MEDICARE ADVANTAGE
SERVICE AREA EXPANSION
APPLICATION
For
Coordinated Care Plans
(CCPs)
Private Fee For Service Plans
(PFFS)
and
Medical Savings Account Plans
(MSA)
Coordinated Care Plan (CCP) applicants seeking to expand the service area of their Medicare Advantage-Prescription Drug contract must timely submit both the MA SAE application and the Part D SAE application as a condition of approval. PFFS SAE applicants that currently offer Part D prescription drug benefits would need to submit both the MA SAE application as well as the Part D SAE application. PFFS SAE applicants that do not offer Part D benefits need only timely submit this MA SAE application. MSA SAE applicants cannot offer Part D benefits. MSA SAE applicants that wish to offer a product in the MSA demonstration are required to complete the Demonstration Addendum.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare and Medicaid Services (CMS)
Center for Beneficiary Choices (CBC)
Medicare Advantage Group (MAG)
PUBLIC REPORTING BURDEN: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0935. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
2008
OMB No. 0938-0935 |
CENTER FOR BENEFICIARY CHOICES MEDICARE ADVANTAGE GROUPMEDICARE ADVANTAGE SERVICE AREA EXPANSION APPLICATION |
H# (if applicable): _____
Check all that apply: Type of MEDICARE ADVANTAGE PLAN
HMO_____ HMO POS____ LOCAL PP0 ____ PFFS _____ MSA _____ PSO_______
SPECIAL NEEDS PLAN REQUESTED: NSTITUTIONAL ___ CHRONIC ___ DUAL ELIGIBLE____OTHER ___
DOES THE APPLICANT CURRENTLY OPERATE AN 1876 COST PLAN: YES ___ NO ___
PARTIAL COUNTY (422.2(1)(II) YES ___ NO ___
PLEASE CHECK ALL OF THE FOLLOWING YOU ARE REQUESTING WITH THIS APPLICATION: MA _____ MA-PD _____ or MA WITH Employer Group Waiver Plan (EGWP) ____
Product Name of each Medicare Advantage Plan(s): |
APPLICANT NAME (LEGAL ENTITY ORGANIZED AND LICENSED UNDER STATE LAW AS A RISK- BEARING ENTITY):
TRADE NAME (IF DIFFERENT)
MAILING ADDRESS:
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CEO OR EXECUTIVE DIRECTOR: NAME AND TITLE: MAILING ADDRESS: If different than above
TELEPHONE NUMBER / E-MAIL ADDRESS: FAX NUMBER: ORGANIZATION’S WEB URL: |
APPLICANT CONTACT PERSON: NAME: E-Mail:
TITLE: FAX:
ADDRESS: TELEPHONE NO: |
TAX STATUS For Profit __ Not For Profit __
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I certify that all information and statements made in this application are true, complete and current to the best of my knowledge and belief and are made in good faith.
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Signature CEO/ Executive Director Date
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NARRATIVE PART
TABLE OF CONTENTS
The table of contents for the completed application is placed after the cover sheet.
For computerized application users: Each chapter and subsection title within the Narrative part is marked for automatic generation of the table of contents on this page. That table appears below with page numbering that reflects a "blank" application. The numbers will change when you generate the table again for the completed application. Please follow the directions in the Technical Instructions to generate the table for the Narrative Part. Note that the table of contents for the Documents Part is not generated automatically, and is to be manually filled in after the table for the Narrative.
I. SUMMARY TABLE 5
II. KEY MANAGEMENT STAFF – [422.503] 6
III. SERVICE AREA – [422.2] 6
I. STATE AUTHORITY TO OPERATE – 422.400, 422.503 8
II. RISK SHARING- 422.208, 422-503 8
III. CONTRACTS FOR ADMINISTRATIVE / MANAGEMENT SERVICES [422.504] 8
IV. PRIVATE FEE-FOR-SERVICE SERVICE AREA EXPANSION: NETWORK/NON-NETWORK MODEL (422.214(A)(2) 8
V. PROVIDER CONTRACTS AND AGREEMENTS – [422.504, 422.520(b)] 9
I. MEDICARE HEALTH BENEFITS AND PROVIDERS – [422.100-422.102] 11
II. HEALTH SERVICES MANAGEMENT 12
III. MEDICARE HEALTH BENEFITS – [422.111, 422.103] 13
I. GENERAL GUIDANCE ON COMPLETING SNP PROPOSAL 15
II. REQUIREMENTS TO SUBMIT A SNP PROPOSAL -- MA AND PART D APPLICATIONS MAY ALSO BE REQUIRED 16
III. KEY DEFINITIONS 22
IV. TEMPLATE FOR COMPLETING SNP PROPOSAL 25
I. MORAL OR RELIGIOUS EXCEPTION – [422.206(b)] 58
II. MEDICARE MARKETING MATERIAL – [422.80] 58
III. ENROLLMENT AND DISENROLLMENT – [422.56, 422.62(d)] 58
I. PART D PRESCRIPTION DRUG BENEFIT 60
ORGANIZATIONAL AND CONTRACTUAL 61
II. KEY MANAGEMENT STAFF – [422.503] 6
III. SERVICE AREA – [422.2] 6
ORGANIZATIONAL AND CONTRACTUAL 8
II. RISK SHARING- 422.208, 422-503 8
III. CONTRACTS FOR ADMINISTRATIVE / MANAGEMENT SERVICES [422.504] 8
IV. PRIVATE FEE-FOR-SERVICE SERVICE AREA EXPANSION: NETWORK/NON-NETWORK MODEL (422.214(A)(2) 9
V. PROVIDER CONTRACTS AND AGREEMENTS – [422.504, 422.520(b)] 9
HEALTH SERVICES DELIVERY 11
I. MEDICARE HEALTH BENEFITS AND PROVIDERS – [422.100-422.102] 11
II. HEALTH SERVICES MANAGEMENT 12
III. MEDICARE HEALTH BENEFITS – [422.111, 422.103] 14
SOLICITATION FOR SPECIAL NEEDS PLANS PROPOSAL 15
I. GENERAL GUIDANCE ON COMPLETING SNP PROPOSAL 15
II. REQUIREMENTS TO SUBMIT A SNP PROPOSAL/MA AND PART D APPLICATIONS MAY ALSO BE REQUIRED 16
III. KEY DEFINITIONS 17
IV. TEMPLATE FOR COMPLETING SNP PROPOSAL 19
ATTACHMENT A 39
ATTACHMENT B 40
ATTACHMENT C 42
II. MEDICARE MARKETING MATERIAL – [422.80] 43
III. ENROLLMENT AND DISENROLLMENT – [422.56, 422.62(d)] 43
PART D PRESCRIPTION DRUG BENEFIT – [422.252] 45
ORGANIZATIONAL AND CONTRACTUAL 46
HEALTH SERVICES DELIVERY 46
MEDICARE 46
(See Medicare Managed Care Manual Chapter 11)
Complete the summary description table.
Complete for the requested MA service area. Complete column I for currently approved service area and column II for the requested area. |
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I – Current Service Area |
II – Service Area Expansion Requested |
Applicant's Current Enrollment as of (date): __________
Group |
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Non-Group |
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Medicaid |
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Medicare – Cost Plan |
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Medicare – Other |
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Total Enrollment |
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Date when the applicant’s operations began or are proposed to begin |
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For MSA SAE Applicant;
Provide a statement as to whether the applicant currently operates a
commercial Health Savings Account (HSA) plan or other type of commercial
tax-favored health plan or a Medicare Advantage Medical Savings Account
(MSA) plan. State the number of enrollees in each plan. Also provide a
description of the commercial and/or Medicare plan.
(Complete only if there has been changes since the initial application, last service area expansion or last monitoring visit.)
Indicate below the individuals responsible for the key management functions.
Staff Function |
Name |
Title |
Employed by |
CEO/President |
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Medical Director |
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Utilization Management |
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Marketing |
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Medicare Sales |
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Government Relations |
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Management Information Systems |
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Medicare Compliance Officer |
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Quality Director |
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NOTE: ALL THE APPLICANTS MUST ENTER ITS REQUESTED SERVICE AREA IN HPMS. NETWORK MODEL PFFS PLANS MUST COMPLETE THIS SECTION.
For your expected Medicare enrollment area, clearly describe the requested service area in terms of geographic subdivisions such as counties, cities or townships.
Provide a detailed map (with a scale) of the complete requested service area clearly showing the boundaries, main traffic arteries, and any physical barriers such as mountains or rivers. On the map:
Show the location of the applicant's contracted ambulatory and hospital providers that will serve Medicare members.
Show the mean travel time from six points on the service area boundary to the nearest contracted primary care provider and hospital site.
Place the map(s) in the Documents Section.
If applicant is proposing to offer more than one plan benefit plan with different service area or delivery system, show on the map (or maps) the geographic boundaries and the providers, as described above, referenced by each proposed benefit plan.
If less than full counties are requested, provide justification for the partial counties request. If the area is not a full county, zip codes must be annotated. (See Medicare Managed Care Manual Chapter 4)
(See Medicare Managed Care Manual Chapters 10 and 11)
The applicant must include a completed State Certification form to document that the applicant is licensed under State law or otherwise authorized to operate as a risk bearing entity that may offer health benefits in the service area for which it is requesting a MA contract. [This form is a separate file cert.doc; place a hard copy in the Documents part].
(Complete only if the risk sharing is different from your existing service area expansion or last monitoring visit.)
Legal-1 Table is a summary of insurance or other arrangements for major types of loss and liability. Complete the table to indicate the types of arrangements in effect, or to be in effect, for the proposed area when approved. [This table is a separate file; legal-1.xlsdoc. Place a hard copy in the Documents Section]. [422.503]
(Complete only if the management contracts or agreements are different from your existing service area. MSA SAE applicants should answer C and D.)
A. Include a copy of each administrative services contract and/or agreement in the documents part of the application.
B. Complete the Administrative / Management Delegated Contracting Matrix for each delegated entity and include it in the Documents Section. [This form is a separate file matrixadm.doc; place a hard copy in the Documents Section].
C. State whether the applicant meets Internal Revenue Service requirements (as a bank, insurance company or other entity as set out in Treas. Reg. Sections. 1.408-2(e)(2) through (e)(5)) and will serve as MA MSA trustee or custodian for receiving Medicare deposits to MSA plan enrollee accounts. State the name of the trustee or custodian line of business. Also, not whether the applicant has or will have a contractual relationship with outside trustees or custodians.
D. If your organization currently offers HSA plans in the commercial market or MSA plans, please describe the relationship with your banking partner. Describe the services provided by the banking partner, such as how do members access funds, how spending is tracked and applied to the deductible, how claims are processed, customer service, etc.
Is the applicant paying providers, for any category of service, the Original Medicare allowable payment rates under Medicare Part A or Part B (Check one response and follow instructions for each response)?
( ) YES. If yes, it will be a Non-Network product. Do not complete Section V. Instead, describe the ‘deeming process’ [422.214(a)(2)(i)] and how providers will be paid. Include a terms and conditions of payment that will apply.
( ) If NO. It will be a network or partial network model PFFS plan. Identify and complete the remainder of Section V for those categories of service for which the applicant will be paying less than the Medicare allowable payment rates for those categories of service or a combination of the two [422.214(a)(2)(ii)].
( ) Combination [422.214(a)(2)(iii)]
Note: For purposes of simplicity and completing this application, the term "provider" means physician, inpatient institutions and other ancillary practitioners, including DME suppliers, etc. For this entire section, applicants must demonstrate that all contractual provisions extend to the level of provider who is actually rendering the service to Medicare beneficiaries and that all levels of contracts and/or agreements meet the CMS requirements. If subcontracts do not mention which insuring organization members will be served, explain how the contracted hospital, IPA, etc., advised its subcontractors about which insuring organizations are covered by subcontractor, e.g., which MA organization memberships will be served. [422.504(i)(4)(v)].
This definition departs from other Medicare definitions of "providers" (hospitals and other inpatient institutions, plus home health services) and "suppliers" (physicians, practitioners and other non-providers).
There should be Ffull documentation of arrangements for health services in the requested service area(s) should be in place at the time that the application is submitted, and be available upon request.. Executed written agreements are considered evidence of an operational health delivery network, which is able to provide access and availability to health services for Medicare enrollees. These arrangements are typically provider contracts, but may also include employment contracts and letters of agreement. CMS will accept any legally binding written arrangements. CMS does not accept letters of intent.
Complete Legal-2 Table "Provider Arrangements" - For each proposed service area or distinctive delivery system(s) applicant should provide insert the number of provider contracts and/or agreements. Contracts and/or agreements should be executed at the time the application is submitted to CMS. [This table is a separate file legal-2.xls place a hard copy in the Documents part. Instructions for this table can be found in the MA Application Guidelinesare at the end of this chapter.]
Provide a sample copy of each category of provider contract(s) and/or agreement(s) between the applicant and its primary health care contractors (i.e., direct contract with physicians, medical group, IPA, PHO, hospitals, skilled nursing facilities, etc.) Place in the Documents part.
Complete the Provider Participation Contracts and/or Agreements matrix for each applicable primary contracted provider. [This matrix is a separate file matrix1.doc; place a hard copy in the Documents part.]
For provider contracts and agreements between medical groups, IPAs, PHOs, etc., including their subcontracting providers, provide a sample copy of each applicable subcontract in the Documents part. (Example: If the applicant contracts with an IPA, which contracts with individual physicians, then provide a sample copy of the contract and/or agreement between the IPA and physicians.)
Complete the Provider Participation Contracts and /or Agreements matrix for each applicable contracted and subcontracted providers. [This matrix is a separate file matrix.1.doc; place a hard copy in the Documents part.]
D. The signature pages from contracted and subcontracted provider (i.e., PCPs, IPAs, medical groups, PHOs or similar entities and hospitals) actual contract(s) and or agreement(s) must be available on site and upon request.
NOTE: For this entire section applicant must demonstrate that all contractual provisions extend to the level of provider who is actually rendering the service to Medicare beneficiaries and that all levels of contracts and/or agreements meet the CMS requirements. [422.505(i)(3)]
(See Medicare Managed Care Manual Chapters 4, 5, 6, and 7)
(Note: For PFFS complete only if answered NO under Organizational and Contractual section IV titled Private Fee-For- Service Expansion)
For each MA benefit plan, describe how health services will be arranged for or provided to the projected Medicare membership. Applicant should explain for each MA benefit plan if all contracted providers are available to the Medicare member on normal referral from PCP or by self- referral or if there are sub-networks (e.g. based on the member's selection of a PCP) and consequently different procedures for accessing care within the sub-networks on the member and member's PCP. Also if the Medicare product in a MA plan is a gatekeeper model, all services for which the member may self-refer should be clearly identified.
B. All applicants that will offer multiple benefit plans need to submit HSD tables as follows: separate table for each county for each plan. However, only one HSD table is needed for different plans that have the same network and service area.
(Note: Please save files as Excel and please submit all tables in hardcopy) Instructions for completing HSD tables can be located in the Guidelines document of the application
Complete HSD-1 County/Delivery System Summary of Physicians by Specialty. Complete these tables on separate file HSD.xls; place hard copies in the Documents apart.]
NOTE: If the applicant uses a sub-network or has multiple delivery systems within the county, a separate HSD 1 table should be completed for each delivery system. Each HSD 1 should be representative of the aggregate numbers of providers for the delivery system. A separate HSD 1 table should be completed for each distinct delivery system to be used within each service area.
Complete HSD-2 Table, Provider List of Physicians and Other Practitioners by County, [Complete this table in its file hsdmc1HSD.xls; place hard copies in the Document part.]
Complete HSD-2A Table, PCP/Specialist Contract Signature Page Index [Complete this table in its file HSD.xls; place a hard copy in the Documents part]
Complete HSD-3 Table, Arrangements For Medicare Required Services by County [Complete this table in its file HSD.xls; place a hard copy in the Documents part]
[Complete this table in its file hsdmc1HSD.xls; place a hard copy in the Documents part]
Complete HSD–3A Table, Ancillary/Hospital Contract Signature Page Index
Complete HSD-4 Table, Arrangements For Additional and Supplemental Benefits by County [Complete this table in its file hsdmc1HSD.xls; place a hard copy in the documents part.]
Complete HSD-5 Table, Signature Authority Grid [Complete this table in its file HSD.xls; place a hard copy in the Documents part]
C. Will the applicant use the same delivery systems for the new service area? If so, how will the applicant assure sufficient providers for projected enrollment? If not, how will services be rendered in the new area?
Availability and accessibility – [422.101(a) 422.112]
Please indicate any variances in regulatory requirements between the current service area with regard to operations and the proposed service area expansion. For example, entity will delegate medical management responsibilities to unique delivery system in expansion, while conducting medical management in-house in current service area.
Describe how the applicant will provide coverage of or arrange for all health care services (that are available to Medicare beneficiaries residing in the plan’s service areas) for their enrollees. Also describe how the applicant will provide for or arrange for additional and mandatory supplemental benefits. [422.112]
The applicant should delineate the specific health care services that are to be provided either inside or outside the requested expansion service area. [422.112]
Please address whether the applicant will use the same delivery system of facilities and providers for each requested MA plan in the expansion area. If the applicant will use identical provider arrangements for more than one MA plan, indicate such on each HSD table. If the applicant is using identical provider arrangements for more than one MA plan, indicate such on each HSD table. If not, clearly delineate variations in the networks.
Explain how the applicant ensures that the number and types of contracted facilities and providers will be sufficient to meet the needs of the projected expansion area enrollment and to cover all MA benefit plans to be offered in the expansion area. If the operation of a network or networks in the expansion area has been delegated or subcontracted, explain how the applicant will oversee the ongoing adequacy of the network.
Explain how the applicant will maintain and monitor its networks of contracted providers (i.e., PCP, specialists, hospitals, SNFs, Home health agencies, ambulatory clinics, etc.) in the expansion area(s) to ensure adequate access of covered services which will meet the needs of the population served. [422.112(a)(1)]
Describe the applicant's process for establishing PCP panels for enrollees and whether a PCP referral is needed to obtain services. If no referral is needed by the PCP then how does the applicant ensure that the enrollee receives access to medically necessary specialty care?
[422.112(a)(2)]
Explain how the applicant will arrange for specialty care by non-contracting providers when specialty providers or facilities are unavailable or inadequate to meet an enrollee’s medical needs. [422.112(a)(3)]
If the applicant proposes to offer a new MA plan with a point of service (POS) benefit complete the following.
[422.105]
Is there a mandatory supplemental or optional supplemental benefit?
What health care services will be covered under the POS benefit and how much will enrollees be charged in using the POS benefit?
Is there an out of network lifetime maximum that the applicant will apply? If so, describe.
Briefly describe how enrollees will be educated regarding the use of the POS benefit.
Describe how the applicant offering a POS through a MA plan will report enrollee utilization data at the plan level by contracted and non-contracted providers. [422.105(f)]
Only respond if different than in existing service area:
Describe and provide policies to ensure health services are provided in a culturally and competent manner to enrollees of different backgrounds. [422.112(a)(8)]
Explain the applicant’s process for assuring availability and accessibility within each new MA plan in the expansion area with reasonable promptness, and in ways that ensure continuity of care. [422.112 (b)]. Moreover, explain the patterns of care for each service area requested and specify how geo-access maps or other methods were used to assure access and availability throughout the service area.
Indicate which medically necessary services are available and accessible 24 hours a day, 7 days a week. [422.112(a)(7)(ii)] and how the enrollee will be so informed.
(Section applicable only for MSA SAE applicants. cComplete only if there haves been changes since the initial application or last monitoring visit.)
How will the applicant communicate information to enrollees on how to access health care from contracted and non-contracted providers?
Explain how the applicant will communicate to enrollees the coverage of services before the deductible is met and after the deductible is met.
Explain any differences in costs if a contracted network is used or not used.
Explain how the applicant will communicate the difference in cost if the contracted network is used or not used.
How will the applicant ensure that appropriate risk-adjustment data is collected and reported to CMS?
Under the MMA (Section 231), Congress provided an option for Medicare Advantage (MA) coordinated care plans to limit enrollment to individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dually eligible; and/or 3) beneficiaries with severe or disabling chronic conditions as recognized by the Secretary. Authority to offer a Special Need Plan (SNP) ends on January 1, 2009.
Organizations that intend to offer SNPs must provide a proposal to CMS that includes information as prompted below for each type of SNP the organization intends to offer. This solicitation for SNP proposals is divided into the following sections:
General Guidance on Completing SNP Proposal
II. Requirements to Submit a SNP Proposal -- MA and Part D Applications May Also Be Required
A. Seeking New Medicare Coordinated Care Plan (CCP) Contract that Includes SNPs
B. Adding SNPs under Existing Medicare CCP Contract – Service Area Unchanged
C. Adding SNPs under Existing CCP Contract – Service Area Changing
D. Procedure for Minimizing Duplication, Including Across Multiple MA-PD Contracts
III. Key Definitions
IV. Template for Completing SNP Proposal
A. Dual Eligible SNP Type
B. Institutional SNP Type
C. Severe or Disabling Chronic Condition SNP Type
Attachments:
A: Subsets for Dual Eligible SNPs
B: SNP Service Area Table
C: Ensuring Delivery of Institutional SNP Model of Care
D: Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries
E: Quality Measurements for Special Needs Plans
F: Crosswalks for Consolidating SNP Proposals for Multiple Contracts
G: Dialysis Facilities Table
H: Transplant Facilities Table
I: Long Term Care Facilities Table
The applicant must follow the step by step instructions in Section IV to propose the type of SNP the applicant intends to offer. Sections IV. A. B. and C. offer prompts for each SNP type. If the applicant is seeking approval for more than one type of SNP, then the template for the proposal should be completed for each of those types. The applicant’s responses should be provided within the Section IV template and within all applicable attachments. The responses to the template as well as the attachments and the documentation for the State and long term care contract should all be in a single Microsoft word document. Documents requested in the template, such as copies of contracts, forms and signature pages should be added to the end of the template Microsoft word document as attachments as text or scanned into the document as a picture or as text. The end result should be only one electronic file should be submitted to CMS for a SNP proposal, which contains all the required data and information.
A SNP proposal responding to this solicitation for the next contract cycle beginning January 1, 2008 WILL NOT be considered by CMS unless the solicitation is submitted by the deadline for MA applications. The application deadline is March 12, 2007. Late proposals, including additional requests when a certain SNP type (for example, any additional proposed dual eligible subsets), WILL NOT be accepted after the MA application deadline. Other associated MA and Part D applications must also be provided; see Section II for instructions on what other applications may be required.
If the applicant has questions about the SNP program or about completing this proposal, please send an e-mail to the following address: [email protected]. To ensure that the applicant’s question is forwarded to the appropriate CMS staff, the subject line of the e-mail must include the phrase “SNP Proposal” and must also include the applicant name and CMS contract number(s).
II. REQUIREMENTS TO SUBMIT A SNP PROPOSAL -- MA AND PART D APPLICATIONS MAY ALSO BE REQUIRED
A. Seeking New Medicare Coordinated Care Plan (CCP) Contract that Includes SNPs
Organizations that do not have a current CCP contract with CMS must complete the full Coordinated Care Plan (CCP) MA application in order to offer a Special Needs Plan (SNP). The application is posted at: http://www.cms.hhs.gov/MedicareAdvantageApps/. In addition, an applicant must offer Part D under the SNP products, and must file the appropriate Part D application. The Part D applications are posted at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/ and click on “Application Guidance.
The MA application should be submitted as described in the MA application guidelines. The Part D application should be submitted per the instructions provided in the Part D application. When the MA application includes a SNP proposal(s), the applicant must make two (2) additional paper hard copies of the MA application cover page and the SNP proposal(s) in the MA application. In addition to the hard copies, the applicant must make three (3) CD electronic copies of the complete SNP proposal(s). The applicant may submit multiple SNP proposals under a given CMS contract number on a CD. All electronic copies must be submitted as Microsoft word files. The applicant must place an external label on each CD using the label format “Hxxxx_SNP”, where Hxxxx is the CMS assigned contract number. The applicant must place the hard copies and CDs in a separate envelope labeled with the organization name and CMS assigned contract number. The separate envelope containing the SNP proposal(s) must be included as part of the applicant’s MA application submission which is mailed to the following address:
Mail two (2) paper hard copies and three (3) CDs for the SNP proposal(s) along with the MA application as instructed in the MA application to:
Center for Beneficiary Choices/MAG/DQPM
Mail Stop C4-22-04
7500 Security Blvd.
Baltimore, MD 21244
B. Adding SNPs under Existing Medicare CCP Contract – Service Area Unchanged
An applicant may propose offering a SNP type not already approved by CMS under an existing Medicare CCP contract, wherein the service area of that contract will be unchanged. A SNP proposal must be submitted in those circumstances. For example, if the applicant is seeking to offer a SNP to serve a specific subset of dual eligibles in coordination with a State Medicaid contract and that subset has not been previously approved by CMS, then a SNP proposal requesting such subset must be submitted to CMS. Similarly, if a dual eligible SNP has previously been approved and the applicant intends to offer a chronic or institutional SNP not previously approved, then a SNP proposal must be submitted to CMS for each SNP type for which prior CMS approval has not been granted. The applicant MUST complete the SNP portion of the MA application for each subset requested. The MA applications are posted at: http://www.cms.hhs.gov/MedicareAdvantageApps/.
When an applicant seeks to add a SNP to its current service area under an existing MA contract, it must also offer prescription drug coverage under Part D. If the applicant already offers Part D along with its Medicare Advantage product in the current service area, it does not need to file a new Part D application. It must maintain its prescription drug coverage by submitting a formulary and bid. If Part D coverage is not part of the applicant’s MA contract, the appropriate Part D application must be completed and submitted per the instructions provided in the Part D application by March 12, 2007. The Part D applications are posted at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/ and click on “Application Guidance.
The SNP proposal must be completed and submitted to CMS as instructed below. The applicant must submit three (3) paper hard copies of each SNP proposal, containing the cover page of the MA contract, the cover page of the CCP application and the SNP portion of the CCP application to CMS. Two (2) complete copies must be delivered to the CMS central office and one (1) complete copy must be delivered to the applicant‘s CMS regional office. In addition, the applicant must submit three (3) CD electronic copies of the complete hard copy SNP proposal to the CMS central office. All electronic copies must be submitted as Microsoft word files. The applicant must place an external label on each CD using the label format “Hxxxx_SNP”, where Hxxx is the CMS assigned contract number. The applicant must place the hard copies and CDs in an envelope labeled with the organization name and CMS assigned contract number.
Mail two (2) paper hard copies and three (3) CDs to:
Center for Beneficiary Choices/ MAG/DSP
Mail Stop C4-22-04
7500 Security Blvd.
Baltimore, MD 21244
Mail one (1) paper hard copy to the CMS Regional Office responsible for the applicant’s contract.
C. Adding SNPs under Existing CCP Contract – Service Area Changing
An applicant may expand its service area under an existing MA contract and seek to offer a SNP in the expanded service area. To do this the applicant must complete a service area expansion (SAE) application for MA contracts. The MA applications are posted at: http://www.cms.hhs.gov/MedicareAdvantageApps/. In addition, if the applicant does not currently offer prescription drug coverage in the service area to be covered under the contract number then, the applicant must also file the appropriate separate Part D application. The Part D applications are posted at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/ and click on “Application Guidance.
In addition to following the directions under the MA and Part D SAE application, if the applicant is seeking a SNP in a new service area AND intends to offer a SNP in its current service area and presently does not have CMS’ approval for the type of SNP intended for the current service area, the applicant must submit the SNP proposal within the MA SAE application. The SNP proposal should include the entire service area to be served by the SNP as instructed Section IV.
The SAE application should be submitted as described in the MA application guidelines.
When the SAE application includes a SNP proposal(s), the applicant must make two (2) additional paper hard copies of the SAE application cover page and the SNP proposal(s) in the SAE application. In addition to the hard copies, the applicant must make three (3) CD electronic copies of the complete SNP proposal(s). The applicant may submit multiple SNP proposals under a given CMS contract number on a CD. All electronic copies must be formatted as Microsoft word files. The applicant must place an external label on each CD using the label format “Hxxxx_SNP”, where Hxxxx is the CMS assigned contract number. The applicant must place the hard copies and CDs in a separate envelope labeled with the organization name and CMS assigned contract number. The separate envelope containing the SNP proposal(s) must be included as part of the applicant’s SAE application submission which is mailed to the following address:
Mail two (2) paper hard copies and three (3) CDs for the SNP proposal(s) along with the MA application to:
Center for Beneficiary Choices/MAG/DQPM
Mail Stop C4-22-04
7500 Security Blvd.
Baltimore, MD 21244
D. Procedure for Minimizing Duplication, Including Across Multiple MA-PD Contracts
There are at least three circumstances in which there could be duplicate information in the applicant’s proposal if it were required to provide an individual SNP approval request for each SNP it wishes to offer. These are listed below with instructions for how this duplication can be minimized. Only these specific instructions can be followed to minimize duplication. Any other approach will not be accepted by CMS.
1. A request is made for approval of multiple SNPs under a single contract across some combination of dual eligible, institutional and severe or disabling chronic condition SNPs.
Instruction: Each section of the template must be completed in its entirety. For multiple requests within a type of SNP follow instructions under 2. below.
2. A request is made for approval of more than one targeted population within a SNP type under the same contract. Examples include all dual, full duals only and Medicaid subset; institution and community based institutional beneficiaries in separate SNP; and different chronic diseases each in separate SNPs.
Instruction: Within Section IV. A, B, and C, follow the instructions imbedded in the template that allow certain elements not to be repeated if they are the same in other populations defined under the same Section IV. A, B, or C. To summarize, for each population, the applicant may copy the template but only provide the elements where there is a change, rather than provide complete responses for each SNP request.
3. A request is made under multiple MA-PD contracts for one or more SNPs. The applicant may follow the instructions below rather than provide multiple complete responses for every SNP request.
Instructions for Completing the SNP Solicitation for Proposals Across Multiple MA-PD Contracts
If the applicant is requesting, under multiple MA-PD contracts, a uniform SNP Model of Care for any of the three SNP types – for dual, institutional, or severe or disabling chronic condition individuals, then the applicant may submit a SNP type-specific baseline proposal to CMS and consolidate the applicant’s responses on all SNP plan requests related to that baseline SNP proposal.
For the purpose of the SNP solicitation and understanding how to consolidate responses under a SNP proposal, a “plan” is a unique combination of a targeted population and Model of Care, as defined in Section III under MA contract number. For example, as instructed in Section IV, if an organization under contract H9999 intends to offer a full dual SNP and a further subsetted dual SNP, then the applicant would be requesting two dual SNPs under H9999, and these “plans” would be labeled as follows (and as instructed in Section IV of the SNP solicitation): H9999_ A_Plan_1, and H9999_A_Plan_2, where A represents a dual eligible SNP request..
The baseline proposal must contain SNP Model of Care information common to all SNP plans of a specific type (i.e., dual, institutional, or severe or disabling chronic condition) as prompted in Section IV. In addition, the applicant must submit supplemental addendums for each requested SNP plan of the particular type (i.e., dual, institutional, or severe or disabling chronic condition) along with the baseline proposal. The addendum would contain a discussion of those elements in Section IV for which the applicant determines the complete answer deviates from the baseline proposal. For selected elements in Section IV, the applicant is required to provide complete information in the same supplemental addendum for each plan of that SNP type, regardless of whether it reflects any duplication. Finally, along with the baseline proposal the applicant must provide a table that crosswalks each contract and plan number (as numbered in Section IV) indicating with a check mark those elements in Section IV that deviate from the baseline proposal.
This consolidated response and the crosswalk must be completed separately for each SNP type (i.e., dual, institutional, or severe or disabling chronic condition). For example, if across multiple contracts the applicant requests both dual and institutional SNPs, then the applicant would provide two consolidated proposals, one for dual and one for institutional SNPs. The only alternative would be to complete a SNP proposal for each contract as Section IV directs.
The specific steps that must be followed to submit a consolidated SNP proposal across multiple contracts are:
Step 1: The baseline SNP proposal is the applicant’s description of the basic Model of Care used for multiple SNPs of a selected type (i.e., dual, institutional, or severe or disabling chronic condition). Develop the baseline SNP proposal(s). This is the document that provides all the detailed information on the SNP type and Model of Care requested by CMS in the “Solicitation for Special Needs Plan Proposal” as follows:
Dual SNP: Section IV, A.2, A.5, A.7 through A.9
Institutional SNP: Section IV, B.2, B.2.c,B.2.d, B.4, B.6.a through B.9
Chronic SNP: Section IV, C.2, C.4, C.6 through C.8
For those elements required by CMS for each SNP plan, the baseline proposal should reference “see supplemental addendum for specific SNP plan”. Those elements include number assignments for each SNP type, relationship to State Medicaid services in the event of subsets, State contracts information if other than subsets, and service area. The specific location of these elements is as follows:
Dual SNP: Section IV, A.1, A.3, A.4, A.6.
Institutional SNP: Section IV, B.1, B.3 and B.5
Chronic SNP: Section IV, C.1, C.3, C.5
Step 2: Develop a supplemental addendum for each SNP plan covered under the baseline SNP proposal. The supplemental addendum is information pertaining to the specific SNP plan. The SNP plan name should be in the following format: CMS contract number, type of SNP code (A = dual, B = institutional, and C = severe or disabling chronic condition), Plan, X (where “X” is the number of the SNP plan in the SNP proposal), with an underscore between each element (Hxxxx_X_Plan_X). An example is “H9999_A_Plan_1”. Two types of information must be provided. For the following elements modify or replace information that is different from the baseline SNP proposal:
Dual SNP: Section IV, A.2, A.5, A.7 through A.9
Institutional SNP: Section IV, B.2, B.2.c,B.2.d, B.4, B.6.a through B.9
Chronic SNP: Section IV, C.2, C.4, C.6 through C.8
For the following elements a complete answer must be provided for each
SNP plan regardless of possible duplication:
Dual SNP: Section IV, A.1, A.3, A.4, A.6.
Institutional SNP: Section IV, B.1, B.3 and B.5
Chronic SNP: Section IV, C.1, C.3, C.5
To provide this information, complete Section IV A, B or C and copy the template as many times as there are requests within a Section A, B, C. Except for required responses for each SNP plan, only elements that are different from the baseline proposal should be represented.
Step 3: Complete one crosswalk for each baseline SNP proposal (i.e., dual, institutional, or severe or disabling chronic condition), listing each contract/plan number combination associated with the baseline SNP proposal as demonstrated below. Provide the following information:
1. Applicant’s contracting name (as provided in HPMS)
2. Date submitted to CMS
3. Name of the baseline SNP proposal. The baseline name should be in the following format: CMS contract number, type of SNP code (A = dual, B = institutional, and C = severe or disabling chronic condition), Baseline, X (where “X” is the number of the baseline SNP proposal), with an underscore between each element. An example is “H9999_A_baseline_1”.
4. For each SNP plan covered by the baseline SNP proposal
a) Contract number (provided by HPMS)
b) Plan number (as required in Section IV of the SNP solicitation, for example A_Plan_2)
c) Check all elements that deviate from or provide additional information relative to the baseline SNP proposal. All checked elements must be addressed in the supplemental addendum for the specific SNP plan. CMS requires a complete response in the addendum for those elements that are pre-checked in the template crosswalks provided in Attachment F. The crosswalks must be used in the format and structure provided.
Step 4: Paper Hard Copies- The applicant must submit three (3) complete paper hard copies for each SNP baseline proposal, its related plan addendums and the plan to baseline crosswalk to CMS. A separate copy must be submitted for each SNP baseline proposal, which includes the crosswalk. A separate copy must be submitted for each plan addendum, which includes all documents relating to the specific plan. Two (2) complete copies must be delivered to the CMS central office and one (1) complete copy must be delivered to the applicant‘s CMS regional office.
Electronic Copies - In addition to submitting the hard copy packages, the applicant must submit (3) complete electronic copies of each packages to CMS central office. A separate electronic file must be submitted for each SNP baseline proposal, which includes the crosswalk. A separate file must be submitted for each plan addendum, which includes all documents relating to the specific plan. All electronic copies of the baseline proposals and addenda must be in Microsoft word format.
The filename of the SNP baseline proposal must be the same as the SNP baseline name as outlined in Step 3 above. The baseline filename should be the CMS contract number, type of SNP code (A = dual, B = institutional, and C = severe or disabling chronic condition), baseline, X (where “X” is the number of the baseline SNP proposal), with an underscore between each element. An example is “H9999_A_Baseline_1”.
The filename of each plan addendum must be the same as the plan addendum name as outlined in Step 2 above. Each filename should be in the following format: CMS contract number, type of SNP code (A = dual, B = institutional, and C = severe or disabling chronic condition), Plan, X (where “X” is the number of the SNP plan), with an underscore between each element (Hxxxx_X_Plan_X). An example is “H9999_A_Plan_1”.
All electronic files are to be submitted on CDs. The applicant must submit each SNP baseline proposal, including the crosswalk, and related plan addenda on a single CD. The applicant may submit multiple SNP baseline proposals and related plan addenda on the same CD provided each SNP baseline proposal and its related plan addenda are placed in sub-directories on the CD using the name of the SNP baseline proposal as the sub-directory. The CD must have an external label which at a minimum has the applicant’s contracting name and SNP baseline proposal name(s).
NOTE to Applicant: CMS will not accept consolidated proposals across contracts under any other format. The only other alternative is to complete a SNP proposal for each MA-PD contract.
Mail two (2) hard copy packages of each baseline proposal and related addenda, as well as three (3) CDs for each package (unless sub-directories are used) to:
Center for Beneficiary Choices/ MAG/DSP
Mail Stop C4-22-04
7500 Security Blvd.
Baltimore, MD 21244
Mail one (1) hard copy package of each baseline proposal and related addenda to the CMS Regional Office responsible for the applicant contract.
The following key definitions are provided here to assist the applicant in ensuring that the SNP types proposed and populations targeted for the plan offerings represented in this proposal are allowable.
Specialized MA plan for special needs individuals: Any type of MA coordinated care plan that exclusively enrolls or enrolls a disproportionate percentage of special needs individuals as set forth in 42 CFR 422.4(a)(1)(iv) that provides specialized care to such individuals, and that provides Part D benefits under 42 CFR Part 423 to all enrollees.
Special needs individual: An MA eligible individual who is institutionalized, as defined below, is entitled to medical assistance under a State plan under title XIX, or is an individual with a severe or disabling chronic condition recognized by the Secretary as benefiting from enrollment in a specialized MA plan. 42 CFR 422.2
Institutionalized: For the purpose of defining a special needs individual, an MA eligible individual who continuously resides or is expected to continuously reside for 90 days or longer in a long term care facility which is a skilled nursing facility (SNF); nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); or an inpatient psychiatric facility. 42 CFR 422.2. For purposes of SNPs, CMS may also consider as institutionalized those individuals living in the community but requiring an institutional level of care based on a State approved assessment.
Severe or disabling chronic condition: Examples of severe and disabling chronic conditions are: AIDS, diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and chronic mental illness. (SNP proposals to serve this type of special needs individual will be evaluated on a case by case basis).
Disproportionate percentage: A SNP that enrolls a greater proportion of the target group of special needs individuals (i.e. dual eligible, institutionalized, or those with a specified severe or disabling chronic condition), than occurs nationally in the Medicare population. This percentage will be based on data acceptable to CMS, including self-reported conditions from the Medicare Current Beneficiary Survey (MCBS) and other data sources. Please consult the following websites for additional information on determining disproportionate percentage.
Risk Adjustment page:
http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/RSD/list.asp#TopOfPage
MCBS page:
http://www.cms.hhs.gov/MCBS/
Subsets for Dual Eligible SNPs: A SNP that targets a more narrow population then is otherwise allowed to coordinate services between Medicare and Medicaid. (Attachment A is the subsetting policy).
Frailty: Generally recognized definitions of frailty include the following from an article in the Journal of Clinical Epidemiology:
Frailty is defined as [1] a state of reduced physiologic reserve associated with increased susceptibility to disability; and [2] defined as frail those who depend on others for the activities of daily living or who are at high risk of becoming dependent.1
The applicant is encouraged to use one of these or a similar definition in its discussion of the SNP Model of Care.
Full benefit duals: A Full-Benefit Dual Eligible Individual is a Medicare beneficiary who is determined eligible by the State for medical assistance for full benefits under Title XIX of the Social Security Act for the month under any eligibility category covered under the State plan, or comprehensive benefits under a demonstration under section 1115 of the Act , or medical assistance under 1902(a)(10)(C) of the Act (medically needy) or section 1902(f) of the Act (States that use more restrictive eligibility criteria than are used by the SSI program) for any month if the individuals was eligible for medical assistance in any part of the month.
A complete breakdown of dual eligible categories is located at the following website:
http://www.cms.hhs.gov/DualEligible/02_DualEligibleCategories.asp#TopOfPage
Zero cost sharing dual eligibles: This category includes Qualified Medicare Beneficiaries (QMB) and QMB pluses, the two categories of dual eligible beneficiaries that have Medicare cost sharing paid by Medicaid. Further information on these categories is located at the following website:
http://www.cms.hhs.gov/DualEligible/02_DualEligibleCategories.asp#TopOfPage
Model of Care:
Background
For the SNP program there are three broad target populations groups – dual eligibles, institutionalized individuals and individuals with severe or disabling chronic conditions. Depending on how specifically the target population is defined, the Model of Care would focus on the unique needs of the targeted population as defined by the applicant (e.g. full benefit dual eligibles, beneficiaries living in the community but requiring an institutional level of care, beneficiaries with congestive heart failure). In addition, for each targeted population, the applicant should address its approach to frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses, and beneficiaries who are at the end of life, as these subsets are likely to be more prevalent among the special needs populations. As the SNP program is intended to provide specialized services and these beneficiaries are among the most complex to treat, SNP programs are expected to include goals and objectives as well as specialized care for these categories of beneficiaries within the overall Model of Care for individuals who are dually eligible, institutionalized, or have a severe or disabling chronic condition.
Definition
The Model of Care describes the applicant’s proposed approach to providing specialized care to the SNP’s targeted population, including a statement of goals and specific processes and outcome objectives for the targeted population to be managed under the SNP.
The Model of Care is in essence the system of care which reflects 1) pertinent clinical expertise and the staff structures; 2) the types of benefits and; 3) processes of care (organized under protocols) that will be used to meet the goals and objectives of the SNP. The Model of Care should be specific enough to imply what process and outcome measures could be used by the applicant to determine if the structures and processes of care are having an intended effect on the target population.
Examples of pertinent clinical expertise and staff structures include clinicians with a certificate to treat individuals with mental illness for a SNP that is targeting beneficiaries with mental illness, or availability and use of nurse practitioners and case managers. Another example is an explanation of how a nursing home staff shall interact with the SNP staff to implement assessment and care management under the SNP.
Examples of types of benefits and processes of care include protocols that drive frequency and character of assessment case and care management, disease management and poly pharmacy management. Protocols are specific enough to define the beneficiary circumstances or conditions for which a set of actions should be taken.
IV. TEMPLATE FOR COMPLETING SNP PROPOSAL
Follow the step by step instructions below and insert answers directly into the template. The applicant should complete only the portions of the template that correlate to the specific SNP type the applicant intends to offer, that is Section A, B or C. If the applicant is seeking approval for more than one type of SNP, then the template for the proposal should be completed for each of those types. The responses to the template as well as the attachments and the documentation for the State and long term care contract should all be in a single Microsoft word document. Documents requested in the template, such as copies of contracts, forms and signature pages should be added to the end of the template Microsoft word document as attachments as text or scanned into the document as a picture or as text. The end result should be only one electronic file should be submitted to CMS for a SNP proposal, which contains all the required data and information.
See Section II for instructions to minimize duplication of responses and otherwise follow the instructions in this template. Any other approach to minimizing duplication will not be accepted by CMS.
The following template provides all the necessary prompts for each type of SNP – Section A dual eligible; Section B institutional; and Section C severe or disabling chronic condition SNPs.
If the applicant intends to target populations under a particular SNP type, for example a dual eligible SNP for all dually eligible beneficiaries and a dual eligible SNP for full benefit dual eligible beneficiaries only, then Section A of the template should be completed twice once for each request, Hxxxx_A_Plan_1, Hxxxx_A_Plan_ 2. It is not necessary to repeat information that is the same for each request within the dual eligible SNP. For example in H9999_A_Plan_2, the applicant must complete any portion of the dual eligible section that is different from the first one, H9999_A_ Plan_ 1. For the second requested subset the applicant must indicate that all information is the same as H9999_A_ Plan_ 1 except as provided and the applicant will list the sections that contain additional information and provide the response using the same example. These additional responses must not be embedded in the discussion for H9999_A Plan_1, but rather must follow H9999_A_ Plan_ 1, presenting clearly the applicant’s specific response to H9999_A Plan_ 2, then followed by H9999_ A_ Plan_ 3, etc.
In this same example, assume the applicant is also offering an institutional SNP. All elements must be completed for the first institutional SNP request H9999_B_Plan_1.
Particular attention should be paid to the circumstance of different SNP offerings within a contract service area wherein one SNP covers only a segment of that service area and another covers a different segment. Specifically, if the applicant is seeking to offer a SNP in a limited segment of the contract service area, the applicant is not required to repeat information that will be the same for each segment. However, in any section where the information is not the same, the applicant must complete that information. For example, information about state contracts, service area and provider network could vary with every request. Include the CMS assigned contract number and plan number (e.g. Hxxx_A_ Plan_1, Hxxxx_A_Plan_2) and the type of information contained in the file. For all files use the following nomenclature H9999_x_Plan_x_proposal; H9999_x_Plan_x_contract
DUAL ELIGIBLE SNP TYPE
Number Assignment for each Dual Eligible SNP Type
State whether the applicant is proposing a dual eligible SNP. If no, proceed to Section B.
State how many different dual eligible SNP types are being proposed.
NOTE to the applicant: This section should be completed and replicated as many times as the number reported in A.1.b. Duplication can be minimized by following the instructions in Section II and IV. 3. Consecutively label each dual eligible SNP type as dual eligible SNP Hxxxx_A_Plan_ 1, Hxxxx_ A_Plan_ 2, etc.
This particular dual eligible SNP type is numbered (insert Hxxx_A_ Plan_ 1, Hxxx_A_ Plan_ 2, etc.)
Type of Dual SNP
Identify what dual eligible population will be served by this SNP:
All Duals: Medicare and Medicaid eligible beneficiaries
Full Duals Only (See definition in Section III)
Zero Cost Sharing Duals: QMB only and QMB pluses (See
definition in Section III)
Other Dual Eligible Subsets/Requires a State contract. (See Attachment B)
Describe the procedure the applicant will use to verify eligibility of dual eligible individuals through the State.
NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment, so the applicant must clearly demonstrate how the eligibility criteria will be verified. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used as an indicator of dual eligible status as this does not reflect the most current State status. The applicant must obtain eligibility status from the respective States.
Relationship of SNP Product to State Medicaid Services in the Event of Other Subsetting
If applicant is not requesting an “Other Dual Eligible Subset” indicate that below and proceed to Section A.4.
NOTE to applicant: If the applicant intends to offer an “Other Dual Eligible Subset” it must be allowable as explained in guidance provided in Attachment A.
Additional subsetting must be approved by CMS and a contract or agreement between the State and the applicant organization must exist and evidence provided to CMS by October 1, 2007 in order for the applicant to actually offer such subsetted dual SNPs effective on January 1, 2008.
The deadline for submission of this documentation was extended from the July 1, 2007 date proposed in the draft SNP solicitation to October 1, 2007 to allow applicants additional time to finalize their State contracts. However, an applicant should submit this documentation as soon as it becomes available so CMS can proceed with final approval as quickly as possible. Further, the applicant must submit a bid for the subset population according to existing Medicare Advantage (MA) rules and regulations which require that the bid be submitted by the first Monday in June. The bid, including its underlying assumptions about the population to be served, cannot be modified in the event the applicant fails to document entry into a contract with the State by the October 1, 2007 deadline. Final approval of the bid is in part contingent on finalizing the contract with the State and providing the necessary documentation to CMS by October 1, 2007. In addition, certain addenda to the contract will have to be signed.
The applicant should be aware that the October 1, 2007 deadline could affect whether and how the SNP product will be featured in the Medicare & You Handbook, and in the Medicare Plan Finder for at least the first month. CMS approval of marketing materials may also be delayed which could subsequently delay marketing of the new SNP product.
If the proposed subset serves the institutional population and/or those living in the community requiring an institutional level of care, the applicant MUST complete this section as well as ALL portions of Section B that are not addressed by information provided in Section A on dual eligibles. If the proposed subset serves a selected dual eligible population with chronic diseases, the applicant must complete this section as well as all portions of section C that are not addressed by information provided in Section A on dual eligibles.
What specific subset of the dual eligible population does the applicant intend to serve under this SNP?
Provide a list of the types of dual eligible enrollees the applicant does not intend to serve.
Explain how the applicant’s subset of individuals coincides with State efforts to integrate Medicare and Medicaid services for the target population. Specifically, provide an explanation from the State for the subset that also includes a discussion of why other dual eligible categories would be excluded from the Medicaid population. For example, if a State Medicaid agency excludes potential enrollees based on age or a specific disease category, the applicant must request that the State provide the reasoning behind the included and excluded categories of dual eligible beneficiaries. The applicant must include the State’s response with the SNP proposal.
Provide the following documentation to support the subset request and verify the applicant’s relationship with the State Medicaid agency.
A signed contract with a State Medicaid agency to serve the population through the SNP. Include a copy of the title page, the page that includes the eligible Medicaid population and the signature page. If this documentation does not exist, then state this and go to A.3.d.2
If applicant’s organization will have a contract with the State to provide Medicaid services to the requested subset of dual eligible individuals that will be effective by January 1, 2008, include a letter from the State that verifies that information. The letter must verify the requested Medicaid subset including a list of the types of dual eligible beneficiaries eligible for the SNP and an assurance that the applicant will have a contract or agreement with the State Medicaid agency effective on January 1, 2008 that will be signed by October 1, 2007.
Provide the name and contact information of the applicant’s contact person at the State Medicaid agency. If the applicant does not have a Medicaid contract to serve any dually eligible beneficiaries, then proceed to Section A.4.d.
State Contracts Information if Other Subsetting is Not being Requested by Applicant
Identify any contracts between the applicant and the State to provide Medicaid services to the dual eligible population. If the applicant does not have a Medicaid contract, proceed to Section A.4.d.
Describe the population(s) the applicant serves under that Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, describe how the applicant will coordinate Medicare and Medicaid services for the targeted dual eligible population.
If the applicant does not have a Medicaid contract indicate whether the applicant intends to work with the State Medicaid agency to assist dual eligible beneficiaries with accessing Medicaid benefits and with coordination of Medicare and Medicaid covered services. State how this will be accomplished.
Provide the name and contact information of the applicant’s contact person at the State Medicaid agency.
Indicate if the applicant will allow CMS to advise the State Medicaid Director that the applicant has applied to CMS to offer a dual eligible SNP.
Yes
No
Exclusive versus Disproportionate Percentage Population
Indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If the applicant selected exclusive, then proceed to Section A.6.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section III., propose the reference point to compare the applicant’s targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
List the expected reasons for enrollment of beneficiaries not part of the target population. (e.g. spouses, beneficiaries who lost their dual eligible status).
State what percentage of the projected enrollment would be the target population.
State what data sources and analytic methods would be used by the applicant to track the disproportionate percentage and compare it to its proposed reference point.
Service Area to be Served by SNP
Complete the table found in Attachment B. List the State and each of the counties in the State to be served by the applicant’s proposed SNP. Complete a separate table for each SNP proposed by the applicant. If the SNP will cover all counties in the State, then the table can list “all counties”.
SNP Model of Care
NOTE to applicant: Refer to the definition of Model of Care in Section III. (clinical expertise required of the Model of Care is elicited under the provider network Section A.8.)
List the goals and objectives of the Model of Care that will drive service delivery under this dual eligible SNP. Address the goals and objectives specific to each of the following: frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses, and beneficiaries at the end of life.
Describe the specific organization of staff (e.g. employees, community service workers, nurse practitioners, case managers) who interact with dual eligible individuals to provide the specialized services available under the Model of Care.
Describe the respective roles of the staff as identified in A.7.b.
Describe the lines of communication and accountability between the SNP and the staff.
Describe the specific steps the SNP takes (e.g. written protocols and training) to ensure that the staff understands how the Model of Care works and to function in accordance with the Model of Care.
State how this Model of Care will identify and meet the needs of dual eligible beneficiaries.
List and explain extra benefits and services that will be provided to meet the needs of dual eligible beneficiaries.
State what specific processes and outcome measures the applicant will use to measure performance of the Model of Care for dual eligible beneficiaries. (See Attachment E)
Meeting the Needs of Frail/Disabled Enrollees
Provide the applicant’s definition of a frail enrollee either using one of the definitions in Section III or something similar.
State whether the applicant’s Model of Care specifically addresses the needs of frail beneficiaries and/or the needs of enrollees with a disability.
If serving enrollees with disabilities, specify the types of disabilities the applicant will address through the SNP.
NOTE to applicant: The response should address at least one of these categories (frail enrollees, enrollees with disabilities, or both)
Address how the Model of Care will identify and meet the needs of frail/disabled beneficiaries as defined in A.7.c.1., A.7.c.2 and A.7.c.3.
List and explain extra benefits and services that will be provided to meet the needs of frail/disabled beneficiaries as defined in A.7.c.1., A.7.c.2 and A.7.c.3.
Address what specific process and outcome measures the plan will use to measure performance of the Model of Care for frail/disabled beneficiaries. (see Attachment E).
Meeting the Needs of Enrollees with Multiple Chronic Illnesses
Address how the Model of Care will identify and meet the needs of beneficiaries with multiple chronic illnesses.
List and explain extra benefits and services that will be provided to meet the needs of individuals with multiple chronic illnesses.
Address what specific process and outcome measures the plan will use to measure performance of the Model of Care for beneficiaries with multiple chronic illnesses. (See Attachment E)
Meeting the Needs of Enrollees that are at the End of Life
Address how the Model of Care will identify and meet the needs of beneficiaries who are at the end of life.
List and explain extra benefits and services that will be provided to meet the needs of individuals facing the end of life.
Address what specific process and outcome measures the plan will use to measure performance of the Model of Care for beneficiaries facing the end of life. (See Attachment E)
Provider Network
State whether the SNP provider and pharmacy networks are different than the networks for the applicant’s other Medicare coordinated care plans (CCP) plans in the same service area under this contract.
Using the Model of Care described in Section III as a guide, describe the pertinent clinical expertise that the applicant will use is in the applicant’s network to meet the special needs of the dual eligible population. Also address the pertinent clinical expertise the applicant believes are necessary in order to meet the needs of frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses, and beneficiaries at the end of life.
If the network does not include sufficient specialists to fully meet the special needs of the target population, describe how access to non-contracted specialists will be arranged. Specifically, describe the policies and procedures that will be followed to make sure enrollees have meaningful access to all necessary providers.
NOTE to applicant: Although the applicant is required to respond to the questions in the SNP proposal regarding the provider network, separate HSD tables are not required unless requested by CMS.
Individuals with End Stage Renal Disease
State whether the applicant intends to enroll beneficiaries with end stage renal disease (ESRD) in its dual eligible SNP. If no, then proceed to Section A.10.
If the applicant intends to enroll individuals with ESRD in its dual eligible SNP, describe how the organization will serve the unique needs of this population.
List the contracted dialysis facilities in “Attachment G –Dialysis Facilities”.
List the contracted transplant facilities in “Attachment H – Transplant Facilities”.
List any additional services that will be provided to beneficiaries with ESRD.
Describe the role of the care coordinator in the assessment and delivery of services needed by beneficiaries with ESRD.
NOTE to applicant: If a SNP is approved to serve ESRD beneficiaries, the exceptions authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver pursuant to 42 CFR 422.52 (c) will be provided to the applicant. The signed waiver will be attached to the MA contract. If this is an MA organization that is adding a SNP, the waiver will be sent following final approval. In both cases the waiver must be signed and returned within 10 calendar days.
Targeting an Alternative Dual Eligible Population to the One Described Above
NOTE to applicant: If the applicant also intends to target an alternative dual eligible population to the one described above, then duplicate the dual eligible section of the template (Section A) here and continue the numbering with A Plan 2, etc. If the applicant is not intending to propose any additional dual eligible SNPS, then proceed to Section B.
INSTITUTIONAL SNP TYPE
Number Assignment for each Institutional SNP Type
State whether the applicant is proposing an institutional SNP. If no, proceed to Section C.
State how many different institutional SNP types the applicant is proposing to offer.
NOTE to the applicant: This section should be completed and replicated as many times as the number reported in B.1.b. Consecutively label each institutional SNP type as institutional Hxxxx_B_Plan_1; Hxxxx_B_Plan_2, etc. Duplication can be minimized by following the instructions in Section II and IV.3.
This particular institutional SNP type is numbered.(insert actual contract number and plan number Hxxxx_B_Plan_x)
Type of Institutional SNP
NOTE to Applicant: Review Attachment C, Ensuring Delivery of Institutional SNP Model of Care, which clarifies the requirements the applicant must meet when offering an institutional SNP, particularly concerning the contractual arrangement between the applicant and a long term care (LTC) facility, and the preparedness of the applicant to provide assessment and services in accordance with the SNP Model of Care if the beneficiary moves to a new residence.
Applicant must review and sign attestation in Attachment D.
Identify what institutional population will be targeted by this SNP:
Institutionalized individuals residing in a long term care facility.
Individuals that reside in specific assisted living facilities (ALF) but requiring an institutional level of care
NOTE to applicant: Refer to Attachment C, Policy clarification # 3, for discussion of targeting beneficiaries who reside in ALFs, etc.
Individuals living in the community but requiring an institutional level of care.
A combination of the above populations (Check all that apply).
Identifying Institutionalized Beneficiaries
Provide the procedure the applicant will utilize to verify that the enrollee meets the definition of institutionalized for enrollees residing in a long term care facility.
Provide a copy of the assessment tool the applicant will utilize to determine eligibility. Indicate who will perform the assessment.
Describe and provide documentation as to how the applicant will utilize the State assessment tool to determine if an individual meets nursing home level of care. Indicate who will perform the level of care assessment
NOTE to applicant: The applicant must use the State assessment tool to determine if a potential enrollee meets the definition of institutionalized as defined in Section III. The applicant must verify an individual’s eligibility prior to enrollment, so the applicant must clearly demonstrate how the eligibility criteria will be verified. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used as an indicator of institutional status.
Identifying Beneficiaries Living in the Community but Requiring an Institutional Level of Care
If the applicant intends to limit eligibility to beneficiaries who reside or agree to reside in certain Assisted Living Facilities (ALF), list these facilities.
Describe and provide documentation as to how the applicant will utilize the State assessment tool to determine if an individual meets nursing home level of care. Indicate who will perform the level of care assessment (e.g. State personnel, applicant’s clinical staff).
NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used as an indicator of institutional status. The applicant must use the State assessment tool to determine if a potential enrollee requires a nursing home level of care.
State Contracts Information
Identify any contracts between the applicant and the State to provide Medicaid services to the dual eligible population. If the applicant does not have a Medicaid contract proceed to Section B.3.d.
Describe the population(s) the applicant serves under the applicant’s existing Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, describe how the applicant will coordinate Medicare and Medicaid services for the dually eligible institutionalized population enrolled in the SNP.
If the applicant does not have a Medicaid contract, indicate whether the applicant intends to work with the State Medicaid agency to assist dual eligible beneficiaries enrolled in the applicant’s institutional SNP with accessing Medicaid benefits and with coordination of Medicare and Medicaid covered services. State how this will be accomplished.
Provide the name and contact information of the applicant’s contact person at the State Medicaid agency.
Indicate if the applicant will allow CMS to advise the State Medicaid Director that the applicant has applied to CMS to offer a dual eligible SNP.
Yes
No
Exclusive versus Disproportionate Percentage Population
Please indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If applicant selected exclusive, then proceed to Section B. 5.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section III., propose the reference point to compare its targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
List the expected reasons for enrollment of beneficiaries not part of the target population (e.g. spouses who may be institutionalized).
State the percentage of the projected enrollment that would constitute the target population.
State the data sources and analytic methods utilized by the applicant to track the disproportionate percentage and compare it to its proposed reference point.
Service Area to be Served by SNP
Complete the table found in Attachment B. List the State and each of the counties in the State to be served by the applicant’s proposed SNP. Complete a separate table for each SNP proposed by the applicant. If the SNP will cover all counties in the State, then the table can list “all counties”.
SNP Model of Care
NOTE to applicant: Refer to the definition of Model of Care in Section III. (Clinical expertise required of the Model of Care is elicited under the provider network Section B.7.).
Description of Model of Care for the Institutional Setting
NOTE to applicant: If this SNP is not targeting institutional status beneficiaries residing in a LTC setting then proceed to Section B.6.b.
List the goals and objectives of the Model of Care that will drive service delivery under this institutional eligible SNP. Address the goals and objectives specific to each of the following: frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses and beneficiaries at the end of life.
Describe how the Model of Care will be implemented in the setting as defined in B.2.c., specifically the approach to patient assessment, as well as the organization, coordination, and delivery of Medicare (and other) services.
Describe the specific organization of staff (e.g. LTC staff, employees, nurse practitioners, case managers) who interact with institutionalized individuals to provide the specialized services available under the Model of Care.
Describe the key roles and interactions between the SNP and LTC facility personnel for the Model of Care to perform as planned. List the key services provided by the SNP, and key services provided by the LTC facility. Describe lines of communication and accountability between the SNP and LTC facility.
Describe the specific steps the SNP takes (e.g., written protocols and training) to ensure that the LTC facility personnel understand how the Model of Care works and how to function in accordance with that Model of Care.
State how this Model of Care will identify and meet the needs of institutionalized beneficiaries.
List and explain extra benefits and services that will be provided to meet the needs of institutionalized beneficiaries.
State what specific processes and outcome measures the applicant will use to measure performance of the Model of Care for dual eligible beneficiaries. (See Attachment E).
Description of Model of Care for Beneficiaries Living in the Community but Requiring an Institutional Level of Care
NOTE to applicant: If this SNP is not targeting beneficiaries living in the community but requiring an institutional level of care, then proceed to Section B.6.c.
List the goals and objectives of the Model of Care that will drive service delivery under this institutional SNP. Address the goals and objectives specific to each of the following: frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses and beneficiaries at the end of life.
Describe how the Model of Care will be implemented in the community setting as defined in B.2.b. and B.2.d.1., specifically the approach to patient assessment, as well as the organization, coordination, and delivery of Medicare (and other) services.
Describe the specific organization of staff (e.g. employees, ALF staff, community service workers, nurse practitioners, case managers) who interact with beneficiaries living in the community but requiring an institutional level of care to provide the specialized services available under the Model of Care.
Describe the key interfaces between the SNP and ALF staff and community service workers for the Model of Care to perform as planned. List the key services provided by the SNP, and key services provided by the ALF staff and community service workers. Describe lines of communication and accountability between the SNP and ALF staff and community service workers.
Describe the specific steps the SNP takes (e.g., written protocols and training) to ensure that the ALF staff and community service workers understand how the Model of Care works and how to function in accordance with that Model of Care.
State how this Model of Care will identify and meet the needs of beneficiaries living in the community but requiring an institutional level of care.
List and explain extra benefits and services that will be provided to meet the needs of beneficiaries living in the community but requiring an institutional level of care.
State what specific processes and outcome measures the applicant will use to measure performance of the Model of Care for beneficiaries living in the community but requiring an institutional level of care. (See Attachment E).
Meeting the Needs of Frail/Disabled Enrollees
Provide the applicant’s definition of a frail enrollee either using one of the definitions in Section III or something similar.
State whether the applicant’s Model of Care addresses the needs of frail beneficiaries and/or the needs of enrollees with a disability.
NOTE to applicant: The response should address at least one of these categories (frail enrollees, enrollees with disabilities or both)
If serving enrollees with disabilities, specify the types of disabilities the applicant will address through the SNP.
NOTE to applicant: The response must include at least one of these categories (frail enrollees, enrollees with disabilities or both)
Address how the Model of Care will identify and meet the needs of frail/disabled beneficiaries as defined in B.6.c.1., B.6.c.2. and B.6.c.3.
List and explain extra benefits and services that will be provided to meet the needs of frail/disabled beneficiaries as defined in B.6.c.1., B.6.c.2. and B.6.c.3.
State what specific process and outcome measures the plan use to measure performance of the Model of Care for frail/disabled beneficiaries. (see Attachment E).
Meeting the Needs of Enrollees with Multiple Chronic Illnesses
Address how the Model of Care will identify and meet the needs of beneficiaries with multiple chronic illnesses.
List and explain extra benefits and services that will be provided to meet the needs of individuals with multiple chronic illnesses.
State what specific process and outcome measures the plan will use to measure performance of the Model of Care for beneficiaries with multiple chronic illnesses. (See Attachment E).
Meeting the Needs of Enrollees that are at the End of Life
Address how the Model of Care will identify and meet the needs of beneficiaries at the end of life.
List and explain extra benefits and services that will be provided to meet the needs of individuals at the end of life.
State what specific process and outcome measures the plan will use to measure performance of the Model of Care for beneficiaries at the end of life. (See Attachment E).
Provider Network
State whether the SNP provider and pharmacy networks (if any) are different from the networks for the applicant’s other Medicare coordinated care plans (CCP) in the same service area under this contract.
Using the Model of Care defined in Section III as a guide, specifically describe the pertinent clinical expertise the applicant will use to meet the special needs of the institutional population. Also address the pertinent clinical expertise the applicant believes are necessary to meet the needs of frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses, and beneficiaries at the end of life.
If the network does not include sufficient specialists to meet the special needs of the target population, describe how access to non-contracted specialists will be arranged. Specifically, describe the policies and procedures that will be followed to make sure enrollees have meaningful access to all necessary providers.
NOTE to applicant: Although the applicant is required to respond to the questions in the SNP proposal regarding the provider network, separate HSD tables are not required unless requested by CMS.
Long Term Care Facilities
List in “Attachment I – Long Term Care Facilities” all of the applicant’s long term care facilities contracted to serve the institutional population under this SNP Model of Care.
Submit a copy of the contract the applicant will utilize when contracting with a long-term care facility. In addition to the terms listed in the Medicare Advantage Managed Care Manual, Chapter 11, Section 100.4, the applicant must adequately address the following, either in the contract with the long term care provider or in provider materials including, but not limited to, written policies and procedures and provider manuals. If the information is addressed in the provider materials, then each element listed below must be referenced in the contract in a meaningful way referring the facility to the particular part of provider materials where the details concerning the element can be found.
Facilities in a chain organization that are contracted to deliver the SNP Model of Care
- If the applicant’s contract is with a chain organization, the chain organization and the applicant agree to a list of those facilities that are included to deliver the SNP Model of Care.
Facilities providing access to SNP clinical Staff
- The facility agrees to provide appropriate access to the applicant’s SNP clinical staff including physicians, nurses, nurse practitioners and care coordinators, to the SNP beneficiaries residing in the applicant’s contracted facilities in accordance with the SNP protocols for operation.
Providing protocols for the SNP Model of Care
- The applicant agrees to provide protocols to the facility for serving the beneficiaries enrolled in the SNP in accordance with the SNP Model of Care. These protocols must be referenced in the contract.
Delineation of services provided by the SNP staff and the LTC facilities under the SNP Model of Care
- A delineation of the specific services provided by the applicant’s SNP staff and the facility staff to the SNP enrollees in accordance with the protocols and payment for the services provided by the facility.
Training plan for LTC facility staff to understand SNP Model of Care
- A training plan to ensure that the LTC facility staff understand their responsibilities in accordance with the SNP Model of Care, protocols and contract. If the training plan is a separate document it should be referenced in the contract.
Procedures for facility to maintain a list of credentialed SNP clinical staff
- Procedures that ensure cooperation between the SNP and facility in maintaining a list of credentialed SNP clinical staff in accordance with the facilities’ responsibilities under Medicare conditions of participation.
Contract Year for SNP
- Contract must include the full CMS contract cycle which begins on January 1st and ends on December 31st. The applicant may also contract with additional LTC facilities throughout the CMS contract cycle.
Grounds for early termination and transition plan for beneficiaries enrolled in the SNP
- Termination clause must clearly state any grounds for early termination of the contract. The contract must include a clear plan for transitioning the beneficiary should the applicant’s contract with the long term care facility terminate.
Individuals with end stage renal disease
State whether the applicant intend to enroll beneficiaries with end stage renal disease (ESRD) in its institutional SNP If no, proceed to Section B.10.
If the applicant intends to enroll individuals with ESRD in its institutional SNP, please describe how the organization will serve the unique needs of this population.
List the contracted dialysis facilities in “Attachment G –Dialysis Facilities”.
List the contracted transplant facilities in “Attachment H – Transplant Facilities”.
List any additional services that will be provided to beneficiaries with ESRD.
Describe the role of the care coordinator in the assessment and delivery of services needed by beneficiaries with ESRD.
NOTE to applicant: If a SNP is approved to serve ESRD beneficiaries, the exceptions authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver pursuant to 42 CFR 422.52 (c) will be provided to the applicant. The signed waiver will be attached to the MA contract. If this is a MA organization that is adding a SNP, the waiver will be sent following final approval. In both cases the waiver must be signed and returned within 10 calendar days.
B.10 Targeting an Alternative Institutional Population to the One Described Above
NOTE to applicant: If the applicant also intends to target an alternative institutional population to the one described above, then duplicate the institutional section of the template (Section B) here and continue with Hxxxx_B_ Plan _2, etc. If the applicant is not intending to propose any additional institutional SNPS, then proceed to Section C.
SEVERE OR DISABLING CHRONIC CONDITION SNP TYPE
Number Assignment for each Severe or Disabling Chronic Condition SNP Type
State whether the applicant is proposing a SNP to serve individuals with severe or disabling chronic conditions
State how many different severe or disabling chronic condition SNP types are being proposed.
NOTE to the applicant: This section should be completed and replicated as many times as the number reported in C.1.b. Duplication can be minimized by following the instructions in Section II and Section IV.3. Consecutively label each severe or disabling chronic condition SNP type as Hxxxx_C_Plan_1; Hxxxx_C_Plan_2, etc.
This particular severe or disabling chronic condition SNP type is numbered… (Insert actual contract number and plan number)
Type of Severe or Disabling Chronic Condition SNP
List the disease(s) the applicant intends to target in this severe or disabling chronic condition SNP.
Provide the procedure the applicant will utilize to verify eligibility of the severe or disabling chronic condition(s) for enrollment in the SNP.
NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment, so the applicant must clearly demonstrate how the eligibility criteria will be verified. There are no CMS files related to Medicare health plan enrollment that can accomplish the task of determining eligibility for a SNP. The values in existing CMS data files may not be used to determine if a potential enrollee meets the eligibility requirement for a chronic condition SNP. The applicant must obtain a letter from the potential enrollee's physician with verification if the enrollee’s condition or request authorization from the beneficiary or his/her representative, consistent with HIPAA, to contact the enrollee’s physician to verify eligibility for the SNP.
State Contracts Information
Identify any contracts between the applicant and the State to provide Medicaid services to the dually eligible population. If the applicant does not have a Medicaid contract, proceed to section C. 3.d.
Describe the population(s) the applicant serves under the applicant’s existing Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, describe how the applicant will coordinate Medicare and Medicaid services for dually eligible beneficiaries with the targeted sever or disabling chronic condition that are enrolled in the applicant’s SNP
If the applicant does not have a Medicaid contract, indicate whether the applicant intends to work with the State Medicaid agency to assist dual eligible beneficiaries enrolled in the chronic SNP with accessing Medicaid benefits and with coordination of Medicare and Medicaid covered services. State how this will be accomplished.
Provide the name and contact information of the applicant’s contact person at the State Medicaid agency.
Indicate if the applicant will allow CMS to advise the State Medicaid Director that the applicant has applied to CMS to offer a dual eligible SNP.
Yes
No
Exclusive versus Disproportionate Percentage Population
Indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If applicant selected exclusive, then proceed to Section C.5.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section III., propose the reference point to compare its targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
List the expected reasons for enrollment of beneficiaries that are not part of the target population (e.g., spouses of beneficiary with chronic condition).
State what percentage of the projected enrollment would be the target population.
State what data sources and analytic methods would be used by the applicant to track the disproportionate percentage and compare it to its proposed reference point.
Service Area to be Served by SNP
Complete the table found in Attachment B. List the State and each of the counties in the State to be served by the applicant’s proposed SNP. Complete a separate table for each SNP proposed by the applicant. If the SNP will cover all counties in the State, then the table can list “all counties”.
SNP Model of Care
NOTE to applicant: Refer to the definition of Model of Care in Section III. (Clinical expertise required of the Model of Care is elicited under the provider network Section C.7.)
List the goals and objectives of the Model of Care that will drive service delivery under this SNP serving individuals with severe or disabling chronic conditions. Address the goals and objectives specific to each of the following: frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses, and beneficiaries at the end of life.
Describe the specific organization of staff (e.g. employees, community service workers, nurse practitioners, case managers) who interact with individuals with sever or disabling chronic conditions to provide the specialized services available under the Model of Care.
Describe the respective roles of the staff as identified in C.6.b.
Describe the lines of communication and accountability between the SNP and the staff.
Describe the specific steps the SNP takes (e.g. written protocols and training) to ensure that the staff understands how the Model of Care works and to function in accordance with the Model of Care.
State how this Model of Care will identify and meet the needs of beneficiaries with severe or disabling chronic conditions.
List and explain extra benefits and services that will be provided to meet the needs of beneficiaries with severe or disabling chronic conditions.
State what specific process and outcome measures the applicant will use to measure performance of the Model of Care for individuals with severe or disabling chronic conditions.( See Attachment E)
Meeting the Needs of Frail/Disabled Enrollees
Provide the applicant’s definition of a frail enrollee either using one of the definitions in Section III or something similar.
State whether this Model of Care specifically addresses the needs of frail beneficiaries, and/or the needs of enrollees with a disability.
If serving enrollees with disabilities, specify the types of disabilities the applicant will address through the SNP.
NOTE to applicant: The response should address at least one of these categories (frail enrollees, enrollees with disabilities or both)
Address how the Model of Care will identify and meet the needs of frail/disabled beneficiaries as defined in C.6.i.1., C.6.i.2 and C.6.i.3.
List and explain extra benefits and services that will be provided to meet the needs of frail/disabled beneficiaries as defined in C.6.i.1., C.6.i.2 and C.6.i.3.
Address what specific process and outcome measures the plan use to measure performance of the Model of Care for frail/disabled beneficiaries. (see Attachment E)
Meeting the Needs of Enrollees with Multiple Chronic Illnesses
Address how the Model of Care will identify and meet the needs of beneficiaries with multiple chronic illnesses.
List and explain extra benefits and services that will be provided to meet the needs of individuals with multiple chronic illnesses.
Address what specific process and outcome measures the plan will use to measure performance of the Model of Care for beneficiaries with multiple chronic illnesses. (See Attachment E).
Meeting the Needs of Enrollees that are at the End of Life
State how this Model of Care will identify and meet the needs of beneficiaries who are at the end of life.
List and explain extra benefits and services that will be provided to meet the needs of beneficiaries facing the end of life.
State what specific process and outcome measures the plan will use to measure performance of the Model of Care for beneficiaries facing the end of life. (See Attachment E)
Provider Network
State whether the SNP provider and pharmacy networks are different than the networks for the applicant’s other Medicare coordinated care plans (CCP) in the same service area.
Using the Model of Care described in Section III as a guide, describe the pertinent clinical expertise that the applicant will use to meet the special needs of individuals with severe or disabling conditions served through this SNP. Also address the pertinent clinical expertise the applicant believes are necessary to meet the needs of frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses, and beneficiaries at the end of life.
If the network does not include sufficient specialists to fully meet the special needs of the target population, describe how access to non-contracted specialists will be arranged. Specifically, describe the policies and procedures that will be followed to make sure enrollees have meaningful access to all necessary providers.
NOTE to applicant: Although the applicant is required to answer fully the questions in the SNP proposal regarding the provider network, separate HSD tables are not required as part of the SNP proposal unless requested by CMS.
Individuals with End Stage Renal Disease
State whether the applicant intends to enroll beneficiaries with end stage renal disease (ESRD) in its chronic SNP. If no, then proceed to Section C.9.
If the applicant intends to enroll individuals with ESRD in its severe or disabling chronic condition SNP, describe how the organization will serve the unique needs of this population.
List the contracted dialysis facilities in “Attachment G –Dialysis Facilities”.
List the contracted transplant facilities in “Attachment H – Transplant Facilities”.
List any additional services that will be provided to beneficiaries with ESRD.
Describe the role of the care coordinator in the assessment and delivery of services needed by beneficiaries with ESRD.
NOTE to applicant: If a SNP is approved to serve ESRD beneficiaries, the exceptions authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver pursuant to 42 CFR 422.52 (c) will be provided to the applicant. The signed waiver will be attached to the MA contract. If this is a MA organization that is adding a SNP, the waiver will be sent following final approval. In both cases the waiver must be signed and returned within 10 calendar days.
C. 9. Targeting an Alternative Chronic Disease SNP to the One Described Above
NOTE to applicant: If the applicant also intends to target an alternative population with a severe or disabling chronic condition to the one described above, then duplicate the Chronic SNP section (Section C) of the template here and continue with Hxxxx_C_ Plan_ 2, etc.
Subsets for Dual Eligible SNPs
Medicare Advantage Organizations (MAO) that offer Dual Eligible SNPs will be able to exclude specific groups of dual eligibles based on the MAO’s coordination efforts with State Medicaid agencies. Requests for dual eligible subsets will be reviewed and approved by CMS on a case by case basis.
To the extent a State Medicaid agency excludes specific groups of dual eligibles from their Medicaid contracts or agreements, those same groups may also be excluded from enrollment in the SNP
For example, if an MAO offering a Dual Eligible SNP has a Medicaid managed care contract with a State Medicaid agency for all dual eligibles except for those who are medically needy with a spend down, the MAO may also exclude those dual eligibles from enrollment in the SNP.
Those dual eligible groups which are included in the SNP request are those in which the MAO offering a SNP coordinates its Medicare related efforts in an integrated way with the State’s Medicaid coverage and administration.
For example, a targeted group could be aged dual eligibles for which the SNP and State provide coordinated care.
MAOs may limit enrollment to dual eligible beneficiaries through a dual eligible SNP without State Medicaid agency coordination (other than to be in compliance with applicable State licensing laws or laws relating to plan solvency), if enrollment is limited to one of the following three categories of dual eligible beneficiaries: 1) all dual eligibles; 2) full benefit dual eligibles or 3) Zero cost sharing duals (QMBs and QMB pluses). (Refer to definitions in Section III).
SNP Service Area
Date
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Ensuring Delivery of Institutional SNP Model of Care
The following clarifies CMS expectations concerning the existence of an appropriate SNP Model of Care and enrollment will be limited to settings where it can be ensured that appropriate care can be delivered.
Background
The Medicare Modernization Act (MMA), Section 231, provided an option for Medicare Advantage (MA) coordinated care plans to limit enrollment to individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dual eligible beneficiaries; and/or 3) beneficiaries with severe or disabling chronic conditions as recognized by the Secretary.
An institutionalized individual was defined by regulation in 42 CFR 422.2 as an individual who continuously resides or is expected to continuously reside for 90 days or longer in a long term care (LTC) facility which is a skilled nursing facility (SNF), nursing facility (NF), intermediate care facility for the mentally retarded (ICF/MR); or inpatient psychiatric facility.
The preamble to the new regulations stated that CMS would also consider an institutional Special Needs Plan (SNP) to serve individuals living in the community but requiring an institutional level of care, although this was not included in the regulatory definition. (Many beneficiaries who would qualify for institutional status in the community reside in some type of assisted living facility (ALF).)
All SNP proposals are required to provide a description of the SNP Model of Care that the Medicare Advantage Organization (MAO) has designed and must implement specifically to serve the special population in the MAO’s SNP. The word “specialized” in the statute clearly contemplates that the SNP product provides for “specialized” benefits that are targeted to meet the needs of the SNP population. Some aspects of the Model of Care concept described in Section III of the SNP solicitation, as well as how it would be implemented, will vary depending on the site of care LTC facility or in the community, based on, for example the availability of and need for staff and community services. Refer to the Model of Care definition in Section III of the SNP solicitation.
Institutional SNPs can be restricted to enrollment of those individuals residing in long term care facilities or to individuals living in the community , or both can be included under an institutional SNP
Policy Clarification #1
MAOs offering an institutional SNP to serve Medicare residents of LTC facilities must have a contractual arrangement with (or own and operate) the LTC facility to deliver its SNP Model of Care. The contracted/owned approach provides assurances that beneficiaries will be assessed and receive services as required under the SNP Model of Care. The institutional setting is complex and requires coordination between the SNP and facility providers and administrative staff, which can not be attained without a strong, well articulated MAO/facility relationship. Without a contractual or ownership arrangement, the MAO can not ensure the complex interface will function appropriately and care will be delivered in accordance with the Model of Care. Furthermore, this approach to limiting enrollment to contracted LTC facilities assures the delivery of uniform benefits
Policy Clarification #2
MAO marketing materials and outreach for new enrollment must make clear that enrollment is limited to the CMS approved targeted population and to those beneficiaries who live in, or are willing to move to, contracted LTC facilities. If the MAO’s institutional SNP enrollee changes residence, the MAO must have appropriate documentation that it is prepared to implement the SNP Model of Care at the beneficiary’s new residence. Appropriate documentation includes that the MAO has a contract with the LTC facility to provide the SNP Model of Care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP Model of Care.
Policy Clarification # 3
An institutional SNP serving individuals living in the community but requiring an institutional level of care may restrict access to enrollment to those individuals that reside in, or agree to reside in, a contracted Assisted Living Facility (ALF) as this is necessary in order to ensure uniform delivery of specialized care.
If a community based institutional SNP is limited to specific assisted living facilities, a potential enrollee must either reside or agree to reside in the MAOs contracted ALF to enroll in the SNP.
Proposals for this type of institutional SNP will be reviewed on a case by
case basis for approval and the applicant must demonstrate the need for the limitation, including how community resources will be organized and provided.
NOTE to applicant: If consolidating SNP proposals across multiple contracts, include all the contract numbers in this consolidated proposal.
Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries
(Name of Organization)
(H number)
I attest that in the event the above referenced organization has a CMS approved institutional SNP, the organization will only enroll beneficiaries in the SNP who (1) reside in a Long Term Care (LTC) facility under contract with or owned by the organization offering the SNP to provide services in accordance with the institutional SNP Model of Care approved by CMS, or (2) agree to move to such a facility following enrollment.
I attest that in the event the above referenced organization has a CMS approved institutional SNP to provide services to community dwelling beneficiaries who otherwise meet the institutional status as determined by the State, the SNP will ensure that the necessary arrangements with the community are in place to ensure beneficiaries will be assessed and receive services as specified by the SNP Model of Care.
I attest that if a SNP enrollee changes residence, the SNP will have appropriate documentation that it is prepared to implement the SNP Model of Care at the beneficiary’s new residence, or disenroll the resident in accordance with CMS enrollment/disenrollment policies and procedures. Appropriate documentation includes that the SNP has a contract with the LTC facility to provide the SNP Model of Care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP Model of Care.
___________________________ ____________________________
CEO DATE
___________________________ ____________________________
CFO DATE
Quality Measurement For Special Needs Plans
CMS is currently working on developing a set of standard quality measures tailored to the special need populations served in the SNP program. Those measures are in development and are not yet available. Each applicant that offers or is seeking to offer a SNP should develop internal process and outcome measures that can be used by the organization to determine if the Model of Care is having its intended effect on the targeted SNP population.
An applicant should determine how its organization will record and report these measures for the specific population served by the SNP and how this information will be used to drive quality improvement.
Crosswalk
Consolidating Proposals for Dual Eligible SNPs |
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Name
of the baseline SNP proposal:
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Number assignment for each dual eligible SNP type |
Type of Dual SNP |
Relationship of SNP product to State Medicaid services in the event of other subsetting |
State contracts information if other subsetting is not being requested by applicant |
Exclusive versus disproportionate percentage population |
Service area to be served by SNP |
SNP Model of Care |
Meeting the needs of frail/disabled enrollees |
Meeting the needs of enrollees with multiple chronic illnesses |
Meeting the needs of enrollees that are at the end of life |
Provider Network |
Individuals
with end |
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Plan # |
A.1 |
A.2 |
A.3 |
A.4 |
A.5 |
A.6 |
A.7 |
A.7.i |
A.7.j |
A.7.k |
A.8 |
A.9 |
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H9999 |
H9999_A_Plan_1 |
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ATTACHMENT F
Crosswalk
Consolidating Proposals for Institutional SNPs |
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Number assignment for each institutional SNP type |
Type of institu- tional SNP |
Identifying institu- tionalized benefici- aries |
Identifying beneficiaries living in the community but requiring an institutional level of care |
State contracts infor-mation |
Exclusive versus dispropor-tionate percentage population |
Service area to be served by SNP |
SNP Model of Care for the institu-tional setting |
Description
of Model of Care for |
Meeting the needs of frail/ disabled enrollees |
Meeting the needs of enrollees with multiple chronic illnesses |
Meeting the needs of enrollees that are at the end of life |
Provider Network |
Long term care facility |
Individuals with end stage renal disease |
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Contract # |
Plan # |
B.1 |
B.2 |
B.2.c |
B.2.d |
B.3 |
B.4 |
B.5 |
B.6.a |
B.6.b |
B.6.c |
B.6.d |
B.6.e |
B.7 |
B.8 |
B.9 |
H9999 |
H9999_B_Plan_1 |
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(Example) |
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ATTACHMENT F
Crosswalk
Consolidating Proposals for Severe or Disabling Chronic Condition
SNPs |
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Name
of the baseline SNP proposal: |
Number assignment for each severe or disabling chronic condition SNP type |
Type of chronic condition SNP |
State contracts information |
Exclusive versus disproportionate percentage population |
Service area to be served by SNP |
SNP Model of Care |
Meeting the needs of frail/ disabled enrollees |
Meeting the needs of enrollees with multiple chronic illnesses |
Meeting the needs of enrollees that are at the end of life |
Provider network |
Individuals
with end stage |
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Contract # |
Plan # |
C.1 |
C.2 |
C.3 |
C.4 |
C.5 |
C.6 |
C.6.i |
C.6.j |
C.6.k |
C.7 |
C.8 |
H9999 |
H9999_C_Plan_1 |
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ATTACHMENT G – Dialysis Facilities Table
Dialysis Facilities
Date
Submitted to CMS: _____________________ |
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Name of Dialysis Facilities |
Medicare Provider # |
Facilities Address |
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ATTACHMENT H –Transplant Facilities Table
Transplant Facilities
Date
Submitted to CMS: _____________________ |
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Name of Transplant Facilities |
Medicare Provider # |
Facilities Address |
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ATTACHMENT I – Long Term Care Facilities Table
Long Term Care Facilities
Date
Submitted to CMS: _____________________ |
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Name of Long Term Care Facilities |
Medicare Provider # |
Facilities Address |
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Under the MMA (Section 231), Congress provided an option for Medicare Advantage (MA) coordinated care plans to limit enrollment to individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dually eligible; and/or 3) beneficiaries with severe or disabling chronic conditions as recognized by the Secretary.
Organizations can view CMS guidance on Special Needs Plans at www.cms.hhs.gov/SpecialNeedsPlans/. Applicants are strongly encouraged to familiarize themselves with these materials before applying.
Organizations that intend to offer Special Needs Plans (SNPs) must provide a proposal to CMS that includes information as prompted below for each type of SNP to be offered. This solicitation for SNP proposals is divided into the following sections:
General Guidance on Completing SNP Proposal Applications
Requirements to Submit a SNP Proposal/MA and Part D Applications May Also Be Required
Key Definitions
Template for Completing SNP Proposal
Attachment A: Subsets for Dual Eligible SNPs
Attachment B: Ensuring Delivery of Institutional SNP Model of Care
Attachment C: Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries
I. GENERAL GUIDANCE ON COMPLETING SNP PROPOSAL
The applicant must follow the step by step instructions in Section IV to propose the type of SNP the applicant intends to offer. Section IV offers prompts for each SNP type. If the applicant is seeking approval for more than one type of SNP, then the template for the proposal should be completed for each of those types. The applicant’s responses should be provided within the Section IV template. Additional documents that are requested in Section IV must be labeled to associate them with the correct SNP type being proposed and appended to the SNP proposal.
A solicitation for a SNP proposal for the next contract cycle beginning January 1, 2008 WILL NOT be considered by CMS unless the solicitation is submitted by the deadline for MA applications. The application deadline is March 12, 2007. Late proposals including changes to an existing SNP (for example, any additional proposed subsets) will not be accepted after the MA application deadline. Other associated MA and Part D applications must also be provided; see Section II for instructions on what other applications may be required.
If the applicant has questions about the SNP program or completing this application, please contact Cathy Barchi at 410-786-7619 or cathy.barchi@ cms.hhs.gov. or Eric Nevins at 410-786-1162 or eric.nevins @cms.hhs.gov.
II. REQUIREMENTS TO SUBMIT A SNP PROPOSAL/MA AND PART D APPLICATIONS MAY ALSO BE REQUIRED
Seeking New Medicare Coordinated Care Plan (CCP) Contract That Includes SNPs
Organizations that do not have a current CCP contract with CMS must complete the full Coordinated Care Plan (CCP) MA application in order to offer a Special Needs Plan (SNP). The application is posted at: http://www.cms.hhs.gov/MedicareAdvantageApps/.
An applicant seeking to become a Medicare Advantage Organization (MAO) offering a Special Needs Plan (SNP) must also offer Part D under the SNP products, and must file a Part D application. This application is posted at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/ and click on “Application Guidance.
The MA application should be submitted as described in the MA application guidelines. When the MA application includes a SNP proposal, in addition to including the SNP portion of the application with the completed MA application, the applicant must make an additional copy of the cover page of the MA application and a copy of the SNP portion of the MA application and place those pages in a separate envelope labeled with the organization name and H number. The separate envelope containing the SNP proposal must be included as part of the applicant’s MA application submission.
Adding SNPs under Existing Medicare CCP Contract – Service Area Unchanged
If the applicant is proposing to offer SNPs under an existing Medicare CCP contract and the service area of that contract will be unchanged, then the applicant must submit the cover page of the MA contract and the applicant must complete the cover page of the CCP application and the SNP portion of the CCP application.
When a contracting MAO seeks to add a SNP to its current service area it must also offer prescription drug coverage under Part D. If the MA Organization already offers Part D along with its Medicare Advantage product in a current service area, it does not need to file a new Part D application. It must maintain its prescription drug coverage by submitting a formulary and bid. If Part D coverage is not part of the applicant’s MA contract, a Part D application must be completed and submitted by March 12, 2007.
The SNP proposal must be completed as instructed below and submitted as follows:
Provide two copies of the SNP proposal (including the MA contract cover sheet and the cover page of the CCP application) to:
Director, Division of Special Programs (DSP)
Medicare Advantage Group
7500 Security Blvd.
Mail Stop C4-22-04
Baltimore, Maryland 21244
In addition, send two copies to your CMS Regional Office.
Adding SNPs under Existing CCP Contract – Service Area Changing
If an MAO is expanding its service area and seeking to offer a SNP in the expanded service area, it must complete the MA service area expansion (SAE) application, including the SNP portion of the SAE application. The MAO must also complete an SAE application for Part D. If the MAO does not currently offer prescription drug coverage in the service area where it is seeking to offer a SNP, it must file a Part D application.
The SAE application should be submitted as described in the MA SAE application guidelines. When the SAE application includes a SNP proposal, in addition to including the SNP portion of the application with the completed SAE application, the applicant must make an additional copy of the cover page of the SAE application and the SNP portion of the SAE application and place those pages in a separate envelope labeled with the organization name and H number. The separate envelope containing the SNP proposal must be included as part of the applicant’s SAE application submission.
III. KEY DEFINITIONS
The following key definitions from 42 CFR Part 422 are provided here to help the applicant ensure that the SNP types proposed and populations targeted for these plan offerings are allowable.
Specialized MA Plan for Special Needs Individuals: Any type of MA coordinated care plan that exclusively enrolls or enrolls a disproportionate percentage of special needs individuals as set forth in Section 422.4(a)(1)(iv) and that provides Part D benefits under part 423 to all enrollees.
Special needs individual: An MA eligible individual who is institutionalized, as defined below, is entitled to medical assistance under a State plan under title XIX, or has a severe or disabling chronic condition(s) and would benefit from enrollment in a specialized MA plan. 42 CFR 422.2
Institutionalized: For the purpose of defining a special needs individual, an MA eligible individual who continuously resides or is expected to continuously reside for 90 days or longer in a long term care facility which is a skilled nursing facility (SNF); nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); or an inpatient psychiatric facility. For purposes of SNPs, CMS may also consider as institutionalized those individuals living in the community but requiring an institutional level of care based on a State approved assessment.
Severe or disabling chronic condition: SNP proposals to serve this type of special needs individual will be evaluated on a case by case basis. Examples of targeted diseases are: AIDS; diabetes; congestive heart failure (CHF); chronic obstructive pulmonary disease (COPD).
Disproportionate percentage: A SNP that enrolls a greater proportion of the target group (dually eligible, institutionalized, or those with a specified chronic illness or disability) of special needs individuals than occur nationally in the Medicare population. This percentage will be based on data acceptable to CMS, including self-reported conditions from the Medicare Current Beneficiary Survey (MCBS) and other data sources.
Subsets for Dual Eligible SNPs: Attachment A is the subsetting policy describing circumstances when a SNP can be targeted to a more narrow population then is otherwise allowed depending on efforts to coordinate services between Medicare and Medicaid.
IV. TEMPLATE FOR COMPLETING SNP PROPOSAL
The template below provides all the necessary prompts for each type of SNP – A.) dual eligible; B.) institutional; and C.) chronic and severe illness SNPs. If the applicant intends to target populations under a particular SNP type, for example a dual eligible SNP for all dually eligible beneficiaries and a dual eligible SNP for fully dually eligible beneficiaries only, then the dual eligible section of the template should be completed and replicated twice, (once for each target population).
Follow the step by step instructions below and insert answers directly into the template. Additional documents must be labeled to associate them with the correct SNP type and design and appended to this proposal.
DUAL ELIGIBLE SNP TYPE
Number Assignment for each Dual Eligible SNP Type
Is the applicant proposing a dual eligible SNP? If no, proceed to Section B.
How many different dual eligible SNP types are being proposed? NOTE to the applicant: This section should be completed and replicated as many times as the number reported in A.1.b. Consecutively label each dual eligible SNP type as dual eligible SNP A.Plan 1., A.Plan 2, etc.
This particular dual eligible SNP type is (insert A.Plan 1, A.Plan 2, etc.):
Type of Dual SNP
Identify what dual eligible population will be served by this SNP:
All Duals
Full Duals
Other Subsets (See Attachment B)
Describe specifically how the applicant will verify eligibility of dually eligible individuals. NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment.
Relationship of SNP Product to State Medicaid Services in the Event of Other Subsetting
If applicant is not requesting other subsetting, indicate that below and proceed to Section A.4. If the applicant intends to further subset the dual eligible population for this SNP as allowed in guidance provided in Attachment A, the applicant must answer the following questions. Additional subsetting must be approved by CMS.
What specific subset of the dually eligible population does the applicant intend to serve under this SNP? Provide a detailed list of dual eligible enrollees the applicant does not intend to serve.
Provide the State’s justification for each excluded category of beneficiary based on State criteria. For example, if a State Medicaid agency excludes potential enrollees based on age or a specific disease category, explain how the applicant’s subset of individuals coincides with State efforts to integrate Medicare and Medicaid services for the target population.
Provide the following documentation to support the subset request and verify the applicant’s relationship with the State Medicaid agency.
A signed contract or agreement with a State Medicaid agency to serve the population through the SNP. Include a copy of the title page, the page that includes the eligible Medicaid population and the signature page. If this documentation does not exist, then state this and go to A.3.c.2
If applicant’s organization will have a contract or agreement with the State to provide Medicaid services to the requested subset of dually eligible individuals that will be effective by January 1, 2008, include a letter from the State that verifies that information. The letter must verify the requested Medicaid subset including a list of the eligible types of dually eligible beneficiaries and an assurance that the applicant will have a contract or agreement with the State Medicaid agency effective on January 1, 2008 and will be signed by July 2, 2007.
NOTE to applicant: If the requested documentation is not provided to CMS by July 2, 2007, the applicant’s request for subsetting based on Medicaid integration will not be approved. All decisions regarding the application process must be made by July 15, 2007 for the 2008 contract year. Any contract or agreement with the State to provide Medicaid service must be signed and provided to CMS by July 2, 2007.
Proceed to Section A. 5., if applicant completed Section A. 3.
State Contracts Information if Other Subsetting is Not being Requested by Applicant
Identify any contracts between the applicant and the State to provide Medicaid services to the dually eligible population. If none, proceed to Section A.4.d.
Please describe the population(s) the applicant serves under that Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, please describe how the applicant will integrate Medicare and Medicaid services for the targeted dually eligible population.
If the applicant does not have a Medicaid contract indicate whether the applicant intends to work with the State Medicaid agency to provide integrated Medicare and Medicaid services to dually eligible beneficiaries.
Will the applicant allow CMS to advise the appropriate State agency that the applicant has applied to CMS to offer a dual eligible SNP?
Exclusive versus Disproportionate Percentage Population
Please indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If the applicant selected exclusive, then proceed to Section A.6.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section III., propose the reference point to compare the applicant’s targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
What are the expected reasons for enrollment of beneficiaries not part of the target population. (e.g. spouses)?
What percentage of the projected enrollment would be the target population?
What data sources and analytic methods would be used by the applicant to track the disproportionate percentage and compare it to its proposed reference point?
Service Area to be Served by SNP
Provide in an excel spreadsheet the State and list of counties to be served by the applicant’s proposed SNP.
SNP Model of Care
Describe the model of care the proposed SNP will use to drive service delivery for the proposed population. Include a discussion of how the service delivery system will be managed including how assessment and problem identification will work, and how services will be organized, coordinated and delivered.
Describe the goals of the model of care that will drive service delivery under the proposed SNP.
Meeting the Needs of Frail Enrollees
Does this model of care specifically address the needs of frail beneficiaries? If no, then proceed to Section A.7.d.
How will this model of care identify and meet the needs of frail beneficiaries?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP Medicare managed care plans including at least the following: benefit design; care management case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of frail beneficiaries.
What specific process and outcome measures will the plan use to measure performance of the model of care for frail beneficiaries?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Disabled Enrollees
Does this model of care specifically address the needs of disabled Medicare beneficiaries? If no, then proceed to Section A.7.e.
How will this model of care identify and meet the needs of disabled beneficiaries?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of disabled individuals.
What specific process and outcome measures will the plan use to measure performance of the model of care for disabled beneficiaries?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Enrollees with Multiple Chronic Illnesses
Does this model of care specifically address the needs of beneficiaries with multiple chronic illnesses? If no, then proceed to Section A. 7. f.
How will this model of care identify and meet the needs of beneficiaries with multiple chronic illnesses?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of individuals with multiple chronic illnesses.
What specific process and outcome measures will the plan use to measure performance of the model of care for beneficiaries with multiple chronic illnesses?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Enrollees that are at the End of Life
Does this model of care specifically address the needs of beneficiaries who are at the end of life? If no, then proceed to A.8.
How will this model of care identify and meet the needs of beneficiaries who are at the end of life?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of individuals facing the end of life.
What specific process and outcome measures will the plan use to measure performance of the model of care for beneficiaries facing the end of life?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Provider Network
Are the SNP provider and pharmacy networks different than the networks for the applicant’s other Medicare Coordinated Care plans (CCP) plans in the same service area?
If the answer to A.8.a. is yes, describe how and why they are different, and how these differences will ensure that the clinical expertise to meet the special care management needs of the special needs population will be in-network and accessible.
If the answer to A.8.a. is no, describe how the provider networks have the clinical expertise to meet the needs of the special needs population.
If the network includes fewer than two physicians in a specialty, describe how access to non-contracted specialists will be arranged. Specifically, describe the policies and procedures that will be followed to make sure enrollees have meaningful access to all necessary providers.
Individuals with end stage renal
Does the applicant intend to enroll beneficiaries with end stage renal disease (ESRD) in its dual eligible SNP? If no, then proceed to Section A.10.
If the applicant intends to enroll individuals with ESRD in its dual eligible SNP, please describe how the organization will serve the unique needs of this population.
List the contracted dialysis facilities in an excel spreadsheet.
List the contracted transplant facilities in an excel spreadsheet.
List any additional services that will be provided to beneficiaries with ESRD.
Describe the role of the care coordinator in the assessment and delivery of services needed by beneficiaries with ESRD.
NOTE to applicant: If a SNP is approved to serve ESRD beneficiaries, the exceptions authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver pursuant to 42 CFR 422.52 (c) will be provided to the applicant. The signed waiver will be attached to the MA contract. If this is a MA organization that is adding a SNP, the waiver will be sent following final approval. In both cases the waiver must be signed and returned within 10 calendar days.
Targeting an Alternative Dual Eligible Population to the One Described Above NOTE to applicant: If the applicant also intends to target an alternative dual eligible population to the one described above, then duplicate the dual eligible section of the template here and continue with A. Plan 2, etc. If the applicant is not intending to propose any additional dual eligible SNPS, then proceed to Section B.
INSTITUTIONAL SNP TYPE
Number Assignment for each Dual Eligible SNP Type
Is the applicant proposing an institutional SNP? If no, proceed to Section C.
How many different institutional SNP types is the applicant proposing to offer? NOTE to the applicant: This section should be completed and replicated as many times as the number reported in B.1.b. Consecutively label each institutional SNP type as institutional SNP B. Plan 1., B. Plan 2, etc.
This particular institutional SNP type is (insert B. Plan 1, B. Plan 2, etc.):
Type of Institutional SNP
NOTE to Applicant: Review Attachment B, “Ensuring Delivery of Institutional SNP Model of Care” which clarifies the requirements the applicant must meet when offering an institutional SNP, particularly concerning the contractual arrangement between the SNP and a long term care (LTC) facility, and the preparedness of the SNP to provide assessment and services in accordance with the SNP model of care if the beneficiary moves to a new residence.
Applicant must review and sign attestation in Attachment C.
Identify what institutional population will be targeted by this SNP:
Institutional residing in a long term care facility
Institutional living in the community but requiring an institutional level of care
Both of the above populations.
Description of model of care for the institutional setting
If this SNP is not targeting institutional status beneficiaries residing in a LTC setting then proceed to Section B.2.d.
If the applicant intends to target services to individuals living in a contracted LTC facility, describe the model of care to be implemented in that setting, specifically the approach to patient assessment, as well as the organization, coordination, and delivery of Medicare (and other) services.
Describe if and how the model distinguishes and accommodates various levels of care. (NOTE to Applicant: In answering this question, applicant may refer to responses in Section A if the model distinguishes and accommodates the needs of beneficiaries who are frail, disabled, at the end of life, or have multiple chronic illnesses.)
Describe the types of SNP providers and other SNP personnel that are key in the performance of this model and what their respective roles are in delivering the model of care.
Describe the key interfaces between the SNP and LTC facility personnel for the model of care to perform as planned. List the key services provided by the SNP, and key services provided by the LTC facility. Describe lines of communication and accountability between the SNP and LTC facility.
Describe the specific steps the SNP takes (e.g., written protocols and training) to ensure that the LTC facility personnel understand how the model of care works and how to function in accordance with that model of care.
Describe how the SNP measures performance and uses that information for quality improvement.
Description of model of care for institutional status beneficiaries who reside in the community
If this SNP is not targeting institutional status beneficiaries residing in the community then proceed to Section B.2.e.
If the applicant intends to target services to individuals living in a community setting, list the types of community settings that could be served by the SNP model of care (e.g., assisted living facility) and describe how the model of care will be implemented in that setting, specifically the approach to patient assessment, as well as the organization, coordination, and delivery of Medicare (and other) services.
Describe if and how the model distinguishes and accommodates various levels of care. (NOTE to Applicant: In answering this question, applicant may refer to responses in Section A if the model distinguishes and accommodates the needs of beneficiaries who are frail, disabled, at the end of life, or have multiple chronic illnesses.)
Describe the types of SNP providers and other SNP personnel that are key in the performance of this model and what their respective roles are in delivering the model of care.
Describe the types and roles of key personnel and other resources in the community that are integral to the performance of the model of care.
Describe the key interfaces between the SNP personnel and personnel and other resources in the community for the model of care to perform as planned. Describe lines of communication and accountability between the SNP and personnel and other resources in the community.
Describe the specific steps the SNP takes (e.g., written protocols and training) to ensure that the personnel and other resources in the community understand how the model of care works and how to function in accordance with that model of care.
Describe how the SNP measures performance and uses that information for quality improvement.
Identifying beneficiaries with an institutional status
Demonstrate how the applicant will utilize the State assessment tool to determine if an individual meets nursing home level of care. Indicate who will perform the level of care assessment. NOTE to applicant: The applicant must use the State assessment tool to determine if a potential enrollee requires a nursing home level of care.
Describe specifically how the applicant will verify eligibility of the institutional population. NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment.
State Contracts Information
Identify any contracts between the applicant and the State to provide Medicaid services to the dually eligible population. If none proceed to Section B.3.d.
Please describe the population(s) the applicant serves under the applicant’s existing Medicaid contract (s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, does the applicant have a plan to integrate Medicare and Medicaid services for the dually eligible institutionalized population enrolled in the SNP?
If the applicant does not have a Medicaid contract, indicate whether the applicant intends to work with the State Medicaid agency to provide integrated Medicare and Medicaid services to institutionalized dually eligible beneficiaries.
Exclusive versus Disproportionate Percentage Population
Please indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
If applicant selected exclusive, then proceed to Section B. 5.
Exclusive
Disproportionate
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section III., propose the reference point to compare its targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
What are the expected reasons for enrollment of beneficiaries not part of the target population (e.g. spouses who may be institutionalized)?
What percentage of the projected enrollment would be the target population?
What data sources and analytic methods would be used by the applicant to track the disproportionate percentage and compare it to its proposed reference point?
Service Area to be Served by SNP
Provide in an excel spreadsheet the State and list of counties to be served by the applicant’s proposed SNP.
SNP Model of Care
Describe the model of care the proposed SNP will use to drive service delivery for the proposed population. Include a discussion of how the service delivery system will be managed including how assessment and problem identification will work, and how services will be organized, coordinated and delivered.
Describe the goals of the model of care that will drive service delivery under the proposed SNP.
Meeting the Needs of Frail Enrollees
Does this model of care specifically address the needs of frail beneficiaries? If no, then proceed to Section B.6.d.
How will this model of care identify and meet the needs of frail beneficiaries?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of frail beneficiaries.
What specific process and outcome measures will the plan use to measure performance of the model of care for frail beneficiaries?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Disabled Enrollees
Does this model of care specifically address the needs of disabled Medicare beneficiaries? If no, then proceed to B.6.e.
How will this model of care identify and meet the needs of disabled beneficiaries?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of disabled beneficiaries.
What specific process and outcome measures will the plan use to measure performance of the model of care for disabled beneficiaries?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Enrollees with Multiple Chronic Illnesses
Does this model of care specifically address the needs of beneficiaries with multiple chronic illnesses? If no, then proceed to B.6. f..
How will this model of care identify and meet the needs of beneficiaries with multiple chronic illnesses?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of beneficiaries with multiple chronic illnesses.
What specific process and outcome measures will the plan use to measure performance of the model of care for beneficiaries with multiple chronic illnesses?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Enrollees that are at the End of Life
Does this model of care specifically address the needs of beneficiaries who at the end of life? If no, then proceed to Section B.7.
How will this model of care identify and meet the needs of beneficiaries who are at the end of life?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of individuals facing the end of life.
What specific process and outcome measures will the plan use to measure performance of the model of care for individuals facing the end of life?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Provider Network
Are the SNP provider and pharmacy networks different than the networks for the applicant’s other Medicare CCP plans in the same service area?
If the answer to B.7.a. is yes, describe how and why they are different and how these differences will ensure that the clinical expertise to meet the special care management needs of the special needs population will be in-network and accessible.
If the answer to B.7.a. is no, describe how the provider networks have the clinical expertise to meet the needs of the special needs population
If the network includes fewer than two physicians in a specialty, describe how access to non-contracted specialists will be arranged. Specifically, describe the policies and procedures that will be followed to make sure enrollees have meaningful access to all necessary providers.
Long Term Care Facilities
List, in an excel spreadsheet, all of the applicant’s long term care facilities contracted to serve the institutional population under this SNP model of care. Include the exact name and location of each facility.
Submit a copy of the contract the applicant will utilize when contracting with a long-term care facility. In addition to the terms listed in the Medicare Advantage Managed Care Manual, Chapter 11, Section 100.4, the long term care provider contract must adequately address the following requirements:
- If the applicant’s contract is with a chain organization, the contract must specify which of its facilities are included to deliver the SNP model of care.
- The facility will provide full access to the SNP clinical staff including physicians, nurses, nurse practitioners and care coordinators, to the SNP beneficiaries residing in the applicant’s contracted facilities in accordance with the SNP protocols for operation.
- The SNP will provide protocols for serving the beneficiaries enrolled in the SNP in accordance with the SNP model of care.
- A delineation of the specific services to be provided by the SNP staff and the facility staff to the SNP enrollees in accordance with the protocols and payment for the services provided by the facility.
- A training plan to ensure that the LTC facility staff understand their responsibilities in accordance with the SNP model of care, protocols and contract.
- Procedures that ensure cooperation between the SNP and facility in maintaining a list of credentialed SNP clinical staff in accordance with the facilities responsibilities under Medicare conditions of participation.
- Contract must be for at least a full CMS contract cycle which begins on January 1st and ends on December 31st.
- Termination clause must clearly state any grounds for early termination of the contract. Early termination may be for cause only. The contract must include a clear plan for transitioning the beneficiary either to another contracted LTC facility or leaving the SNP should the applicant’s contract with the long term care facility terminate.
Individuals with end stage renal disease
Does the applicant intend to enroll beneficiaries with end stage renal disease (ESRD) in its dual eligible SNP? If no, proceed to Section C.
If the applicant intends to enroll individuals with ESRD in its institutional SNP, please describe how the organization will serve the unique needs of this population.
List the contracted dialysis facilities in an excel spreadsheet.
List the contracted transplant facilities in an excel spreadsheet.
List any additional services that will be provided to beneficiaries with ESRD.
Describe the role of the care coordinator in the assessment and delivery of services needed by beneficiaries with ESRD.
NOTE to applicant: If a SNP is approved to serve ESRD beneficiaries, the exceptions authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver pursuant to 42 CFR 422.52 (c) will be provided to the applicant. The signed waiver will be attached to the MA contract. If this is a MA organization that is adding a SNP, the waiver will be sent following final approval. In both cases the waiver must be signed and returned within 10 calendar days.
B.10 Targeting an Alternative Institutional Population to the One Described Above NOTE to applicant: If the applicant also intends to target an alternative institutional eligible population to the one described above, then duplicate the institutional section of the template here and continue with B. Plan 2, etc. If the applicant is not intending to propose any additional institutional SNPS, then proceed to Section B.
CHRONIC AND SEVERE ILLNESS SNP TYPE
Is the applicant proposing a chronic disease SNP?
How many different chronic and severe illness SNP types are being proposed? NOTE to the applicant: This section should be completed and replicated as many times as the number reported in C.1.b. Consecutively label each chronic and severe illness SNP type as chronic SNP C.1., C.2, etc.
This particular chronic and severe illness SNP type is (insert C.1, C.2, etc.):
Type of Chronic SNP
List the disease(s) the applicant intends to target in its chronic SNP.
Describe specifically how the applicant will verify eligibility of the chronic SNP population. NOTE to applicant: The applicant must verify an individual’s eligibility prior to enrollment.
State Contracts Information
Identify any contracts between the applicant and the State to provide Medicaid services to the dually eligible population. In none, proceed to section C. 3.d.
Please describe the population(s) the applicant serves under the applicant’s existing Medicaid contract(s).
If the applicant has a contract(s) to serve Medicaid beneficiaries, does the applicant have a plan to integrate Medicare and Medicaid services for dually eligible beneficiaries with the targeted chronic illnesses that are enrolled in the applicant’s SNP?
If the applicant does not have a Medicaid contract, indicate whether the applicant intends to work with the State Medicaid agency to provide integrated Medicare and Medicaid services to dually eligible beneficiaries with the chronic illnesses targeted under this SNP.
Exclusive versus Disproportionate Percentage Population
Please indicate whether the SNP will exclusively enroll individuals in the target population or whether its enrollment will include a disproportionate percentage of the target population.
Exclusive
Disproportionate
If applicant selected exclusive, then proceed to section C.5.
If the organization is requesting that its SNP cover a disproportionate percentage of special needs individuals as defined in Section III., propose the reference point to compare its targeted enrollment percentage to the incidence of that type of beneficiary in the Medicare population.
What are the expected reasons for enrollment of beneficiaries not part of the target population (e.g., spouses of beneficiary with chronic disease)?
What percentage of the projected enrollment would be the target population?
What data sources and analytic methods would be used by the applicant to track the disproportionate percentage and compare it to its proposed reference point?
Service Area to be Served by SNP
Provide in an excel spreadsheet the State and list of counties to be served by the applicant’s proposed SNP.
SNP Model of Care
Describe the model of care the proposed SNP will use to drive service delivery for the proposed population. Include a discussion of how the service delivery system will be managed including how assessment and problem identification will work, and how services will be organized, coordinated, and delivered.
Describe the goals of the model of care that will drive service delivery under the proposed SNP.
Meeting the Needs of Frail Enrollees
Does this model of care specifically address the needs of frail beneficiaries? If no, then proceed to Section C.6.d.
How will this model of care identify and meet the needs of frail beneficiaries?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program.
List and explain how extra benefits and services will be provided to meet the needs of frail beneficiaries
What specific process and outcome measures will the plan use to measure performance of the model of care for frail beneficiaries?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Disabled Enrollees
Does this model of care specifically address the needs of disabled Medicare beneficiaries? If no, then proceed to Section C.6.e.
How will this model of care identify and meet the needs of disabled beneficiaries?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program
List and explain how extra benefits and services will be provided to meet the needs of disabled individuals.
What specific process and outcome measures will the plan use to measure performance of the model of care for disabled beneficiaries?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Enrollees with Multiple Chronic Illnesses
Does this model of care specifically address the needs of beneficiaries with multiple chronic illnesses? If no, then proceed to Section C.6.f.
How will this model of care identify and meet the needs of beneficiaries with multiple chronic illnesses?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program
List and explain how extra benefits and services will be provided to meet the needs of individuals with multiple chronic illnesses.
What specific process and outcome measures will the plan use to measure performance of the model of care for beneficiaries with multiple chronic illnesses?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Meeting the Needs of Enrollees that are at the End of Life
Does this model of care specifically address the needs of beneficiaries who are at the end of life? If no, then proceed to Section C.7.
How will this model of care identify and meet the needs of beneficiaries who are at the end of life?
Indicate what distinguishes the applicant’s SNP model of care from the model of care in non-SNP managed care plans including at least the following: benefit design; care management, case management, medical management and disease management strategies; health delivery system configuration; and any other important aspects of the program
List and explain how extra benefits and services will be provided to meet the needs of beneficiaries facing the end of life.
What specific process and outcome measures will the plan use to measure performance of the model of care for beneficiaries facing the end of life?
Provide specific examples of how performance reports will be used to ensure continuous quality improvement.
Provide a copy of the performance reports that would be generated.
Provider Network
Are the SNP provider and pharmacy networks different than the networks for the applicant’s other Medicare CCP plans in the same service area?
If the answer to C.7.a. is yes, describe how and why they are different, and how these differences will ensure that providers with the clinical expertise necessary to meet the special care management needs of the special needs population will be in-network and accessible.
If the answer to C.7. a. is no, describe how the provider networks have the clinical expertise to meet the needs of the special needs population
If the network includes fewer than two physicians in a specialty, describe how access to non-contracted specialists will be arranged. Specifically, describe the policies and procedures that will be followed to make sure enrollees have meaningful access to all necessary providers.
Individuals with end stage renal disease
Does the applicant intend to enroll beneficiaries with end stage renal disease (ESRD) in its dual eligible SNP? If no, then proceed to Section C.10.
If the applicant intends to enroll individuals with ESRD in its dual eligible SNP, please describe how the organization will serve the unique needs of this population.
List the contracted dialysis facilities in an excel spreadsheet.
List the contracted transplant facilities in an excel spreadsheet.
List any additional services that will be provided to beneficiaries with ESRD.
Describe the role of the care coordinator in the assessment and delivery of services needed by beneficiaries with ESRD.
NOTE to applicant: If a SNP is approved to serve ESRD beneficiaries, the exceptions authority in 42 CFR 422.50(a)(2)(iii) would apply and a waiver pursuant to 42 CFR 422.52 (c) will be provided to the applicant. The signed waiver will be attached to the MA contract. If this is a MA organization that is adding a SNP, the waiver will be sent following final approval. In both cases the waiver must be signed and returned within 10 calendar days.
C. 10. Targeting an Alternative Chronic Disease SNP to the One Described Above NOTE to applicant: If the applicant also intends to target an alternative population with a chronic or severe illness to the one described above, then duplicate the Chronic SNP section of the template here and continue with C. Plan 2, etc.
ATTACHMENT A
Subsets for Dual Eligible SNPs
Dual Eligible SNPs will be able to exclude specific groups of dual eligibles based on their coordination efforts with State Medicaid agencies.
To the extent a State Medicaid agency excludes specific groups of dual eligibles from their Medicaid contracts or agreements, those same groups may also be excluded from the SNP’s contract with CMS.
For example, if a Dual Eligible SNP has a Medicaid managed care contract with a State Medicaid agency for all dual eligibles except for those who are medically needy with a spend down, the SNP contract with CMS may also exclude those dual eligibles.
Dual Eligible SNPs may exclude multiple groups of dual eligibles based on their coordination efforts with State Medicaid agencies.
Those dual eligible groups which are included in the SNP request are those in which the SNP coordinates its efforts in an integrated way with the State.
For example, an included targeted group could be aged dual eligibles for which the SNP and State provide coordinated care.
There is no requirement that a SNP have a companion Medicaid contract or agreement with a State Medicaid agency for dual eligibles. SNPs may offer dual eligible plans without State Medicaid agency coordination (other than compliance with applicable State licensing laws or laws relating to plan solvency), but may only limit enrollment in these plans to full benefit dual eligibles.
ATTACHMENT B
Ensuring Delivery of Institutional SNP Model of Care
The following clarifies CMS policy and application requirements to ensure an appropriate SNP model of care is articulated and approved for all the institutional settings in which the plan may operate and that enrollment is limited to those settings to ensure that appropriate care can be delivered.
Background
The Medicare Modernization Act (MMA), Section 231, provided an option for Medicare Advantage (MA) coordinated care plans to limit enrollment to individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dually eligible; and/or 3) beneficiaries with severe or disabling chronic conditions as recognized by the Secretary.
An institutionalized individual was defined by regulation in 42 CFR 422.2 as an individual who continuously resides or is expected to continuously reside for 90 days or longer in a long term care (LTC) facility which is a skilled nursing facility (SNF), nursing facility (NF), intermediate care facility for the mentally retarded (ICF/MR); or inpatient psychiatric facility.
The preamble to the new regulations stated that CMS would also consider an institutional Special Needs Plan (SNP) to serve individuals living in the community but requiring an institutional level of care, although this was not included in the regulatory definition. (Many beneficiaries who would qualify for institutional status in the community reside in some type of assisted living facility (ALF).)
All SNP applications are required to provide a description of the SNP model of care that the Medicare Advantage Organization (MAO) has designed and must implement specifically to serve the special population in the MAO’s SNP. This model of care drives the approach to patient assessment, as well as the organization, coordination and delivery of Medicare (and other) services by a team of providers based on the level and type of care needed by the beneficiary. Some aspects of the model of care, as well as how it would be implemented, would vary depending on the site of care (LTC facility versus in the community).
Medicare Advantage Organizations (MAOs) offering an institutional SNP can limit enrollment to individuals in one or more contracted institutions and the institutions would, in effect, comprise the SNP service area. Institutional SNPs can restrict enrollment to those individuals residing in a long term care facility and are not required to serve individuals in a community setting.
An institutional SNP can limit its enrollment to those individuals living in the community who require an institutional level of care as determined by a State assessment, and the MAO is not required to serve individuals residing in a long term care facility.
The MAO can also serve both populations in its institutional SNP.
Policy Clarification #1
MAOs
offering an institutional SNP to serve Medicare residents of LTC
facilities must have a contractual arrangement with (or own and
operate) the LTC facility to deliver its SNP model of care. If for
any reason the MAO’s contract with a long term care facility
terminates, the SNP enrollee will be offered the option to move to
one of the MAO’s other contracted facilities or be
disenrolled.
The contracted/owned approach provides assurances that beneficiaries will be assessed and receive services as required under the SNP model of care. The institutional setting is complex and requires coordination between the SNP and facility providers and administrative staff, which can not be attained without a strong, well articulated MAO/facility relationship. Without a contractual or ownership arrangement, the MAO can not ensure the complex interface will function appropriately and care will be delivered in accordance with the model of care will be delivered.
Policy Clarification #2
An MAO may continue to designate where it will target the operation of its SNP model of care – in contracted LTC facilities, in the community (e.g., assisted living facilities), or both. MAO marketing materials and outreach for new enrollment must be limited to the CMS approved target. If the MAO’s institutional SNP enrollee changes residence, the MAO must have appropriate documentation that it is prepared to implement the SNP model of care at the beneficiary’s new residence, or disenroll the resident. Appropriate documentation includes that the MAO has a contract with the LTC facility to provide the SNP model of care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP model of care.
ATTACHMENT C
Attestation for Special Needs Plans (SNP) Serving Institutionalized Beneficiaries
(Name of Organization)
(H number)
I attest that in the event the above referenced organization has a CMS approved institutional SNP, the organization will only enroll beneficiaries in the SNP who (1) reside in a Long Term Care (LTC) facility under contract with the organization offering the SNP to provide services in accordance with the institutional SNP model of care approved by CMS, or (2) agree to move to such a facility following enrollment.
I attest that in the event the above referenced organization has a CMS approved institutional SNP to provide services to community dwelling beneficiaries who otherwise meet the institutional status as determined by the State, the SNP will ensure that the necessary arrangements with the community are in place to ensure beneficiaries will be assessed and receive services as specified by the SNP model of care.
I attest that if a SNP enrollee changes residence, the SNP will have appropriate documentation that it is prepared to implement the SNP model of care at the beneficiary’s new residence, or disenroll the resident in accordance with CMS enrollment/disenrollment policies and procedures. Appropriate documentation includes that the SNP has a contract with the LTC facility to provide the SNP model of care, and written documentation of the necessary arrangements in the community setting to ensure beneficiaries will be assessed and receive services as required under the SNP model of care.
___________________________ ____________________________
CEO DATE
___________________________ ____________________________
CFO DATE
(See Medicare Managed Care Manual Chapters 2, 4, 13, and 14 and the Medicare Marketing Guidelines)
If the applicant is requesting an exception to covering a particular counseling or referral service due to moral or religious grounds, state the service and explain the reasons for the request.
Definition: [422.80(b)]
Marketing materials include any applicable informational materials targeted to Medicare beneficiaries which: (1) Promotes the applicant, or any MA plan offered by the applicant; (2) Inform Medicare beneficiaries that they may enroll, or remain enrolled in an MA plan offered by the applicant; (3) Explain the benefits of enrollment in a MA plan, or rules that apply to enrollees; (4) Explain how Medicare services are covered under an MA plan; including conditions that apply to such coverage.
The marketing materials listed below do not have to be submitted with the application or approved prior to the contract being awarded. However, before an applicant can market or advertise its Medicare products, the applicant must be in compliance with the statutory requirements for approval of marketing materials and election forms as outlined in Section 1851 of the Social Security Act, Section 422.80 of the CFR and the Medicare Marketing Guidelines.
Advertising Materials (related to SAE only)
Provider Directory (template)
Provider Marketing Materials (if applicable)
Subscriber agreement/Evidence of coverage
Summary of Benefits
(Section applicable only for MSA SAE applicants. Ccomplete only if there have been changes since the initial
aApplication or last monitoring visit.)
Describe how the applicant will ensure that individuals enroll in your MSA plan only during their Initial Coverage Election Period (ICEP), or the Annual Coordinated Election Period (AEP).
Describe how the applicant will ensure that individuals disenroll from your MSA plan only during the appropriate election periods (SEP or AEP).
Describe how the applicant will ensure that individuals enrolled in health benefit plans with FEHB, VA or DOD are not able to enroll in your MSA plan.
Describe the systems, policies and procedures for identifying Medicare working aged enrollees. Note that such individuals are excluded from enrollment in an MA MSA plan. Also note that should an MA MSA plan enrollee become working aged after enrollment, disenrollment is required.
Describe how the applicant will ensure that individuals who elect hospice do not enroll in your MSA plan.
Describe how the applicant will obtain assurances from the enrollee that he or she will reside in the United States for at least 183 days during the year for which election is effective.
Describe how the applicant will incorporate the establishment of member MSA accounts into the plan’s enrollment process. How will the MSA trustee validate these enrollments?
(Not applicable to MSA SAE applicants.)
The Medicare Modernization Act requires that coordinated care plans offer at least one MA plan that includes a Part D prescription drug benefit (an MA-PD) in each county of its service area. To meet this requirement, the applicant must timely complete and submit a separate Medicare Advantage Group Prescription Drug Plan application (MA-PD application) in connection with the MA-PD. Failure to file the required MA-PD application will result in a denial of this application and will be considered an “incomplete” MA application.
The MA-PD application can be found at:
http://www.cms.hhs.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.asp#TopOfPage or the applicant may contact Marla Rothouse at 410/786-8063. Specific instructions to guide MA applicants in applying to qualify to offer a Part D benefit during 2007 are provided in the MA-PD application.
The MA-PD application is an abbreviated version of the application used by stand-alone Prescription Drug Plan (PDPs), as the regulation allows CMS to waive provisions that are duplicative of MA requirements or where a waiver would facilitate the coordination of Part C and Part D benefits. Further, the MA-PD application includes a mechanism for applicants to request CMS approval of waivers for specific Part D requirements under the authority of 42 CFR 423.458 (b)(2).
Service Area Maps……………………………………………………………………………….
State Certification Form [crt.doc] ……………………………………………………………….
Legal Table 1 [legal-1.xls] ……………………………………………………………………..
Template Contracts/Agreements for Administrative/Management Services……………………
Matrix for Administrative/Management Services [matrixadm.doc] …………………………….
Legal Table 2 – Provider Arrangements [legal-2.xls]…………………………………………..
Template Contracts/Agreements for Direct Provider Contracts...........…………………………
Matrix for Direct Provider Contracts/Agreements [matrix1.doc]………………………………..
Template Contracts for Subcontracts (Medical Groups, IPAs, PHOs, etc.)…..………………....
Matrix for Subcontracted Provider Contracts/Agreements [matrix1.doc]..………………………
HSD Table 1 [HSD.xls]………………………………………………………………………
HSD Table 2 [HSD.xls]………………………………………………………………………
HSD Table 2A [HSD.xls]..…………………………………………………………………..
HSD Table 3 [HSD.xls]………………………………………………………………………
HSD Table 3A [HSD.xls]…………………………………………………………………….
HSD Table 4 [HSD.xls]………………………………………………………………………
HSD Table 5 [HSD.xls]………………………………………………………………………
Marketing Materials ……………………………………………….
To add the page numbers for the Documents table of contents, place cursor at the end of each line (using the End key) and type in the page number. Do not press ENTER, just place the cursor at the end of the next line for the next page entry.
1 How to Select a Frail Elderly Population? A Comparison of Three Working Definitions; Paw, Dekker, Fesken, Schouten and Kromhout, Journal of Clinical Epidemiology, Volume 52, Issue 11, November 1999, pages 1015-1021
| File Type | application/msword |
| File Title | MEDICARE ADVANTAGE |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2007-01-19 |
| File Created | 2007-01-19 |