JustCare

Tag: Special Needs Plan

  • Insurers focus on Medicare Advantage Special Needs Plans to maximize profits

    Insurers focus on Medicare Advantage Special Needs Plans to maximize profits

    Laura Beerman writes for HealthLeaders about how Medicare Advantage insurers are making out like bandits from offering care to people in Medicare Advantage “Special Needs Plans” or SNPs. Insurers like the Medicare Advantage program because they profit more from Medicare Advantage plans than from other insurance they offer. Providing Medicare coverage to people who have both Medicare and Medicaid in D-SNPs is even more lucrative than providing Medicare coverage to people who have only Medicare.

    Medicare Advantage Special Needs Plans are intended to cover people with Medicare and Medicaid, people with chronic or disabling conditions, including people with diabetes, HIV/AIDS, and dementia, as well as people living in a nursing home or requiring nursing care at home. But, it is not clear that most of the SNPs actually provide people with good Medicare benefits from high quality providers. People eligible for SNPs should seriously consider traditional Medicare, which makes it easy to get care from the providers you want to see anywhere in the US. People with Medicare and Medicaid generally have no out-of-pocket costs in traditional Medicare.

    Insurers are getting an increasing number of SNP enrollees. The number of SNP enrollees has doubled in the last five years. Insurers are also offering more SNP plans. Insurers make twice the profits from SNPs covering people with Medicare and Medicaid than they do from people without Medicaid in Medicare Advantage plans.

    It’s not clear whether people in SNPs understand what they are giving up when they opt for a SNP instead of traditional Medicare. People with Medicare and Medicaid in SNPs tend to be especially vulnerable, in poor health and living on small incomes, struggling to make ends meet. They also often struggle to keep their Medicaid eligibility.

    The Biden administration made it a little harder for the Medicare Advantage insurers to run away with as many taxpayer dollars as they’d like. As a result of some reforms that rein in Medicare Advantage payments a little, the Medicare Advantage market is changing somewhat. Insurers want big profits. So, some insurers have ended some Medicare Advantage plans that are less profitable.

    More than half of people in D-SNPs (people with Medicare and Medicaid) are in either a UnitedHealth Medicare Advantage plan or a Humana Medicare Advantage plan.

    Here’s more from Just Care:

  • Who’s enrolling in Medicare Special Needs Plans?

    Who’s enrolling in Medicare Special Needs Plans?

    Becker’s Payer Issues reports that Medicare Advantage Special Needs Plans–health plans for people with Medicare and Medicaid–are the fastest growing segment of the Medicare Advantage market. They offer coverage in 45 states. But, at least one study of Special Needs Plans suggest that they might not offer better care management than standard Medicare Advantage plans, even though they cost more.

    Nearly half of dual-eligibles–people with Medicare and Medicaid–are enrolled in a Special Needs Plan, about 5.5 million out of 12.5 million. The vast majority of them (87 percent) have incomes under $20,000 a year. Four in ten of them have incomes under $10,000.

    One in eight dual-eligibiles (13 percent) are living in a long-term care facility. Only one in 100 people with Medicare live in a long-term care facility. And, about half of dual-eligibles are people of color. One in five people in the Medicare population are people of color.

    In Traditional Medicare, dual-eligibles represent 17 percent of the population and 33 percent of spending. Inexplicably, spending information for the dual-eligibles in Medicare Advantage is not available. More than four in ten of the dual-eligible population (44 percent) is in fair or poor health; overall, 17 percent of people with Medicare are in fair or poor health.

    The government offers people three different types of Special Needs Plans. With 4.9 million enrollees, D-SNPs for dual-eligibles have the largest population. C-SNPs provide care to 450,000 people with chronic or disabling conditions, particularly people with disabilities and cardiovascular disease. And, !-SNPs serve 107,000 people getting institutional care.

    Clearly, the health insurance industry sees big dollar signs with Special Needs Plans. They get paid more for dual-eligibles and, as it is, they get paid handsomely for treating the general Medicare population through Medicare Advantage. Enrollment in Special Needs Plans is up more than 17 percent in four years. Enrollment in Medicare Advantagage is up 8.3 percent.

    And, you guessed it, UnitedHealthcare covers 39.9 percent of people enrolled in Special Needs Plans. Humana covers 15 percent of people enrolled in Special Needs Plans.

    Here’s more from Just Care:

  • People with Medicare and Medicaid in Special Needs Plans at extra risk

    People with Medicare and Medicaid in Special Needs Plans at extra risk

    A paper in Health Affairs by Marc A. Cohen et al. explains that people with Medicare and Medicaid, “dual-eligibles,” enrolled in commercial Medicare Special Needs Plans, a type of Medicare Advantage plan, are now at extra risk. A new guideline by the Center for Medicare and Medicaid Services (CMS) severely restricts their right to disenroll from these plans. Yet, the data show that dual-eligibles with complex conditions may need to leave Special Needs Plans in order to get appropriate care.

    Dual-eligibles with complex conditions have been disenrolling at high rates from Special Needs Plans. And, it’s likely it’s because they are not getting the care they need. It’s hard to believe that dual-eligibles are jumping at the chance to leave their SNPs if they are getting the care they need. Changing health plans is never fun, always involves time and energy, and usually also stress and frustration.

    Keeping enrollees who choose to leave SNPs from disenrolling is not in these enrollees’ best interests. As of January 1, 2019, however, dual-eligibles may not leave their Special Needs Plan any month of the year, a protection they have always had. They must remain in their SNPs for at least three months, except during the Medicare Advantage Open Enrollment Period, between January and March of each year. Many states limit the disenrollment rights of dual-eligibles even further.

    The new guideline from the Centers for Medicare and Medicaid Services (CMS) supports the financial interests of Special Needs Plans (SNPs) that fail to provide good care to their enrollees. Cohen et al. explain that there is a high correlation between enrollees with complex conditions disenrolling from SNPs and low-quality SNPs. Another recent study showed high rates of disenrollment from Medicare Advantage plans for dual-eligibles with complex conditions.

    The new policy compromises the health of low income older adults and people with disabilities. It gives SNPs the ability to count on additional Medicare and Medicaid income that they previously had not been able to count on, even when they deliver poor care. Supporters of the new policy claim that it gives enrollees more time to adjust to the SNPs. Of course, if the SNPs are not serving their needs, it’s unclear why forcing enrollees to remain in the SNPs is helpful to them.

    To determine whether disenrollment from SNPs was associated with poor SNP performance, the paper’s authors looked at SNP quality measures. They found that the SNPs with poor performance were far more likely to see high disenrollment rates. Unfortunately, dissatisfied enrollees will no longer be able to leave as quickly as they had been able to.

    Here’s more from Just Care:

  • What’s a Medicare Special Needs Plan?

    What’s a Medicare Special Needs Plan?

    Medicare offers commercial health insurance coverage to help people with special needs through Medicare Special Needs Plans. The commercial health plans are a type of Medicare Advantage plan, which are only available in certain areas to certain people. If you qualify, should you join?

    Each Special Needs Plan (SNP) contracts with the Centers for Medicare and Medicaid Services to meet the needs of people with particular conditions. If you enroll in a Medicare SNP, you will only be covered for care from doctors and hospitals in its network.

    Who can enroll in a Medicare Special Needs Plan? A Medicare Special Needs Plan (SNP) is exclusively for people who have particular disabling conditions that the health plan is designed to address, people with both Medicare and Medicaid, “dual-eligibles,” and nursing home residents or other people who need an institutional level of care.

    What are your costs in a Medicare Special Needs Plan? As with all Medicare Advantage plans, your costs will vary depending upon the SNP you join and the care you use. However, if you are enrolled in Medicaid as well as Medicare, you should have no out-of-pocket costs so long as you use network providers. Each SNP sets premiums, copays and deductibles differently. All SNPs must provide Medicare Part D drug coverage, but each may cover a different array of drugs and set different copays. 

    What are your additional benefits in a Medicare Special Needs Plan? SNPs should offer care management and care coordination services to help you better manage your conditions. But, each one is different. If you are considering one of these plans, you should make sure you understand what additional benefits will be available to you, your out-of-pocket costs, and any restrictions on your access to care. For example, are you required to get a referral from a primary care doctor in order to see a specialist?

    Before enrolling in a Medicare Special Needs Plan, make sure you know the tradeoffs between enrolling in that plan and enrolling in traditional Medicare, which covers your care from most doctors and hospitals anywhere in the U.S. Click here to learn key differences between traditional Medicare and Medicare Advantage plans.

    If you are unhappy with your SNP, you have the right to disenroll. However, beginning in January 2019, you can no longer disenroll any month. As a general rule, you must remain in the plan for at least three months. Exception: You may disenroll at any time during the Medicare Advantage Open Enrollment Period, between January and March 31 of each year.

    Two recent studies reveal that people enrolled in Medicare Advantage plans, including Special Needs Plans, tend to disenroll at high rates and enroll in traditional Medicare when they develop complex conditions.

    Here’s more from Just Care: