Medicare Special Needs Plans:

CMS Should Improve Information Available about Dual-Eligible Plans' Performance

GAO-12-864: Published: Sep 13, 2012. Publicly Released: Sep 19, 2012.

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James C. Cosgrove
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Why GAO Did This Study

About 9 million of Medicare's over 48 million beneficiaries are also eligible for Medicaid because they meet income and other criteria. These dual-eligible beneficiaries have greater health care challenges than other Medicare beneficiaries, increasing their need for care coordination across the two programs. In addition to meeting all the requirements of other MA plans, D-SNPs are required by CMS to provide specialized services targeted to the needs of dual-eligible beneficiaries as well as integrate benefits or coordinate care with Medicaid services. GAO was asked to examine D-SNPs' specialized services to dual-eligible beneficiaries. GAO (1) analyzed the characteristics of dual-eligible beneficiaries in D-SNPs and other MA plans, (2) reviewed differences in specialized services between D-SNPs and other MA plans, and (3) reviewed how D-SNPs work with state Medicaid agencies to enhance benefit integration and care coordination. GAO analyzed CMS enrollment, plan benefit package, projected revenue, and beneficiary health status data; reviewed 15 D-SNP models of care and 2012 contracts with states; and interviewed representatives from 15 D-SNPs and Medicaid agency officials in 5 states.

What GAO Found

About 9 percent of the dual-eligible population is enrolled in 322 Medicare dual-eligible special needs plans (D-SNP), a type of Medicare Advantage (MA) plan. All dual-eligible beneficiaries are low income, but those in D-SNPs tended to have somewhat different demographic characteristics relative to those dual-eligible beneficiaries in other MA plans. On the basis of the most current data available (2010-2011), compared to those in other MA plans, dual-eligible beneficiaries in D-SNPs were more frequently under age 65 and disabled, more likely to be eligible for full Medicaid benefits, and more frequently diagnosed with a chronic or disabling mental health condition. In spite of these differences, the health status of D-SNP enrollees as measured by their expected cost to Medicare was similar to the health status of dual-eligible enrollees in other MA plans in 2010. D-SNPs provide fewer supplemental benefits--benefits not covered by Medicare fee-for-service (FFS)--on average, than other MA plans. Of the 10 supplemental benefits offered by more than half of D-SNPs, 7 were offered more frequently by other MA plans and 3 were offered more frequently by D-SNPs. Yet D-SNPs spent proportionately more of their rebate--additional Medicare payments received by many plans--to fund supplemental benefits compared to other MA plans, and less to reduce Medicare cost-sharing, which is generally covered by Medicaid. The models of care GAO reviewed, of 107 submitted for 2012, described in varying detail how the D-SNP planned to provide specialized services, such as health risk assessments, and meet other requirements, such as measuring performance. However, the Centers for Medicare & Medicaid Services (CMS), which administers Medicare and oversees Medicaid, did not require D-SNPs to use standardized measures in the models of care, which would make it possible to compare the performance of D-SNPs. While D-SNPs are not required to report that information to CMS, such information would be useful for future evaluations of whether D-SNPs met their intended results, as well as for comparing D-SNPs. CMS stated that contracts between D-SNPs and state Medicaid agencies are an opportunity to increase benefit integration and care coordination. Our review of the contracts indicated only about one-third of the 2012 contracts contained any provisions for benefit integration, and only about one-fifth provided for active care coordination between D-SNPs and Medicaid agencies, which indicates that most care coordination was done exclusively by D-SNPs, without any involvement of state Medicaid agencies. However, some D-SNP contracts with state Medicaid agencies specified that the agencies would pay the D-SNPs to provide all or some Medicaid benefits. Representatives from the D-SNPs and Medicaid officials from the states GAO interviewed expressed concerns about the contracting process, such as limited state resources for developing and overseeing contracts, as well as uncertainty about whether Congress will extend D-SNPs as a type of MA plan after 2013, and the implementation of other initiatives to coordinate Medicare and Medicaid benefits for dual-eligible beneficiaries that could replace D-SNPs. To increase D-SNPs' accountability, GAO recommends improving D-SNP reporting of services provided to dual-eligible beneficiaries and making this information available to the public. In its comments on a draft of GAO's report, CMS generally agreed with our recommendations.

For more information, contact James C. Cosgrove at (202) 512-7114 or CosgroveJ@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: In January 2014, CMS reorganized and revised the model of care elements required of all special needs plans (SNP), including dual-eligible SNPs (D-SNP), in order to promote clarity and enhance the focus on care coordination, care transition, care needs, and activities. SNPs that were required to submit a model of care were required to use this revised model of care structure for the first time as part of the calendar year 2015 application cycle. After reviewing the reorganized model of care elements in Ch. 5 of the Medicare Managed Care Manual, GAO determined that the revised elements required D-SNPs to report more comprehensive and detailed information on the characteristics and health needs of beneficiaries in their plan area, including those of the most vulnerable beneficiaries. The revised elements also place a focus on care coordination, as specific elements from the original model of care are now reorganized underneath an overarching element of care coordination. However, CMS still does not require D-SNPs to explicitly state the extent of services they expect to provide in their models of care (e.g., by requiring D-SNPs to report the number of beneficiaries that they expect to receive services). Therefore, while these revised elements could serve to help increase accountability and facilitate a more systematic evaluation of D-SNPs, CMS has not indicated that it intends to require D-SNPs to report the extent of services they expect to provide, which would help enable CMS to evaluate if D-SNPs are meeting their intended goals.

    Recommendation: To increase D-SNPs' accountability and ensure that CMS has the information it needs to determine whether D-SNPs are providing the services needed by dual-eligible beneficiaries, especially those who are most vulnerable, the Administrator of CMS should require D-SNPs to state explicitly in their models of care the extent of services they expect to provide, to increase accountability and to facilitate evaluation.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  2. Status: Closed - Not Implemented

    Comments: CMS officials told us that CMS has revised its contract with the National Committee for Quality Assurance (NCQA) to include the development of quantifiable care coordination outcome measures that will be designed for all Medicare Advantage (MA) coordinated care plans, including special needs plans (SNP). These measures have not yet been developed, as the period of performance for the contract is September 30, 2014 through September 28, 2016. However, CMS officials told us that quality measures are not reported as part of SNPs' models of care, and that the quality outcomes measures that are developed through this contract are intended to be sufficiently robust to potentially add to the Part C Star Ratings system in the future. As such, they will potentially be included as part of the HEDIS measures collected annually by CMS. According to CMS officials, the revised contract with NCQA was not a direct result of GAO's recommendations. Rather, the modified contract reflects the recognition that effective care coordination processes are vital to high-quality care for MA enrollees, particularly those most vulnerable. CMS also continues to require all D-SNPs, as well as all SNPs and MA plans, to submit standard performance and outcome measures. According to CMS officials, all SNP-specific HEDIS measures have remained the same since GAO issued GAO-12-864, though they noted that HEDIS, Health Outcomes Survey (HOS), and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measure specifications for all MA plans--including D-SNPs--may be refined over time.

    Recommendation: To increase D-SNPs' accountability and ensure that CMS has the information it needs to determine whether D-SNPs are providing the services needed by dual-eligible beneficiaries, especially those who are most vulnerable, the Administrator of CMS should require D-SNPs to collect and report to CMS standard performance and outcome measures to be outlined in their models of care that are relevant to the population they serve, including measures of beneficiary health risk, beneficiary vulnerability, and plan performance.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  3. Status: Closed - Not Implemented

    Comments: CMS officials said that CMS systematically analyzes outcome data via HEDIS, CAHPS, and HOS on a yearly basis, and that these analyses are ongoing efforts and not a direct result of GAO's recommendation in GAO-12-864. They said that CMS has taken steps to make more data on D-SNPs available to the public as a result of this recommendation. Specifically, CMS now makes the SNP model of care summary reports, as well as the Structure and Process Measures and HEDIS reports, publically available. However, we are closing this recommendation as not implemented because it refers specifically to an analysis of standard performance and outcome measures from D-SNPs' models of care, and CMS officials have made clear that they do not intend to include these types of measures in D-SNPs' models of care.

    Recommendation: To increase D-SNPs' accountability and ensure that CMS has the information it needs to determine whether D-SNPs are providing the services needed by dual-eligible beneficiaries, especially those who are most vulnerable, the Administrator of CMS should systematically analyze these data and make the results routinely available to the public.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  4. Status: Open

    Comments: According to CMS officials, due to budget constraints, as of August 2014 CMS had not conducted an evaluation to examine the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve. Officials said that they were uncertain whether an evaluation of D-SNPs would be conducted in the future, since the likelihood of an evaluation would be dependent on availability of funding for an independent contract. However, they noted that, to the extent that CMS is able to develop solid care coordination outcome measures (which would be incorporated into the HEDIS requirements), that they expect these measures will serve as key indicators of D-SNP performance.

    Recommendation: To increase D-SNPs' accountability and ensure that CMS has the information it needs to determine whether D-SNPs are providing the services needed by dual-eligible beneficiaries, especially those who are most vulnerable, the Administrator of CMS should conduct an evaluation of the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve, and report the results in a timely manner.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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