As Part of an ongoing series, we have previously provided details on the structure, funding, and evaluation of the Maternal, Infant, Early Childhood, Home Visiting (MIECHV) program, Medicare therapy caps, and community health center funding.  This post marks is the first in an exploratory series illuminating the structure, funding, and outlook of the Special Needs Plans (SNPs).  Additionally, drawing on potential riders affected by the current health care minibus, the “minibus” refers to a handful of policy provisions tied together in one piece of legislation. Undoubtedly, this minibus will carry a number of provisions into law. The number of riders who will be on board when the minibus leaves the station remains to be seen. However, as Congress gears up for a mega-package in December – including the debt limit and the budget – there is the potential to incorporate the minibus and/or a health care stabilization package.

Future posts will review additional details of other potential riders on the minibus.

Overview

SNPs, which are a subset of Medicare Advantage plans, are expressly designed to target care and limit enrollment to individuals with special needs. SNPs include:

• Dual-eligible special needs plans (D-SNPs), designed for individuals dually eligible for Medicare and Medicaid. D-SNP plans provide a coordinated Medicaid and Medicare benefit package that offers more integrated care than regular Medicare Advantage plans or traditional Medicare FFS. D-SNPscontract with the state Medicaid agency to provide Medicaid benefits or arrange for Medicaid benefits to be provided.

• Chronic condition special needs plans (C-SNPs), limited to individuals with specific severe or disabling chronic conditions.

• Institutional special needs plans (I-SNPs), restricted to individuals whom, for 90 days or longer, have needed or are expected to need the level of services provided in an institutional setting.

Current SNP authorization provisions are set to expire December 31, 2018. For these programs to continue, Congress will need to extend or permanently authorize the programs.

Released in September 2017, the most recent Comprehensive SNP Report published by the Centers for Medicare & Medicaid Services (CMS), indicates that there are more than 2 million current D-SNP beneficiaries, over 345,000 individuals enrolled in C-SNPs, and approximately 67,000 I-SNP recipients. Additionally, of the 583 SNP plans, D-SNPs constitute approximately 65% of all SNP plans.

Medicare and Medicaid Integration in D-SNPs

D-SNPs are intended to coordinate Medicare and Medicaid services, as well as integrate the financial structure of the Medicare and Medicaid programs. However, studies have shown that some D-SNPs do not clinically or financially integrate Medicaid benefits, and do not cover some or all of Medicaid’s LTSS or behavioral health services. Fully Integrated Dual Eligible (FIDE) SNPs were created through the ACA to promote the full integration and coordination of Medicare and Medicare benefits, and financing of services, for dually eligible beneficiaries.

However, to date there are very few FIDE SNPs. In 2013, the Medicare Payment Advisory Commission (MedPAC) recommended to reauthorize only those D-SNP plans that assume clinical and financial responsibility for Medicare and Medicaid benefits, and to allow the authority for all other D-SNPs to expire.

Next Steps for SNPs

Both the Senate and House have indicated movement on SNP reauthorization intentions. On Tuesday, September 26^th, the same day the Graham-Cassidy healthcare bill “died”, the Senate unanimously passed The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017. This bill would permanently authorize SNPs. Additionally, the bill works to improve Medicare and Medicaid integration among D-SNPs. It includes requirements on coordinating Medicaid’s long term services and supports and behavioral health services in D-SNP contracts and thus addresses some of the Medicare-Medicaid integration issues noted above. Further, the bill authorizes the Secretary of HHS to establish procedures to develop a unified Medicare and Medicaid appeals and grievance process for individuals in D-SNPs, which aims to improve the administrative processes between Medicare and Medicaid for dually eligible beneficiaries.

Other provisions of the bill call for improving C-SNPs care management, revising the current chronic care definition, and directing the HHS Secretary, every five years, to revisit the definition of a qualifying chronic condition. The CHRONIC Care Act additionally extends the Independence at Home demonstration program for two years, expands the use of telehealth services, and rescinds funding meant to improve the Medicare fee-for-service program. CBO estimates that the CHRONIC Care Act would reduce direct spending for the Medicare and Medicaid programs by $217 million from 2018-2022. This bill has been referred to the House Ways and Means Committee and Energy and Commerce Committee.

On the House side, the House Ways and Means Committee introduced and approved bill H.R. 3168. As it pertains to SNPs, H.R. 3168 has similar, if not the same, provisions as the CHRONIC Care Act.  H.R. 3168 would create a unified Medicare and Medicaid appeals and grievance process for D-SNPs; improve C-SNP care management; revise the definition of chronic care and Medicare-Medicaid integration requirements for D-SNPs; and direct the Secretary to revisit the definition of a qualifying chronic condition every five years. However, while the Senate bill permanently authorizes SNPs, the House bill would reauthorize D-SNPs and C-SNPs for only 5 years and only permanently reauthorize I-SNPs. CBO estimates H.R. 3168 would increase direct spending by $119 million between 2017 and 2027.

Also of note, the House Energy and Commerce Health Subcommittee unanimously advanced seven Medicare-related bills to the full Committee on September 13^th. These bills include many of the same provisions that are in the CHRONIC Care Act, but did not include a bill focused on SNP reauthorization. So far the E&C Committee held a hearing on SNPs in July and published a discussion draft on SNP reauthorization.

In short, SNP reauthorization contains an array of moving parts. We will be watching how SNP reauthorization interacts with the rest of the health care minibus, the health care stabilization package, and a large mega-deal encompassing the budget and debt limit.

*Nicole Meyerson of MLS Strategies also contributed to this post.