5, 2011 14

15. NCQA Approval (Continued) The specific time periods for approvals are as follows: Plans that receive a score of 85 percent or higher are granted SNP approval for 3 years Plans that receive a score of 75 percent to 84 percent will be granted SNP approval for 2 years Plans that receive a score of 70 percent to 74 percent will be granted SNP approval for 1 year 15

16. Medicare-Medicaid Coordination Office The Affordable Care Act established a new office– the Medicare-Medicaid Coordination Office (MMCO) - to more effectively integrate benefits under Medicare and Medicaid, and to improve Federal and State coordination for dual eligible MMCO just announced they awarded demonstration design contracts to 15 states for 1 million dollars each to design state models to integrate care for dual eligible 16

17. Dual SNP Contracting

18. Dual SNP Contracting Timeline For MA contract year 2012, all new and expanding MAOs offering dual-eligible SNPs must have executed contracts with the State Medicaid agency covering the 2012 MA contracting period MAOs with State Medicaid agency contracts covering Contract Year 2012 must submit a copy of the completed State Medicaid agency contract as part of the 2012 MA Application’s SNP Proposal by July 1, 2011 HPMS memo on the 2012 contracting requirements forthcoming 18

19. Dual SNP Contracting Timeline CMS must receive the executed D-SNP State Medicaid agency contract by July 1, 2011 CMS is currently reviewing the contract submission timeframe for future application years so it aligns with both state and federal contracting cycles 19

20. Questions? 20