FEATURE
SPECIAL NEEDS REQUIRES SPECIAL COVERAGE Tom James , MD
Edgar was having trouble paying for his health care . He knew he needed medical care but just could not afford his medicines or the copayments needed to continue to see his specialists . Edgar is a 48-year-old man living in the LatinX community of East Los Angeles . He was diagnosed with AIDS some five years ago . With his medications , he is keeping his viral load low ; but because he has to skip pills when he cannot afford them , he has never gotten to non-detectable levels . Through the AIDS Healthcare Foundation , he found that he was eligible for Medicare Disability , and thus could enroll in a traditional Medicare plan , a Medicare Advantage plan or a Special Needs Plan . In his location , there is a “ Chronic Condition Special Needs Plan ,” commonly termed a C-SNP , that is specifically geared to people who are HIV positive or have AIDS . By joining PHP Health Plan ( formerly called Positive Healthcare Plan ), he was one of only 700 members of this unique C-SNP . After enrolling , Edgar gained access to a Spanish-speaking case manager who called him within 30 days of his enrollment , found out what antiviral drugs he is supposed to take , and helped him with reduced copayments at pharmacies in his area . His case manager has access to infectious disease physicians in the LA area who work with the AIDS Healthcare Foundation and particularly with individuals who are lost in the health care system .
C-SNP plans are part of a group of Medicare-based health plans that target people with specific health care issues ( see box to the right ). Most C-SNP plans are integrated into larger Medicare Advantage health plans , but some , like PHP in Los Angeles , focus on single diseases . VillageHealth , a national kidney disease consulting firm , has established a C-SNP plan in the Riverside , California region for people with End Stage Renal Disease ( ESRD ). The premise is that these conditions are so costly to Medicare , that CMS would prefer to have private organizations go at financial risk to care for these patients . To keep health care services low , C-SNP health plans employ more case managers than do traditional Medicare Advantage plans . In health plans dedicated to a single disease , the case managers make an initial assessment and based upon the person ’ s needs may call as frequently as daily for a while or no less often than every other month . These are not social calls , although relationships are established . These calls check on the individual ’ s
Chronic Condition Special Needs Plans — based upon " severe or disabling chronic conditions ":
• Chronic alcohol and other drug dependence
• Autoimmune disorders
• Cancer ( excluding pre-cancer conditions )
• Cardiovascular disorders
• Chronic heart failure
• Dementia
• Diabetes mellitus
• End-stage liver disease
• End-Stage Renal Disease ( ESRD ) requiring any mode of dialysis
• Severe hematologic disorders
• HIV / AIDS
• Chronic lung disorders
• Chronic and disabling mental health conditions
• Neurologic disorders
• Stroke CMS : Your Guide to Medicare Special Needs Plans
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