Medicare Special Needs Plans: Lessons from Dual-Eligible Demonstrations for CMS, States, Health Plans, and Providers Final rept

摘要

This study reviews the experiences of eleven contracting programs that pool Medicare and Medicaid funding to create integrated systems of care for beneficiaries eligible for both programs (dual eligible beneficiaries). Spons ored by the Centers for Medicare and Medicaid Services (CMS) in partnership three states (Massachusetts. Minnesota, and Wisconsin), these demonstration contractors operate under a Medicare payment waiver and a range of Medicaid waiver authorities. Section 231 of the 2003 Medicare Modernization Act (MMA) created the opportunity for Medicare Advantage health plans to develop Special Needs Plans (SNPs) that focus enrollment and services on Medicare beneficiaries who reside in nursing facilities, who are dual eligible beneficiaries, or who have severe and disabling chronic conditions. The MMA allowed changes in enrollment targeting, but it did not direct CMS to specify requirements for other 'special' things that SNPs might do or provide (e.g., benefits, care management, coordination with Medicaid). This flexibility has the potential to stimulate health plans, providers, and states to innovate and demonstrate models to inform future policy for SNPs. These 11 demonstration contractors all achieved MA SNP approval beginning in 2006, with Medicare waiver provisions continuing through 2007. The demonstration experience is valuable to other SNPs, states, and CMS as they think about how the SNP provisions can best serve special needs populations. The components of the models tested in the demonstration include case-mix adjusted payment, long-term care benefits for both community and institutional settings, and methods to coordinate clinical care 5 across acute care and chronic care settings. Information on enrollees, utilization, finance, service delivery, and marketing should be valuable to health plans. Information on the three approaches to integrated models, including targeting, benefits, and payment approaches should be of special interest to states. The contractors' experience as MA SNPs should help CMS shape regulations for the Medicare bidding processes, appropriate clinical care (including pharmacy coverage), ensuring comprehensive services, and marketing practices.