Dual Eligible Special Needs Plans (D-SNPs)
Dual Eligible Special Needs Plans (D-SNPs)Model of Care training & AttestationRequirement
Proprietary and confidential;Not for further distributionwithout Aetna approvalProprietaryJuly 21020
Our missionOur Special Needs Plan(SNP) program is designedto optimize the health andwell-being of our aging,vulnerable and chronicallyill members. 2020 Aetna Inc.Proprietary2
Our objectives Explain Dual Eligible Special Needs Plans (D-SNPs) Describe what D-SNPs offer Describe which dually eligible individuals qualify for theseplans Describe our Model of Care and care plan management programs Describe how Medicare and Medicaid benefits are coordinated under the plans Expand on the enhanced benefits of D-SNPs Complete your D-SNP Model of Care Training Attestation to receive credit Explain how to get answers to your questions 2020 Aetna Inc.Proprietary3
CMS requirementsThe Centers for Medicare & Medicaid Services (CMS) requires all contracted medical providers andstaff receive basic training about the Special Needs Plans (SNPs) Model of Care. This training andcompletion of an attestation are required for new providers and annually thereafter.The SNPs Model of Care is the plan for delivering coordinated care and care management to specialneeds members.This course will describe how Aetna and their contracted providers can work together tosuccessfully deliver the SNPs Model of Care. 2020 Aetna Inc.Proprietary4
Aetna is emerging as anindustry leader in servingdual populations by: Developing best-in-classoperating and clinicalmodels Collaborating withmembers, providers andcommunityorganizations Pursuing quality solutionsthat address the fullcontinuum of ourmembers’ health careand social determinantneedsProprietary 20 Aetna Inc.5
Changing DSNP regulatory environment20182021All SNPs madepermanentEnhanced Coordinated DSNP ModelBalanced Budget Act DSNP is responsible to coordinate thedelivery of Medicare and Medicaidservices States define process for DSNPs tonotify the State when “high-risk” full dualis admitted to hospital or SNFcoordination2020 NewrequirementsNew requirements for 2020 onassistance with Medicaid services andsupporting appeals process2021New minimumintegrationrequirementsNo further enrollment allowed if not incompliance. Individual states determineapproach to integration States afforded flexibility; multipleoptions States may link DSNP contracts toMedicaid MCOs or require bids 2020 Aetna Inc.ProprietaryLimitedIntegrationHighly Integrated DSNP (HIDE SNP) Single parent organization offers bothDSNP and Medicaid MCO with MLTSSor behavioral health services Partially or fully aligned models; Statesmay limit to fully aligned modelMid-LevelIntegrationModified Fully Integrated DSNP (FIDE SNP) DSNP operates as a singlemanaged care organization that isresponsible for all Medicare andMedicaid covered benefitsFullIntegration6
Future State: Types of DSNPsHIDE SNPDSNP Non-IntegratedA Dual Eligible Special Needs Planthat may or may not havemembership aligned with anotherMCO. D-SNP notifies the state whena high-risk dual (determinedby state) is admitted tohospital or SNFA Highly Integrated Dual Eligible(HIDE) Special Needs Plan has asingle parent organization thatoffers both DSNP and MedicaidMCO with MLTSS or behavioralhealth servicesPartially aligned model: Non-exclusively alignedmembershipStates have flexibility in thedetermining who is includedin the data to be shared, howand where the data will besent and timeframes aroundwhen notification will occur. Exclusively aligned membership Considered an applicableintegrated plan and requireintegrated G&AMost of Aetna’s current plansare DSNP Non-Integrated FIDE SNPA Fully-Integrated Dual Eligible(FIDE) Special Needs Plan fullyintegrates care for dually eligiblebeneficiaries. FIDE operates as asingle managed care organization(entity) that is responsible for allMedicare and Medicaid coveredbenefits DSNP limited to Medicaid MCOs,No opportunity to participate ifwe were not Medicaid MCO Exclusively aligned membership Like a fully aligned HIDE, a FIDErequires integrated G&Aprocedures and denial noticeFully aligned model:Some states may limit to fullyaligned model only7 2020 Aetna Inc.Proprietary
What is a Special Needs Plan?A special needs plan (SNP) is a MedicareAdvantage (MA) coordinated care plan(CCP) specifically designed to providetargeted care and limit enrollment tospecial needs individuals. A special needsindividual could be any one of thefollowing: An institutionalized individual, A dual eligible, or An individual with a severe or disablingchronic condition, as specified by CMSA SNP may be any type of MA CCPincluding: a local or regional preferred providerorganization (i.e., LPPO or RPPO) plan a health maintenance organization(HMO) plan; or an HMO Point-of-Service (HMO-POS)plan. 2020 Aetna Inc.ProprietarySNP TypeMembership Limited to:Chronic condition SNP (CSNP)People who have specific chronic or disablingconditions Renal Disease (ESRD), HIV/AIDS,chronic heart failure, or dementia)Institutional SNP (1-SNP)People who live in certain institutions (like anursing home) or who require nursing care athomeDual Eligible SNP (DSNP)People who are eligible for both Medicareand Medicaid8
Special Needs Plans featuresMedicare SNPs feature: Enrollment limited to beneficiaries within the target SNP population Benefit plans are custom designed to meet the needs of the target population Additional special election periods throughout the year during which membersmay change their plan Three types of SNPs are designed for specific groups of members with specialhealth care needs:1.Individuals dually eligible for Medicare and Medicaid (D-SNP)2.Individuals with chronic conditions (C-SNP)3.Individuals who are institutionalized or eligible for nursing home care (ISNP) 2020 Aetna Inc.Proprietary9
Duals Special Needs Plan Operating RequirementsSpecial Needs Plans (SNP) must meet all core Medicare Advantage (Part C and Part D) requirementsand specific incremental or modified requirements Some SNP specific requirements apply to all SNPs and some to DSNPs onlyKey SNP Requirements1. MA-PD Plan, SNP, and Service Area Approval2. Part D Prescription Coverage3. Eligibility4. State Medicaid Agency Contracts (SMACs) which may include additional state specificrequirements5.Model of Care6.Enrollment7.Benefit Flexibility8.Cost Sharing9.SNP-Specific Plan Benefit Packages10. Marketing and Sales11. Member materials12. Network Directory 2020 Aetna Inc.ProprietaryNote: Medicare-Medicaid Plans (MMPs) are not DSNPs; theyare demonstration plans that operate under state-specific 3way contracts which include additional requirements andmodifications of core MA-PD operating requirements10
State Medicaid Agency Contracts (SMAC)A State Medicaid AgencyContract (SMAC) is a contractbetween the State and MCO putinto effect by the MedicareImprovement for Patient &Providers Act (MIPPA) 2008 law.Why do we need a SMAC?CMS requires all MedicareAdvantage Organizations seeking tooffer a DSNP to enter into anagreement with each state’sMedicaid Agency. 2020 Aetna Inc.ProprietaryState Payments to D-SNPs for MedicaidServicesStates may make capitated payments to DSNPs for Medicaid services, including (inorder of increasing complexity): Medicare beneficiary cost sharing Drugs excluded from Part D “Wraparound” Medicaid acute careservices (vision, dental, hearing,transportation) Other Medicaid services that overlap withMedicare (behavioral health, DME) Long-term supports and services (nursingfacility, HCBS, home health, personal careassistance)State payments may go to D-SNPs that arealigned with companion Medicaid plans, orto “stand-alone” D-SNPs that are notaffiliated with Medicaid plansOpportunities for financial and clinicalintegration are greater when plans arealigned11
Aetna D-SNP 2021 footprint 2020 Aetna Inc.Proprietary12
Who are dual eligibles?Primary coverage for dual eligibles:MedicareDualsMedicaid Medicare is always primary Medicaid is the payer of last resort andsupplements Medicare coverageHow do people become dual eligible?Enrolled inMedicarePart A and/orPart B 2020 Aetna Inc.ProprietaryReceives full Medicaidbenefits and/orassistance withMedicare premiums orcost sharing via one ofthe four “MedicareSavings Program” (MSP)categories Meet State income and asset criteria for theState’s Medicare Savings Program; and Eligible for, or enrolled in Medicare Part A; or Have full Medicaid coverage through eithermandatory coverage groups (e.g. SSI) or optionalcoverage groups such as institutionalized, homeand community based, or medically needyindividuals13
Model of Care goalsEach Special Needs Plan program must develop aModel of Care (MOC) and a Quality ImprovementPlan to evaluate its effectiveness.The MOC is a plan for delivering caremanagement and care coordination to:1.Improve quality2.Increase access3.Create affordability4.Integrate and coordinate care acrossspecialties5.Provide seamless transitions of care6.Improve use of preventive health services7.Encourage appropriate use and costeffectiveness8.Improve member health14
DSNP Care TeamDSNP Care Management Program extends beyond traditional case and diseasemanagement programs, offering personal, comprehensive support for 100 percent ofDSNP members. Integrated team-based care management model with a personal touch Balanced clinical approach that integrates medical, functional, environmental ,behavioral health and psycho-social needs through a core care management teamCare Management Team Nurse care managers Social workers Care coordinators Member advocateSupported by Pharmacists Medical director Behavioral health Other Aetna clinicalprograms & services 2020 Aetna Inc.Proprietary15
Our personalized, holistic and local caremanagement strategyEvery DSNP Member issupported by a dedicatedDSNP Care TeamRegistered nurse Comprehensive health risk assessmentSocial worker Transitional care if discharged from thehospital Assistance with accessing communityresources and support Coordination of Medicare and Medicaidbenefits, services and providers Help navigating the health care system 2020 Aetna Inc.ProprietaryOur care team Individualized and personalized careplanAssesses member’s needs andrisk levels; develops andoversees care planIdentifies and addresses socialdeterminants of healthCare coordinatorCompletes initial outreach,Health Risk Assessment andassists with benefit navigationand appointment schedulingMember advocateAssists member with Medicaidrecertification and accessingMCD benefits16
Interdisciplinary care team (ICT)The interdisciplinary care team (ICT):SNPmanagementteam Each member is managed by a care teamHomehealth Participants are based on the member’s needs Care managers will keep the team updatedwith information involving the member’scare planVendorsMember& caremanagerPrimarycareproviderSpecialists Team meets formally Smaller meetings occur, as neededFamily/caregiverPharmacistsSocialservices 2020 Aetna Inc.Proprietary17
Interdisciplinary care team’s (ICT) role Determine each member’s goals and needs Coordinate member care Identify problems and anticipate member crisis Educate members about their conditions and medications Coach members to use their individualized care plan Refer members to community resources Manage transitions–Identify problems that could cause transitions–Try to prevent unplanned transitions Coordinate Medicare and Medicaid benefits for members Identify and assist members with changes in their Medicaideligibility 2020 Aetna Inc.Proprietary18
Health risk assessmentThe health risk assessments (HRAs): Help identify members with the most urgent needs Are an important part of the member’s care coordination Contain member self-reported information Help create the member’s Individualized care plan Assess the following needs of each member:– Medical– Functional– Cognitive– Psychosocial– Mental health Are completed by phone by the care management team:– Within 90 days of enrollment– Repeated within 365 days of last HRA19 2020 Aetna Inc.Proprietary
Individualized care plan (ICP)An ICP is the mechanism for evaluating the member’scurrent health status. It is the ongoing action plan toaddress the member’s care needs in conjunction withthe ICT and member.These plans contain member-specific problems, goalsand interventions, addressing issues found during theHRA and any team interactions. An ICP is developed andmaintained for each D-SNP member using: Health risk assessment results Laboratory results, pharmacy, emergency departmentand hospital claims data Care manager interaction Interdisciplinary care team input Member preferences and personal goalsThis is a living document that changes as the memberchanges.20Proprietary
2020 Aetna Inc.Proprietary
Care coordinationIntegrate and coordinate care across specialtiesThe health plan integrates and coordinates care for D-SNP members across the care continuumthrough a central point of contact. The care manager (CM) functions as this central contact across allsettings and providers.To improve coordination of care: The PCP is the gatekeeper and responsible for identifying the needs of the beneficiary. The CM coordinates care with the member, the member’s PCP and other participants of themember’s ICT. All SNP members have a PCP and a CM.Through seamless transitions between care settings by: Notifying the member’s PCP of the transition Sharing the member’s ICP with the PCP, the hospitalist, the facility, and/or themember/caregiver (where applicable) Contacting the member prior to a planned transition to provide educational materials andanswer questions related to the upcoming transition 2020 Aetna Inc.Proprietary21
Care coordination continued Post-hospitalization transition ofcare:This is the post-hospitalization program forD-SNP members, which includes phone callsafter being discharged home from thehospital. Members receive a 3-day posthospital call and a 14-day follow-up call. Theycan get more contact as needed.During these calls, the CM: Helps the member understand dischargediagnosis and instructions Facilitates follow-up appointments Helps schedule transportation Helps with needed home health care andmedical equipment Resolves barriers to obtaining medications Educates the member on new or continuingmedical conditions 2020 Aetna Inc.Proprietary22
A Recap: Why we are uniqueEach DSNP member has a personal care team that includes a nursecase manager, social worker, pharmacist, behavioral health specialistand non-clinical support staff. The care team helps the member manage their conditions andmedications, coordinate access to benefits across Medicare andMedicaid, schedule their medical appointments and arrangetransportation The care team will also collaborate with caregivers andproviders when needed.Each DSNP member receives an individualized care plan, tailoredto their specific needs.Each DSNP member has a designated care manager assigned tothem that will walk with the member and share their journeythrough the health care continuum.Note: Other MCOs do not always designate specific care managers totheir DSNP members. 2020 Aetna Inc.Proprietary23
Additional benefits for D-SNPs may include Medication therapy management Diet and nutritional education Behavioral health services End-of-life support services Social work support Home and community-based services partnerships Non-emergency transportation Meal programs Over-the-counter allowance 2020 Aetna Inc.Proprietary24
Working with our providersProvider partners are an invaluable part of the interdisciplinary care team. Our D-SNPModel of Care offers an opportunity for us to work together for the benefit of our member,your patient, by: Enhancing communication Focusing on each individual member’s special needs Delivering care management programs to help with the patient’s medical and nonmedical needs Supporting the member’s plan of careYou can access your member’s HRA and ICP by visiting our secure provider portal: For all DSNP markets (except VA and NJ): https://aetna-prd.assurecare.com/provider/ For VA: rtal For NJ: indexSee slide 29 for instructions on how to request access to the provider portal 2020 Aetna Inc.Proprietary25
Provider role Communicate with D-SNP care managers, ICTmembers, members and caregivers Collaborate with our organization on the ICP Review and respond to patient-specificcommunication Maintain ICP in member’s medical record Participate in the ICT Remind member of the importance of the HRA,which is essential in the development of the ICP Encourage the member to work with their caremanagement team Complete MOC training upon onboarding andagain annually. Direct documents-forms/dsnps-modelof-care.pdf26
Staff roleWhat can you do to help D-SNP members? Remind members of the importance of the HRA Encourage members to work with their SNP Care Management team Encourage our PCPs and other providers to participate with themember’s ICT Remind the PCP to access the D-SNP member’s ICPs– For all DSNP markets (except VA and NJ): https://aetnaprd.assurecare.com/provider/– For portal– For NJ: ndex Remind providers and their staff to perform their MOC trainingannually– Direct link: dsnps-model-of-care.pdf 2019 Aetna Inc.Proprietary27
Complete your Attestation to receive creditEVIDENCE OF TRAINING COMPLETION REQUIREDIn accordance with the Centers for Medicare and Medicaid Services ("CMS")regulations for Managed Care Organizations and your contractual relationshipwith us, there are specific compliance regulations that must be adhered to byyou as our "first-tier entity" including this Special Needs Plan Model of Care(“SNP MOC”). Training and completion of a D-SNP Attestation confirming thistraining was completed initially within 90 days of hire/contracting and annuallythereafter.Complete the 2021 SNP MOC Attestation online at this link.See next slide for Attestation support. 2019 Aetna Inc.Proprietary28
Complete your Attestation SupportD-SNP MOC ATTESTATION COMPLETION SUPPORT If you or your authorized representative have already completed the D-SNP MOC ATTESTATION ,you may disregard this notice.If you receive an error message at the D-SNP MOC ATTESTATION link, check your browser settingsand ensure it complies with: Microsoft Windows 10 using Microsoft Edge, Internet Explorer 11, or acurrent version of Firefox, or Chrome. Microsoft Windows 8 using Internet Explorer 11 or later, or acurrent version of Firefox, or Chrome. Mac OS X v11 or later using Safari 7 or later, or a currentversion of Firefox, or Chrome.An authorized representative may complete one attestation for multiple providers, groups ororganizations if all Tax ID’s are identified with the attestation. Credit is given at the Tax ID/EIN levelonly. No other provider identifier will be accepted for credit.Once the DSNP MOC Attestation is completed, you’ll receive an email asking you to verify your emailaddress. After you verify your email you’ll receive a copy of your signed Attestation for your records.Did you not receive the “Click to Sign” option in the attestation? You must click the START buttonwhich begins on the second page, select an answer and/or respond to all drop down or form fields.If you missed answering any fields, you won’t receive the “Click to Sign” link at bottom of the page.Tax ID#(s) must be only numbers (a total of 9 digits) with no hyphens, spaces or letters: 123456789;if your Tax ID# has zeros in the beginning or end, you must add those to get to the required 9 digits.If you have any questions or need help with this requirement, please email us atDSNPMOC@aetna.com or call us at 1-800-624-0756 (TTY:711). 2029 Aetna Inc.Proprietary28
Contact usFor general MOC attestation questions please email us atDSNPMOC@aetna.comFor Care Management, email: All DSNP markets (except VA and NJ): MCRDSNP@aetna.com VA: ABH VA DSNP@Aetna.com NJ: NJ FIDE SNP CM@Aetna.comTo request access to the secure provider portal, email: All DSNP markets (except VA and NJ): MCRDSNP@aetna.com VA: Aetnabetterhealth-VAProviderRelations@aetna.com NJ: NJ FIDESNP Providers@Aetna.com30
Thank youAetna individual health benefits plans are underwritten by Aetna Health Inc. (Aetna).Aetna does not discriminate on the basis of race, color, national origin, disability, age, sex, genderidentity, sexual orientation or health status in the administration of the plan, including enrollmentand benefit determinations.Aetna is the brand name used for products and services provided by one or more of the Aetnagroup of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). 2020 Aetna Inc.31
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2020 Aetna Inc. 3 Proprietary Our objectives Explain Dual Eligible Special Needs Plans(D-SNPs) Describe what D-SNPs offer
174. 200314 MD MURSLEEN KHAN Eligible 175. 200316 SHAILENDRA CHAUDHARY Eligible 176. 200326 MINAL Eligible 177. 200328 JATIN ANAND Eligible 178. 200329 SHIPRA KUMARI Eligible 179. 200332 VIVEK SHARMA Eligible 180. 200335 RAHUL Eligible 181. 200336 MD HABIBULLAH Eligible 182. 200337 MD ZIA Eligible 183. 200338 RAVI KUMAR SUMAN Eligible
- This product is called Blue Cross Medicare Advantage Dual Care Plus (HMO SNP). Dual-Eligible: A program for those who qualify for both Medicare and Medicaid. Special Needs: An integrated care model to improve the health of our most vulnerable members. Plan: An insurance vehicle to insure coordination of benefits in a
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