medical needs such as medication and follow up visits but also deal with the Social Determinants of Health ( SDoH ). Issues such as transportation , access to food and home care services are generally not dealt with in medical offices but have a great impact upon compliance and better health .
For Edgar , the case manager ensured that his antivirals and other medications were being addressed . Patients living with chronic HIV tend to have cardiovascular complications at earlier ages than their non-infected counterparts . Cardiomyopathy , pericardial effusions , lipodystrophy and other cardiovascular complications are more prevalent among people with chronic HIV . Because of this higher prevalence associated with chronic treated HIV , such patients need to be screened for glucose and lipid disorders on at least an annual basis . C-SNP plans such as PHP may include high levels of participation in annual screening for lipid disorders or diabetes in their quality programs . This both satisfies some of the requirements of CMS but also is particularly relevant to the population in their health plan . PHP is restricted to people who meet Medicare criteria for participation and who have a positive HIV test .
C-SNP plans are funded through premiums and Medicare payments . The latter are predicated upon the degree of risk . With all Medicare Advantage plans including C-SNP , the anticipated cost of care for any individual in the plan is calculated off of the Health Risk Appraisal ( HRA ). While HRAs are touted as providing the primary care physician a tool for focusing on risk , it also has actuarial value to CMS anticipating the cost of care for a population . The conditions found in the list of Chronic Conditions for Special Needs Plans are large populations with higher costs than others . When an insurer or other organization seeks to provide the care for people on Medicare with one of these conditions , they are banking on their ability to provide Medicare mandated services at a cost less than that Medicare would have experienced . If it does , then that health plan can make a profit : but only at its own risk , as it must cover the costs of medically necessary services regardless . It does so by managing care i . e ., keeping in very close touch with its members to ensure that they do follow up with their appointments and only use the hospital ER and inpatient care when ambulatory services would not be appropriate . Patients with chronic conditions may see multiple physicians in multiple health systems . A case manager working with the lead physician can help the member stay focused on a more integrated health care experience .
There are other Special Needs Plans that were established under CMS , including one for institutionalized Medicare recipients , the I-SNP or Institutional Special Needs Plans . These are restricted to people enrolled in Medicare Advantage who have been , or are expected to be for more than 90 days , in a long-term care skilled nursing facility or a long-term intermediate care facility , including those for individuals with intellectual disabilities or psychiatric needs . There is a government assessment to ascertain whether the institution would qualify . On a national basis , Optum accepts the
Special Needs Plans
Dual eligible Special Needs Plans ( D-SNP )
Institutional Special Needs Plans ( I-SNP )
Chronic Condition Special Needs Plans ( C-SNP )
FEATURE
Must be eligible for Medicaid and for Medicare
Must be in a long-term nursing or behavioral health facility for 90 days or more
Must be Medicare eligible and have one of 15 chronic conditions
risk and coordinates the care for some 70,000 members in some 1,800 nursing facilities . On a regional basis , American Health Plans , based in Tennessee , contracts with nursing facilities to make sure that they provide the services and communicate with the case management team of American Health Plans .
The largest of the Special Needs Plans are for those individuals who are both Medicare and Medicaid eligible . They began operating in 2006 as a demonstration project and was made permanent in the Bipartisan Budget Act of 2018 ( P . L . 115-123 ). As of last year , D-SNP plans , or Dual Eligible Special Needs Plans , were operating in 43 states with 3 million dual eligible members . In Kentucky and a few other states , the Medicaid and the Medicare Advantage components are administered by a single insurer . This is called a Fully Integrated Dual Eligible Special Needs Plan ( FIDE SNP ). For physician practices , this is better than having the dual eligible person covered under one Medicaid plan and a separate Medicare Advantage plan . However , because Medicaid is considered payer of last resort , then for a person in a D-SNP plan , the claim is first passed through Medicare Advantage claims algorithms and then on to Medicaid . When both elements — Medicaid and Medicare — are in the same insurer , the movement between Medicare first then to Medicaid claims is seamless . When there are two separate organizations , it becomes cumbersome and difficult for the treating physician to track the progress .
All SNP plans are required under section 1859 ( f )( 7 ) of the Social Security Act to have a Model of Care ( MOC ) that is approved by the National Committee for Quality Assurance ( NCQA ). Medicare put this requirement in to balance the financial concepts of risk with the need for quality care services . By using a non-governmental agency , NCQA , to approve the MOC of each SNP , Medicare is striving to achieve balance .
The efforts of Medicare to improve quality of care and create efficiencies focuses first on the health plans with the hope that the health plans work closely with those doctors , hospitals and other providers to reduce barriers while monitoring for less efficient use of health care resources . The constellation of plans can be confusing . Understanding the major health plans , and developing working relationships , are both key .
Dr . James is the Interim Chief Medical Officer , Passport Health Plan by Molina Healthcare .
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