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entitled 'Medicare Special Needs Plans: CMS Should Improve Information
Available about Dual-Eligible Plans' Performance' which was released
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United States Government Accountability Office:
GAO:
Report to Congressional Requesters:
September 2012:
Medicare Special Needs Plans:
CMS Should Improve Information Available about Dual-Eligible Plans'
Performance:
GAO-12-864:
GAO Highlights:
Highlights of GAO-12-864, a report to congressional requesters.
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.
What GAO Recommends:
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.
View [hyperlink, http://www.gao.gov/products/GAO-12-864]. For more
information, contact James C. Cosgrove at (202) 512-7114 or
CosgroveJ@gao.gov.
[End of section]
Contents:
Letter:
Background:
Dual-Eligible Beneficiaries in D-SNPs Had Similar Health Status to
Other Dual-Eligible Beneficiaries:
D-SNPs Typically Offer Fewer Supplemental Benefits Than Other MA
Plans, and Information on Planned Services Is Not Comparable:
Although Some D-SNP Contracts with State Medicaid Agencies Expressly
Provide for Benefit Integration or Care Coordination, Most Do Not:
Conclusions:
Recommendations for Executive Action:
Agency and Other External Comments and Our Evaluation:
Appendix I: Comments from the Department of Health & Human Services:
Appendix II: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Legislation Establishing and Modifying Authority for Special
Needs Plans (SNP) to Operate under the Medicare Advantage (MA) Program:
Table 2: Percentage of Rebate Allocated to Supplemental Benefits,
Reducing Cost Sharing, and Premium Reduction, 2012:
Figures:
Figure 1: Enrollment of Dual-Eligible Beneficiaries by Plan Type, 2011:
Figure 2: Characteristics of Dual-Eligible Beneficiaries in D-SNPs
Compared with Dual-Eligible Beneficiaries in Other MA Plans and FFS:
Figure 3: Average Risk Scores of Dual-Eligible Beneficiaries by
Characteristic and Plan Type, 2010:
Figure 4: Supplemental Benefits Offered by More Than Half of Dual-
Eligible Special Needs Plans (D-SNP) Compared with Other Medicare
Advantage (MA) Plans, 2012:
Figure 5: Dual-Eligible Special Needs Plans (D-SNP) Integration of
Medicaid Benefits, 2012:
Abbreviations:
CMS: Centers for Medicare & Medicaid Services:
C-SNP: chronic condition special needs plan:
D-SNP: dual-eligible special needs plan:
ESRD: end-stage renal disease:
FFS: fee-for-service:
FIDESNP: fully integrated dual-eligible special needs plan:
HCPP: health care prepayment plan:
HEDIS: Healthcare Effectiveness Data and Information Set:
HHS: Department of Health and Human Services:
I-SNP: institutional special needs plan:
MA: Medicare Advantage:
MedPAC: Medicare Payment Advisory Commission:
MIPPA: Medicare Improvements for Patients and Providers Act of 2008:
MMA: Medicare Prescription Drug, Improvement, and Modernization Act of
2003:
NCQA: National Committee for Quality Assurance:
PACE: Program of All-Inclusive Care for the Elderly:
PPACA: Patient Protection and Affordable Care Act:
SNP: special needs plan:
SSA: Social Security Act:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 13, 2012:
The Honorable Sander Levin:
Ranking Member:
Committee on Ways and Means:
House of Representatives:
The Honorable Henry A. Waxman:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Pete Stark:
Ranking Member:
Subcommittee on Health:
Committee on Ways and Means:
House of Representatives:
About 9 million of Medicare's over 48 million beneficiaries are also
eligible for Medicaid, a joint federal-state program that finances
health insurance coverage for certain categories of low-income adults
and children.[Footnote 1] In 2007, these individuals, referred to as
dual-eligible beneficiaries, made up 18 percent of all Medicare
beneficiaries but accounted for 31 percent of Medicare spending.
[Footnote 2] In the same year, dual-eligible beneficiaries were about
15 percent of Medicaid enrollees but accounted for nearly 40 percent
of Medicaid spending.[Footnote 3] Disproportionate spending for these
individuals is largely because dual-eligible beneficiaries are more
likely than other Medicare beneficiaries to be disabled; report poor
health status and limitations in their activities of daily living,
such as bathing and toileting; and have cognitive impairments, mental
disorders, and certain chronic conditions such as diabetes and
pulmonary disease. In addition, dual-eligible beneficiaries' health
care services must be coordinated across Medicare and Medicaid, and
each program has its own set of covered services, provider networks,
regulations, and payment policies.
The Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (MMA) authorized the creation of a type of Medicare Advantage
(MA) plan referred to as a special needs plan (SNP), to address the
unique needs of certain Medicare populations.[Footnote 4] About 1.2
million of the dual-eligible population is enrolled in dual-eligible
SNPs (D-SNP),[Footnote 5] which are SNPs exclusively for dual-eligible
beneficiaries. Dual-eligible beneficiaries may also choose to enroll
in other types of SNPs for which they are eligible, including
institutional SNPs (I-SNP) for individuals residing in nursing
facilities or institutions, chronic condition SNPs (C-SNP) for
individuals with severe or disabling chronic conditions, or other MA
plans, or remain in Medicare fee-for-service (FFS).[Footnote 6] In
addition to meeting all the requirements of other MA plans, all SNPs,
including D-SNPs, are required by the Centers for Medicare & Medicaid
Services (CMS)--the agency in the Department of Health and Human
Services (HHS) that administers Medicare and oversees Medicaid--to
provide specialized services targeted to the needs of their
beneficiaries, including a health risk assessment and an
interdisciplinary care team for each beneficiary enrolled.[Footnote 7]
You asked us to examine the extent to which D-SNPs provide unique
services for dual-eligible beneficiaries and how D-SNPs and states
work together to serve these beneficiaries. In this report, we (1)
describe the characteristics and health status of dual-eligible
beneficiaries in D-SNPs and how they compare to those of dual-eligible
beneficiaries in other MA plans and Medicare FFS, (2) determine the
extent to which D-SNPs' specialized services differ from those offered
by other MA plans, and (3) describe how D-SNPs work with state
Medicaid agencies to enhance benefit integration and care coordination
for dual-eligible beneficiaries.
To describe the demographic characteristics of dual-eligible
beneficiaries in D-SNPs and how they compare to those of dual-eligible
beneficiaries in other MA plans and Medicare FFS, we analyzed July
2011 enrollment data from CMS. To compare the mental health
characteristics and health status of dual-eligible beneficiaries in D-
SNPs with dual-eligible beneficiaries enrolled in other MA plans and
FFS, we analyzed CMS data on 2010 beneficiary risk scores, which
measure expected Medicare costs for each beneficiary on the basis of
demographic and diagnosis data.[Footnote 8] Specifically, we
calculated the average risk scores for dual-eligible beneficiaries in
D-SNPs, other MA plans, and FFS in 2010.[Footnote 9] In all of these
analyses, we used enrollment and plan benefit data to identify the
type of plan (D-SNP, other MA plan, or FFS) in which each beneficiary
was enrolled.
To determine the extent to which D-SNPs' specialized services differed
from services offered by other MA plans, we used CMS's 2012 plan
benefit data to compare D-SNPs' supplemental benefits, such as dental
and vision coverage, that are outside the original Medicare FFS
benefit package, with the supplemental benefits offered by other MA
plans.[Footnote 10] We also used CMS's 2012 bid pricing tool data,
which contain information MA plans submitted to CMS on their projected
revenue requirements for providing Medicare-covered services to
enrolled beneficiaries, to understand how D-SNPs and other MA plans
fund the supplemental benefits they offer. Additionally, we
interviewed officials from 15 D-SNPs that had enrolled at least 100
dual-eligible beneficiaries in both 2010 and 2011 to discuss what
services are available to dual-eligible beneficiaries in D-SNPs and,
when applicable, whether differences exist between the care
coordination services they offer in their D-SNPs and their MA
organization's other MA plans. We judgmentally selected these D-SNPs
to cover a range of geographic regions and plan sizes. We also
reviewed the 2012 models of care submitted to CMS by these 15 D-SNPs--
representing 14 percent of the 107 models of care we received from
CMS.[Footnote 11] The model of care provides a narrative description
of how the D-SNP will address certain clinical and nonclinical
elements, such as a health risk assessment and an adequate provider
network. We focused in particular on how D-SNPs identified the most-
vulnerable subpopulations--beneficiaries that need the most-intensive
care--and how they planned to meet these care needs.[Footnote 12]
To describe how D-SNPs worked with state Medicaid agencies, we
analyzed all of the 124 contracts between D-SNPs and state Medicaid
agencies that were submitted to CMS for 2012 to determine whether the
contracts contained provisions expressly addressing benefit
integration and care coordination for dual-eligible beneficiaries
between the D-SNP and the state Medicaid agency.[Footnote 13] We
supplemented this analysis with interviews of officials from five
state Medicaid agencies judgmentally selected to cover a range of
geographic areas,[Footnote 14] and with officials from our sample of D-
SNPs.
We assessed the reliability of the data we received from CMS by
performing appropriate electronic data checks and by interviewing
agency officials who were knowledgeable about the data. This allowed
us to determine that the data were suitable for our purposes. We did
not independently verify the statements of interview respondents or
the statements in documents, such as models of care that were
submitted by D-SNPs.
Our analysis has several limitations. We limited our analysis to the
50 states and the District of Columbia.[Footnote 15] Although most of
the analysis is based on 2012, the demographic data are from 2011, and
the health status data are from 2010, the most recent years available.
The contracts between D-SNPs and state Medicaid agencies we reviewed
are limited to contracts submitted to CMS for 2012. Because only 40
percent of all D-SNPs were required to submit contracts in that year,
these contracts may not represent the full range of possible D-SNP
arrangements with state Medicaid agencies. Additionally, because we
judgmentally selected the state Medicaid agencies and D-SNPs for our
interviews, we cannot generalize the findings from these interviews to
all states and all D-SNPs. We did not assess the quality of care
provided by D-SNPs.
We conducted this performance audit from September 2011 through
September 2012 in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform
our work to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our
research objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
Background:
Special Needs Plans:
SNPs, including D-SNPs, have been reauthorized several times since
their establishment was first authorized in 2003. For example, the
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
and the Patient Protection and Affordable Care Act (PPACA) both
contained provisions reauthorizing and modifying SNPs. See table 1 for
a summary of legislation establishing and modifying SNPs.
Table 1: Legislation Establishing and Modifying Authority for Special
Needs Plans (SNP) to Operate under the Medicare Advantage (MA) Program:
Legislation: The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003[A];
Specific provisions: Authorized the establishment of MA coordinated
care plans that exclusively serve individuals in three classes of
special needs: (1) beneficiaries entitled to Medicare and Medicaid
(dual-eligible beneficiaries), (2) beneficiaries with severe or
disabling chronic conditions, or (3) institutionalized beneficiaries.
Authorized HHS to designate other MA plans that disproportionately
serve special needs individuals as new SNPs.
Authorized SNPs to restrict enrollment to individuals in the classes
of special needs through December 31, 2008.
Legislation: The Medicare, Medicaid and SCHIP Extension Act of 2007[B];
Specific provisions: Beginning on January 1, 2008, and extending
through December 31, 2009, established a moratorium on the authority
of HHS to designate other MA plans disproportionately serving special
needs individuals as SNPs and to permit enrollment of individuals in a
new or expanding SNP (which was not subsequently extended).
Extended authority for SNPs to restrict enrollment to individuals in
the classes of special need through December 31, 2009.
Legislation: The Medicare Improvements for Patients and Providers Act
of 2008[C] (MIPPA);
Specific provisions: Effective January 1, 2010, requires all D-SNPs to
have contracts with state Medicaid agencies to provide--or arrange to
provide--benefits to eligible individuals under Medicaid. Made an
exception through December 31, 2010, for existing plans not expanding
their service areas.
Extended the moratorium on the authority of HHS to designate other MA
plans that disproportionately serve special needs individuals as SNPs
through December 31, 2010, but lifted the moratorium on new SNPs and
existing SNPs at the end of 2009.
Extended authority for SNPs to restrict enrollment to individuals in
the classes of special need through December 31, 2010.
Legislation: The Patient Protection and Affordable Care Act (2010)[D]
(PPACA);
Specific provisions: Effective January 1, 2012, and subsequent years,
required all SNPs to be approved by the National Committee for Quality
Assurance (NCQA) based on standards established by HHS.
Extends the exception for existing D-SNPs that do not expand their
current service areas to continue operating without contracts with
state Medicaid agencies through December 31, 2012.
Authorized special payment rules for fully integrated SNPs for dual-
eligible beneficiaries.
Extended authority for SNPs to restrict enrollment to individuals in
the classes of special need through December 31, 2013.
Source: GAO analysis.
[A] Pub. L. No. 108-173, § 231, 117 Stat. 2066, 2207.
[B] Pub. L. No. 110-173, § 108, 121 Stat. 2492, 2496. The acronym
SCHIP stands for the State Children's Health Insurance Program.
[C] Pub. L. No. 110-275, § 164, 122 Stat. 2494, 2571.
[D] Pub. L. No. 111-148, § 3205, 124 Stat. 119, 457.
[End of table]
In 2012, 322 D-SNPs are operating in 38 states and the District of
Columbia.[Footnote 16] CMS pays D-SNPs the same way that it pays other
MA plans; that is, a monthly amount determined by the plan bid--the
plan's estimated cost of providing Medicare Part A and Part B
benefits--in relation to a benchmark, which is the maximum amount the
Medicare program will pay MA plans in a given locality. CMS then
adjusts the monthly payments to MA plans on the basis of
beneficiaries' risk scores.[Footnote 17] If an MA plan's bid exceeds
the benchmark, the plan must charge each of its beneficiaries an
additional premium to make up the difference. If a plan's bid is less
than the benchmark, a proportion of the difference is returned to the
plan as additional Medicare payments called rebates, which must be
used to reduce premiums, reduce cost sharing, or provide mandatory
supplemental benefits, such as vision and dental care.[Footnote 18]
Beginning in 2012, CMS has begun to phase in PPACA-mandated
modifications in the rebate amount and introduced varied rebate
amounts based on CMS's assessments of plan quality.[Footnote 19] For
2012, rebates ranged from 66.67 percent of the difference between a
plan's bid and benchmark for plans with the lowest quality ratings to
73.33 percent of the difference for plans with the highest quality
ratings.
D-SNPs must meet the same requirements as other MA plans, such as
submitting an application to CMS. And like other MA plans, D-SNPs that
meet minimum enrollment requirements are also required to submit data,
such as the Health Effectiveness Data and Information Set (HEDIS)
quality measures.[Footnote 20] In addition, they must conduct quality
improvement activities, which include the reporting of certain
structure and process measures, such as describing how they manage
medication reconciliation associated with patient transitions between
care settings.[Footnote 21]
CMS requires D-SNPs to develop a model of care that describes their
approach to caring for their target population.[Footnote 22] The model
of care must describe how the plan will address 11 clinical and
nonclinical elements established in CMS guidance: (1) describing the
specific target population, (2) tracking measurable goals, (3)
describing the staff structure and care management goals, (4)
providing an interdisciplinary care team, (5) establishing a provider
network that has specialized expertise and describing the use of
clinical practice guidance and protocols, (6) training plan employees
and the provider network on the model of care, (7) performing health
risk assessment, (8) creating individualized care plans, (9)
establishing a communications network, (10) providing care management
for the most vulnerable subpopulations, and (11) measuring plan
performance and health outcomes. These models of care are reviewed and
approved by NCQA--a private health care quality organization--on the
basis of scoring criteria developed with CMS that emphasized the
inclusion of in-depth descriptions or case studies. In their MA
applications, D-SNPs must also "attest" that they meet a total of 251
subelements related to the 11 elements in their model of care.
New and expanding D-SNPs are required to contract with state Medicaid
agencies in 2012, and beginning in 2013, all D-SNPs will be required
to have contracts with state Medicaid agencies.[Footnote 23] According
to CMS, the contracts are an opportunity to improve the integration of
Medicare and Medicaid benefits, and the agency has implemented this
requirement with the goal of "increased integration and coordination"
for dual-eligible beneficiaries.[Footnote 24]
D-SNPs do not cover the same categories of dual-eligible
beneficiaries, but their chosen category(ies) must correspond to those
under the Medicaid program in the state in which the D-SNP is being
offered. Dual-eligible beneficiaries fall into two main categories.
One group, termed full-benefit dual-eligible beneficiaries, may
receive the entire range of Medicaid benefits, including long-term
care. The other group, partial-benefit dual-eligible beneficiaries,
does not receive Medicaid-covered health care services, but Medicaid
covers Medicare premiums or cost-sharing, or both, for these
beneficiaries. Some D-SNPs limit enrollment to full-benefit dual-
eligible beneficiaries, while others are open to all dual-eligible
beneficiaries. Additionally, some D-SNPs are open only to disabled
beneficiaries under age 65, whereas others are open only to those aged
65 and over.
Other Initiatives for Care Coordination for Dual-Eligible
Beneficiaries:
Recently, the federal government, states, researchers, and advocates
have focused increased attention on care coordination for dual-
eligible beneficiaries. PPACA required HHS to establish the Federal
Coordinated Health Care Office (generally known as the Medicare-
Medicaid Coordination Office) within CMS to more-effectively integrate
Medicare and Medicaid benefits and to improve federal-state
coordination for dual-eligible beneficiaries to ensure that they
receive full access to the items and services to which they are
entitled.[Footnote 25] Experts believe that, in addition to benefiting
dual-eligible beneficiaries, more-effective benefit integration and
care coordination can generate significant savings by, for example,
lowering emergency room use.
The Medicare-Medicaid Coordination Office, working with the Center for
Medicare & Medicaid Innovation (called the Innovation Center), is
beginning a financial alignment initiative that is expected to enroll
up to 2 million beneficiaries in 26 states and is intended to align
Medicare and Medicaid services and funding so as to reduce costs while
improving beneficiaries' care.[Footnote 26] Through these
demonstrations, the federal and state governments expect to realize
savings from aligning the payments and integrating care. Under
existing coordination efforts, integrating benefits requires an
investment of resources from states to work with D-SNPs, or other
stakeholders, but according to experts most of the financial savings
accrue to Medicare, because most savings result from services that are
largely paid for by Medicare, such as reductions in the number or
length of hospital stays. Under the financial alignment initiative,
savings will be shared by Medicare and Medicaid without reference to
whether the savings are achieved in Medicare or Medicaid services,
although the allocation of these savings between Medicare and Medicaid
has not yet been finalized. Two models will be tested: a managed FFS
model, under which payments are adjusted retrospectively, and a
capitated model under which one payment is made to an MA plan under a
three-way contract among Medicare, the state Medicaid agency, and the
plan.
The initiative is being conducted under the demonstration authority of
the Innovation Center, under which the Secretary of HHS may conduct
evaluations that analyze both quality of care and changes in spending.
[Footnote 27] For purposes of testing models under this authority,
budget neutrality--which would require that no more be spent under the
demonstration than is currently being spent on care for dual-eligible
beneficiaries--does not apply. The Secretary can expand the
demonstrations nationwide if the demonstrations are determined to
reduce spending without reducing the quality of care or improve the
quality of care without increasing spending.[Footnote 28]
The state demonstrations under the financial alignment initiative do
not necessarily include D-SNPs, and in some cases may replace D-SNPs.
As of June 2012, all 26 states had submitted their proposals for the
demonstrations. Decisions about implementation of these designs had
not been announced as of July 2012 yet implementation of these models
is expected to begin by January 2013 and continue into 2014.
Dual-Eligible Beneficiaries in D-SNPs Had Similar Health Status to
Other Dual-Eligible Beneficiaries:
The demographic and mental health characteristics of dual-eligible
beneficiaries enrolled in D-SNPs in 2011 differed from those of dual-
eligible beneficiaries in other MA plans and, to a lesser extent, from
those of dual-eligible beneficiaries in FFS.[Footnote 29] Despite
these differences, dual-eligible beneficiaries in D-SNPs and dual-
eligible beneficiaries in FFS and other MA plans had very similar
health status in 2010, the year for which the most recent data were
available, as measured by Medicare risk scores.
Dual-Eligible Beneficiaries in D-SNPs Had Characteristics That Were
Generally Similar to Their FFS Counterparts but Differed in Key
Respects from Such Beneficiaries in Other MA Plans:
Dual-eligible beneficiaries in D-SNPs (9 percent of all dual-eligible
beneficiaries in 2011, as shown in figure 1) were most similar to dual-
eligible beneficiaries in FFS, but differed substantially from dual-
eligible beneficiaries in other MA plans on certain demographic and
mental health measures.[Footnote 30]
Figure 1: Enrollment of Dual-Eligible Beneficiaries by Plan Type, 2011:
[Refer to PDF for image: pie-chart]
FFS: 80%;
Other MA[A]: 10%;
D-SNP: 9%;
Other: 1%: including:
PACE[B]: 15%;
Coast plan/HCPP[C]: 16%;
I-SNP[D]: 27%;
C-SNP[E]: 42%.
Source: GAO analysis of CMS data.
Notes: Percentages are based on 9,188,828 dual-eligible beneficiaries
in Medicare and Medicaid as of July 2011. Data sources include CMS's
2011 enrollment data, 2011 plan benefit package data, and 2010 risk
score data (used only to determine residence). Data exclude dual-
eligible beneficiaries in Puerto Rico and those living outside of the
50 states and the District of Columbia in 2010.
[A] Other MA plans include non-SNP health maintenance organizations
(including point of service options), local and regional preferred
provider organizations, provider-sponsored organizations, private fee-
for-service plans, and medical savings account plans.
[B] Program of All-Inclusive Care for the Elderly (PACE), which
provides a range of integrated preventative, acute care, and long-term
care services for the frail elderly.
[C] Cost plans provide original Medicare services, but enrollees can
receive covered services outside of the health maintenance
organization or competitive medical plan network. Health care
prepayment plans (HCPP) are union-or employer-sponsored plans that
provide or arrange for some or all of Part B Medicare benefits on a
prepayment basis, while payments for Part A services are made on a FFS
basis.
[D] Institutional special needs plan (I-SNP).
[E] Chronic condition special needs plan (C-SNP).
[End of figure]
A larger proportion of dual-eligible beneficiaries in D-SNPs, as well
as dual-eligible beneficiaries in FFS, were under age 65 and disabled
in 2011 compared with those in other MA plans (see figure 2).
Additionally, similar proportions of dual-eligible beneficiaries in D-
SNPs and dual-eligible beneficiaries in FFS (15 and 16 percent,
respectively) were diagnosed with a chronic or disabling mental health
condition such as major depressive disorder or schizophrenia, compared
with just 10 percent of dual-eligible beneficiaries in other MA plans.
Among the characteristics in our analysis, the largest difference
between D-SNPs and other MA plans was the proportion of full-benefit
beneficiaries in each plan type: 80 percent of dual-eligible
beneficiaries in D-SNPs and 75 percent of dual-eligible beneficiaries
in FFS were eligible for full Medicaid benefits, compared with just 34
percent of dual-eligible beneficiaries in other MA plans.
Figure 2: Characteristics of Dual-Eligible Beneficiaries in D-SNPs
Compared with Dual-Eligible Beneficiaries in Other MA Plans and FFS:
[Refer to PDF for image: horizontal bare graph]
Percentage of dual-eligible beneficiaries:
Beneficiary characteristics: Under 65 and disabled[A];
Dual-eligible special needs plans: 38%;
Other MA plans: 26%;
Medicare fee-for-service: 44%.
Beneficiary characteristics: Chronic or disabling mental|health
condition[B];
Dual-eligible special needs plans: 15%;
Other MA plans: 10%;
Medicare fee-for-service: 16%.
Beneficiary characteristics: Eligible for full Medicaid benefits;
Dual-eligible special needs plans: 80%;
Other MA plans: 34%;
Medicare fee-for-service: 75
Beneficiary characteristics: Lived in institution[C];
Dual-eligible special needs plans: 4%;
Other MA plans: 7%;
Medicare fee-for-service: 12%.
Beneficiary characteristics: 85 and older;
Dual-eligible special needs plans: 8%;
Other MA plans: 13%;
Medicare fee-for-service: 12%.
Beneficiary characteristics: Racial/ethnic minority[D];
Dual-eligible special needs plans: 60%;
Other MA plans: 40%;
Medicare fee-for-service: 41%.
Beneficiary characteristics: Female;
Dual-eligible special needs plans: 63%;
Other MA plans: 66%;
Medicare fee-for-service: 61%.
Source: GAO analysis of CMS data.
Notes: Sources include CMS's 2011 enrollment data, 2011 plan benefit
package data, and 2010 risk score data. Percentages for demographic
data are based on about 851,000 dual-eligible beneficiaries in D-SNPs,
882,000 in other MA, and 7.3 million in FFS as of July 2011.
Percentages for chronic or disabling mental health conditions are
based on about 755,000 dual-eligible beneficiaries in D-SNPs, 757,000
in other MA, and 7.1 million in FFS for whom risk score data were
available as of July 2010, the most recent year available, and are
based on 2009 diagnosis data. Actual totals vary for each
characteristic due to missing data. Data exclude beneficiaries in
Puerto Rico and those living outside of the 50 states and the District
of Columbia in 2010.
[A] Under 65 and disabled does not include beneficiaries with ESRD.
[B] A chronic and disabling mental health condition is defined as a
diagnosis of schizophrenia; schizoaffective disorder; or major
depressive, bipolar, or paranoid disorders.
[C] Refers to beneficiaries who lived in an institution during July
2011.
[D] Racial or ethnic minorities include Black, Hispanic, Asian, and
North American Native beneficiaries, and beneficiaries who reported
"Other" race; however, CMS's enrollment data have limitations in
accurately identifying beneficiary race and ethnicity, resulting in an
underreporting of Hispanics, Asian/Pacific Islanders, and American
Indian/Alaskan Natives.
[End of figure]
While dual-eligible beneficiaries in D-SNPs were generally similar to
those in FFS, there were several demographic measures on which dual-
eligible beneficiaries in D-SNPs differed from both those in FFS and
other MA plans. A smaller proportion of dual-eligible beneficiaries in
D-SNPs lived in institutions (e.g., nursing facilities, intermediate
care facilities, or inpatient psychiatric hospitals) in July 2011
compared with dual-eligible beneficiaries in FFS, and, to a lesser
extent, other MA plans. D-SNPs also enrolled a smaller proportion of
dual-eligible beneficiaries who were 85 or older compared with the
other plan types, as well as a larger proportion of beneficiaries who
were racial or ethnic minorities.[Footnote 31]
Health Status of Dual-Eligible Beneficiaries in D-SNPs Was Similar to
That of Dual-Eligible Beneficiaries in FFS and Other MA Plans:
Dual-eligible beneficiaries in D-SNPs had very similar health status
as measured by their 2010 risk scores, the year for which the most
recent data were available, when compared with dual-eligible
beneficiaries in FFS and other MA plans.[Footnote 32] As shown in
figure 3, the average risk score--which predicts Medicare costs--of
dual-eligible beneficiaries in D-SNPs (1.29) was similar to the
average scores for dual-eligible beneficiaries in FFS (1.35) and other
MA plans (1.34).[Footnote 33] Just under 20 percent of dual-eligible
beneficiaries in D-SNPs and dual-eligible beneficiaries in FFS and
other MA plans were expected to cost Medicare at least twice as much
as the average Medicare FFS beneficiary, and less than 10 percent in
each plan type were expected to cost at least three times the average.
Figure 3: Average Risk Scores of Dual-Eligible Beneficiaries by
Characteristic and Plan Type, 2010:
[Refer to PDF for image: vertical bar graph]
Beneficiary characteristic: All dual-eligible beneficiaries;
Average risk score:
Dual-eligible special needs plans: 1.29;
Other MA plans: 1.34;
Medicare fee-for-service: 1.35.
Beneficiary characteristic: Under 65 and disabled;
Average risk score:
Dual-eligible special needs plans: 1.10;
Other MA plans: 1.13;
Medicare fee-for-service: 1.11.
Beneficiary characteristic: 85 and older;
Average risk score:
Dual-eligible special needs plans: 1.64;
Other MA plans: 1.63;
Medicare fee-for-service: 1.68.
Beneficiary characteristic: Eligible for full Medicaid benefits;
Average risk score:
Dual-eligible special needs plans: 1.28;
Other MA plans: 1.50;
Medicare fee-for-service: 1.39.
Beneficiary characteristic: Eligible for Medicaid premium and cost-
sharing assistance;
Average risk score:
Dual-eligible special needs plans: 1.34;
Other MA plans: 1.23;
Medicare fee-for-service: 1.24.
Beneficiary characteristic: Chronic or disabling mental health
condition[A];
Average risk score:
Dual-eligible special needs plans: 1.64;
Other MA plans: 1.78;
Medicare fee-for-service: 1.72.
Beneficiary characteristic: Racial/ethnic minority[B];
Average risk score:
Dual-eligible special needs plans: 1.21;
Other MA plans: 1.24;
Medicare fee-for-service: 1.29.
Beneficiary characteristic: Female;
Average risk score:
Dual-eligible special needs plans: 1.31;
Other MA plans: 1.32;
Medicare fee-for-service: 1.38.
Beneficiary characteristic: Living long-term in institution[C];
Average risk score:
Dual-eligible special needs plans: 1.95;
Other MA plans: 1.98;
Medicare fee-for-service: 2.00.
Source: GAO analysis of CMS data,
Notes: Sources include CMS's 2010 enrollment data, plan benefit
package data, and risk score data. Data exclude new enrollees,
beneficiaries with ESRD, and those living in Puerto Rico and outside
of the 50 states and the District of Columbia. We adjusted all average
risk scores to account for CMS's normalization factor of 1.041 in
2010; additionally, we adjusted average risk scores of D-SNPs and
other MA plans downward by 3.41 percent to account for diagnostic
coding differences between MA plans and FFS.
[A] A chronic or disabling mental health condition is defined as a
diagnosis of schizophrenia; schizoaffective disorder; or major
depressive, bipolar, or paranoid disorders.
[B] Racial or ethnic minorities include Black, Hispanic, Asian, and
North American Native beneficiaries, and beneficiaries who reported
"Other" race; however, CMS's enrollment data have limitations in
accurately identifying beneficiary race and ethnicity, resulting in an
underreporting of Hispanics, Asian/Pacific Islanders, and American
Indian/Alaskan Natives.
[C] Refers to beneficiaries who were considered to be "long-term
institutional" (i.e., living in an institution for at least 3 months)
as of July 2010.
[End of figure]
The average risk scores of dual-eligible beneficiaries in each plan
type also generally were similar across demographic groups. However,
there were some differences between plan types. Dual-eligible
beneficiaries in D-SNPs who were eligible for full Medicaid benefits
had lower average risk scores than those of similar beneficiaries in
other MA plans and FFS.[Footnote 34] Dual-eligible beneficiaries in D-
SNPs with a chronic or disabling mental health condition also had
lower average risk scores than those in other MA plans. Additionally,
partial-benefit dual-eligible beneficiaries in D-SNPs had higher
average risk scores than their counterparts in other MA plans and FFS.
D-SNPs Typically Offer Fewer Supplemental Benefits Than Other MA
Plans, and Information on Planned Services Is Not Comparable:
Dual-eligible beneficiaries in D-SNPs do not necessarily get more
benefits than those in other MA plans, although D-SNP representatives
told us their care coordination services are more comprehensive than
other MA plans. D-SNPs and other MA plans varied in how frequently
they offered supplemental benefits--benefits not covered by FFS--and
MA plans offered more of these supplemental benefits than D-SNPs.
While the models of care we reviewed described in varying detail how
the D-SNPs plan to provide other services, such as health risk
assessments, to beneficiaries, most D-SNPs did not provide--and are
not required to provide--estimates of the number of dual-eligible
beneficiaries that would receive the services.
D-SNPs Offered Fewer of Their 10 Most-Common Supplemental Benefits
Than Other MA Plans:
D-SNPs provide fewer supplemental benefits, 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.[Footnote 35] (See figure 4.) These
3 supplemental benefits were offered much more frequently by D-SNPs
compared to other MA plans: they offered dental benefits one-and-a-
half times more often, over-the-counter drugs nearly twice as often,
and transportation benefits almost three times more often. However, a
smaller proportion of D-SNPs compared to other MA plans offered
hearing benefits, as well as benefits for certain inpatient settings
and outpatient services. For some of the services D-SNPs offered less
frequently, dual-eligible beneficiaries may receive some coverage
through Medicaid. In addition, according to CMS, some of the benefits
offered more frequently by other MA plans (e.g. international
outpatient emergency) are not necessarily as useful a benefit for D-
SNPs.[Footnote 36]
Figure 4: Supplemental Benefits Offered by More Than Half of Dual-
Eligible Special Needs Plans (D-SNP) Compared with Other Medicare
Advantage (MA) Plans, 2012:
[Refer to PDF for image: vertical bar graph]
Percentage of plans:
Type of supplemental benefit: Vision[A];
Dual-Eligible Special Needs Plans: 89%;
Other MA Plans: 92%.
Type of supplemental benefit: Preventive health care[B];
Dual-Eligible Special Needs Plans: 87%;
Other MA Plans: 97%.
Type of supplemental benefit: Dental[C];
Dual-Eligible Special Needs Plans: 77%;
Other MA Plans: 46%.
Type of supplemental benefit: Transportation[D];
Dual-Eligible Special Needs Plans: 68%;
Other MA Plans: 24%.
Type of supplemental benefit: International outpatient emergency[E];
Dual-Eligible Special Needs Plans: 67%;
Other MA Plans: 96%.
Type of supplemental benefit: Over-the-counter drugs[F];
Dual-Eligible Special Needs Plans: 65%;
Other MA Plans: 33%.
Type of supplemental benefit: Outpatient hospital blood[G];
Dual-Eligible Special Needs Plans: 57%;
Other MA Plans: 84%.
Type of supplemental benefit: Hearing[H];
Dual-Eligible Special Needs Plans: 55%;
Other MA Plans: 64%.
Type of supplemental benefit: Skilled nursing facility[I];
Dual-Eligible Special Needs Plans: 52%;
Other MA Plans: 67%.
Type of supplemental benefit: Inpatient hospital acute[J];
Dual-Eligible Special Needs Plans: 52%;
Other MA Plans: 86%.
Notes: Source data are for the 2012 contract year. The following types
of MA plans are included: health maintenance organizations, local
preferred provider organizations, regional preferred provider
organizations, private fee-for-service plans, and provider-sponsored
organizations. We excluded plans that charged a Part C premium.
[A] Vision benefits can include coverage for routine eye exams,
contact lenses, or eyeglasses (lenses and frames).
[B] Preventive health care benefits can include screenings and
immunizations beyond what Medicare fee-for-service (FFS) covers, as
well as health education and fitness club membership.
[C] Dental benefits can include oral exams, teeth cleanings, fluoride
treatments, dental X-rays, or emergency dental services.
[D] Transportation benefits can include travel from a beneficiary's
home to medical appointments.
[E] International outpatient emergency benefits can include additional
services beyond what Medicare FFS covers.
[F] Over-the-counter drug coverage can include nonprescription
medicines not covered under Medicare Part D.
[G] Outpatient blood benefits can include units of blood received as
an outpatient or as part of a Part B-covered service for the first
three units not covered by Medicare FFS.
[H] Hearing benefits can include coverage for hearing tests, hearing
aid fittings, and hearing aid evaluations.
[I] Skilled nursing facility benefits can include waiving the 3-day
inpatient hospital stay requirement in Medicare FFS.
[J] Inpatient hospital acute benefits can include additional days
beyond what Medicare FFS covers.
[End of figure]
For the three most-common D-SNP supplemental benefits--vision,
prevention, and dental--we analyzed the individual services covered
under these benefits and found that D-SNPs' vision and dental benefits
were generally more comprehensive than those offered by other MA
plans. For example, in their vision benefit, a larger proportion of D-
SNPs compared to other MA plans covered contact lenses and eyeglasses.
In addition, a larger proportion of D-SNPs compared to other MA plans
included in their dental benefit coverage of oral surgery,
extractions, and restorative services. However, D-SNPs were less
likely than other MA plans to include membership in health clubs as
part of their preventive health care benefits.
Despite offering these supplemental benefits somewhat less often than
other MA plans, D-SNPs allocated a larger percentage of their rebates
to supplemental benefits than other MA plans. (See table 2.) They were
able to do so largely because they allocated a smaller percentage of
rebates to reducing cost-sharing. Most dual-eligible beneficiaries
will have their cost-sharing covered by Medicaid, so D-SNPs have less
need than other MA plans to cover cost-sharing. We also found that D-
SNPs tended to receive smaller rebates than other MA plans ($70 per
member per month on average compared to $108).
Table 2: Percentage of Rebate Allocated to Supplemental Benefits,
Reducing Cost Sharing, and Premium Reduction, 2012:
Supplemental benefits[A];
D-SNPs: 51%;
Other MA: 14%.
Reduce A/B cost share[B];
D-SNPs: 19%;
Other MA: 53%.
Part B premium buy down[C];
D-SNPs: 1%;
Other MA: 6%.
Part D basic premium buy down[D];
D-SNPs: 19%;
Other MA: 11%.
Part D supplemental premium buy down[E];
D-SNPs: 10%;
Other MA: 15%.
Source: GAO analysis of CMS data.
Notes: Data are from CMS's 2012 bid pricing tool. The following types
of MA plans are included: health maintenance organizations, local
preferred provider organizations, regional preferred provider
organizations, private fee-for-service plans, and provider-sponsored
organizations. We excluded plans that charged a Part C premium.
Numbers may not add up to 100 percent due to rounding.
[A] MA plans may use their rebates to offer supplemental benefits,
which are benefits beyond the Medicare FFS package.
[B] MA plans may use their rebates to reduce cost-sharing for Parts A
and B.
[C] Beneficiaries in MA plans continue to pay the Part B premium;
however, MA plans may use their rebates to reduce beneficiaries' Part
B premiums.
[D] MA plans may use their rebates to reduce the premium for the basic
Part D drug benefit.
[E] MA plans may use their rebates to reduce supplemental premiums for
drug benefits beyond the basic Part D package.
[End of table]
Models of Care Describe How D-SNPs Plan to Provide Specialized Health
Care Services, but CMS Lacks Standard Measures Needed for Evaluation:
Although the 15 models of care we reviewed described the types of
services D-SNPs intended to provide, D-SNPs generally did not state in
their models of care how many of their enrolled beneficiaries were
expected to receive these services. The criteria D-SNPs are evaluated
on in the approval process emphasize the inclusion of in-depth
descriptions and case studies rather than details about how many
beneficiaries would likely receive these services, for example, the
number of beneficiaries that will use additional services targeted to
the most vulnerable. CMS does not require D-SNPs to report that
information in the models of care, although such information could be
useful for future evaluations of whether D-SNPs met their intended
goals,[Footnote 37] as well as for comparisons among D-SNPs.[Footnote
38] Three D-SNPs we interviewed told us that a lack of specificity in
the model-of-care scoring criteria confused some D-SNPs; having more
specific scoring criteria may also eliminate some uncertainty in the
approval process.
Knowing the extent of the special services D-SNPs expect to provide
would assist future evaluations of whether they met their goals, but
most models of care did not include this information. For example, all
15 D-SNPs stated in their models of care that they planned to conduct
health risk assessments for beneficiaries within 90 days of enrollment
and an annual reassessment, as they are required to do by CMS.
However, only 4 provided information on how many members had actually
completed a health risk assessment or reassessment in prior years,
with cited completion rates for 2010 ranging from 52 to 98 percent. In
addition, none of the D-SNPs we reviewed indicated in their models of
care how many beneficiaries were expected to receive add-on services
such as social support services that were intended for the most-
vulnerable beneficiaries. The models of care we reviewed did include,
as required in the model-of-care scoring criteria, information about
how the D-SNP identifies the most vulnerable beneficiaries in the plan
and the add-on services and benefits that would be delivered to these
beneficiaries. D-SNPs' models of care described a variety of methods
used to identify these beneficiaries: health risk assessments (10 D-
SNPs); provider referrals (9); and hospital admissions or discharges
(7). However, the models of care generally did not indicate how many
or what proportion of beneficiaries were expected to be among the most
vulnerable, although one D-SNP's model of care stated that complex-
care patients constituted over one-third of its membership.
Furthermore, it was sometimes unclear whether the services described
as targeted to these beneficiaries were in addition to those available
to all dual-eligible beneficiaries in the D-SNP. D-SNPs also described
the services that they plan to offer to the most-vulnerable
beneficiaries, the most frequent being complex/intensive case
management (6 D-SNPs). Other services D-SNPs planned to offer the most-
vulnerable beneficiaries included 24-hour hotlines, social support
services, and supplemental benefits beyond what was planned to be
offered to all dual-eligible beneficiaries in the D-SNP.
CMS guidance also requires D-SNPs to describe how they intend to
evaluate their performance and measure outcomes in achieving goals
identified in their models of care, but CMS does not stipulate the use
of standard outcome or performance measures in the model of care, such
as measures of patient health status and cognitive functioning. As a
result, it would be difficult for CMS to use any data it might collect
on these measures to compare D-SNPs' effectiveness or evaluate how
well they have done in meeting their goals. Furthermore, without
standard measures, it would not be possible for CMS to fully evaluate
the relative performance of D-SNP models of care. While it is not
required, an evaluation of D-SNPs could both help to improve the D-SNP
program and inform other initiatives to better coordinate care for
dual-eligible beneficiaries. The models of care we reviewed had little
uniformity in the measures plans selected. Four D-SNPs discussed their
approach to performance and health outcome measurement largely in
general terms, such as describing which datasets they would use or the
categories of outcomes that would be measured. The other 11 D-SNPs
provided specific measurements, which included measuring items such as
readmissions, emergency room utilization, and receipt of follow-up
calls after inpatient stays. Were CMS to move to a standard set of
performance and outcome measures, it could be less burdensome and no
more costly than what some D-SNPs currently collect. Using standard
measures could also streamline the models-of-care review process.
D-SNPs Reported More-Comprehensive Care Coordination Services and
Greater Beneficiary Interaction Than Other MA Plans:
Of the 15 D-SNPs we interviewed, 9 were in organizations that offered
both D-SNPs and other MA plans, and representatives from 7 of those D-
SNPs told us that their care coordination services are different from
those in their organization's other MA plan offerings. For example, a
representative from one D-SNP told us that while care coordination and
case management were available in both types of plans offered by that
organization, dual-eligible beneficiaries in the D-SNP are
continuously enrolled in case management, whereas dual-eligible
beneficiaries in other MA plans who need these services receive them
for only a limited time. A representative from another D-SNP said that
the plan provides care coordination services similar to those of other
MA plans offered by its organization but that dual-eligible
beneficiaries in the D-SNP who need these services are identified
faster than are dual-eligible beneficiaries in the other MA plans. A
representative of a third D-SNP said it has a community resource unit
that is not available in other MA plans offered by its organization,
which works with local agencies such as long-term care providers and
adult protective services.
Multiple representatives of the 15 D-SNPs we interviewed described
their care coordination services as being "high touch"--meaning that
the plans, particularly the case managers, have frequent interaction
with dual-eligible beneficiaries in the D-SNP. For example,
representatives from one D-SNP told us that its plan includes in-
person meetings with case managers. Representatives from another D-SNP
described several specific examples of care coordination successes,
such as when a case manager followed up on a beneficiary's Medicaid
reenrollment application to ensure that the beneficiary did not lose
eligibility, and another situation in which a case manager worked with
the complex social and housing needs of a beneficiary who had both
physical and mental health issues. Representatives from a third D-SNP
noted that they have providers who conduct home visits to help prevent
hospitalization.
Although Some D-SNP Contracts with State Medicaid Agencies Expressly
Provide for Benefit Integration or Care Coordination, Most Do Not:
CMS stated that contracts between D-SNPs and state Medicaid agencies
are an opportunity to increase benefit integration and care
coordination.[Footnote 39] However, only about one-third of the 2012
contracts we reviewed contained any provisions expressly providing for
D-SNPs to deliver Medicaid benefits, thereby achieving benefit
integration. Only about one-fifth of the contracts expressly 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. Further, D-
SNP representatives and state Medicaid officials expressed concerns
about resources needed to contract with D-SNPs, and uncertainty about
the future of D-SNPs.
Some Contracts Include Provisions to Address the Integration of
Benefits or Meaningful Coordination of Services between D-SNPs and
Medicaid Agencies, but Most Do Not:
Benefit Integration:
The 2012 D-SNP contracts with state Medicaid agencies we reviewed
varied considerably in their provisions for integration of benefits
and state payments to D-SNPs for covering specific services. According
to CMS, "[t]his variability is to be expected, as States and MA
organizations can develop agreements for [D-SNPs] to assume
responsibility for providing or arranging for a wide range of Medicaid
services based on each State's ability and interest in integrating its
Medicaid program with Medicare via a SNP."[Footnote 40] Thirty-three
percent of the 124 D-SNP contracts with state Medicaid agencies for
2012 that we reviewed expressly provided for the delivery of at least
some portion of Medicaid benefits, thereby integrating Medicare and
Medicaid benefits. The contracts varied in the extent of the Medicaid
benefits for which a plan was responsible. About 10 percent provided a
limited number of Medicaid services, such as dental or vision
benefits. In contracts where there was some integration of Medicare
and Medicaid benefits, states contracted for the different services,
making comparisons among the contracts difficult. Of the 23 percent
that integrated most or all Medicaid benefits, 64 percent of D-SNPs
provided all Medicaid benefits, including long-term care support
services in community settings and institutional care; 25 percent
provided most Medicaid benefits, including long-term support services
in community settings but not institutional care; and 11 percent
provided most Medicaid benefits but did not provide any long-term
support services or institutional care. (See figure 5.)
Figure 5: Dual-Eligible Special Needs Plans (D-SNP) Integration of
Medicaid Benefits, 2012:
[Refer to PDF for image: pie-chart]
No benefits: 67%;
Some benefits: 10%;
Most benefits: 23%; of that:
No long-term support services: 11%;
Community long-term support services: 25%;
Community long-term support services and institutional care:
64%.
Source: GAO analysis of D-SNP/state contracts.
Note: Percentages are based on 124 D-SNP/state Medicaid agency
contracts for 2012 that were reviewed by GAO.
[End of figure]
Sixty-seven percent of contracts between D-SNPs and state Medicaid
agencies did not expressly provide for D-SNPs to cover Medicaid
benefits. To carry out MIPPA's requirement that each D-SNP contract
provide or arrange for Medicaid benefits to be provided, CMS guidance
has required that contracts list the Medicaid benefits that dual-
eligible beneficiaries could receive directly from the state Medicaid
agency or the state's Medicaid managed care contractor(s).[Footnote 41]
For D-SNPs contracting with state Medicaid agencies to provide all or
some Medicaid benefits, the capitated payment reflected variation in
coverage and conditions. One state that contracts for all Medicaid
benefits except a limited number of services including long-term care
services paid the D-SNP at a rate of $423 per member per month.
Another state, which contracted for a limited number of benefits,
including Medicare-excluded drugs, expanded dental coverage, and case-
management services, paid the D-SNP $132 per member per month. This
state's Medicaid agency retained responsibility for inpatient hospital
services and long-term care coverage. Some contracts, rather than
stating a single capitation rate, gave payment rates for different
categories, including risk or acuity level, beneficiary age, and
service location, as well as whether the beneficiary was designated as
nursing home eligible and whether services for these beneficiaries
were provided in the community or facility setting. Within one state,
payment rates ranged from just under $170 per month for dual-eligible
beneficiaries who were neither nursing home eligible nor had a chronic
mental health condition and were living in the community to over
$8,600 per month for dual-eligible beneficiaries residing in a nursing
facility and requiring the highest level of care.
Some of the 2012 contracts providing for payments from state Medicaid
agencies to D-SNPs did not address the direct provision of benefits,
often providing for payments to the D-SNP for assuming the state's
responsibility for paying dual-eligible beneficiaries' Medicare
copayments, coinsurance, and deductibles. These payments ranged from
$10 to $60 per member per month.
Coordination of Services:
While all contracts between D-SNPs and state Medicaid agencies for
2012 provided for some level of care coordination to beneficiaries,
approximately 19 percent expressly provided for active coordination of
beneficiary services between the D-SNP and the state Medicaid agency.
[Footnote 42] Most active coordination occurs when dual-eligible
beneficiaries transition between care settings or between Medicare and
Medicaid. Thirteen percent of all contracts contained provisions
requiring D-SNPs and the state Medicaid agency to coordinate the
transition of beneficiaries between care settings (such as hospital to
nursing home) within a given time frame. For example, one state's D-
SNP contracts directed the plans to notify the Medicaid service
coordinators or agency caseworker, as applicable, no later than 5
business days after a dual-eligible beneficiary had been admitted to a
nursing facility. The other 6 percent of contracts included provisions
for providing different coordination activities such as requiring the
plan to work with Medicaid staff to coordinate delivery of wrap-around
Medicaid benefits.
The remaining 81 percent of all contracts did not specifically address
D-SNPs' coordination with state Medicaid staff, such as case managers.
Rather, these contracts indicated that the D-SNP would coordinate
Medicaid and Medicare services but did not specify the role of the
state Medicaid agency in coordinating those services. Because D-SNPs
are required by Medicare to provide care coordination services to dual-
eligible beneficiaries, these services are often provided without
reimbursement or payment from the state Medicaid agency.
D-SNP and State Officials Expressed Some Concerns about Contracting:
Concerns about Resource Investment:
D-SNP representatives and state Medicaid officials we spoke with
reported that contract development and submission to CMS are resource-
intensive. State officials reported that because they had limited
resources, they needed to balance the benefits of the contract with
the time and resources needed to develop and oversee it. As one state
Medicaid official said, the state "bandwidth"--resources--was a
challenge, and she was concerned about contracting with the large
number of D-SNPs in her state. This official added that the state did
not want to be in the position of making contractual commitments that
could not be honored because of limited funds or other resources. In
contrast, the plan representatives we interviewed expressed interest
in continuing to operate D-SNPs and were therefore eager to contract
with states despite any challenges that might exist. Beginning in
2013, D-SNPs will not be permitted to operate without state contracts.
Representatives from 12 of the 15 plans and officials from 3 of the 5
state Medicaid agencies we spoke with pointed out that establishing a
contract between Medicaid and a Medicare plan highlights conflicts
between federal and state requirements. A representative from one D-
SNP told us that it was challenging for plans and state Medicaid
agencies to agree about the characterization of dual-eligible
beneficiaries because Medicare and some states have different
definitions. Officials from one state Medicaid agency and D-SNP
representatives reported difficulty reconciling the difference between
the Medicare contracting cycle, which is based on the calendar year,
and the fiscal year contracting cycle for their states. They reported
that, if a contract would not cover the entire calendar year, CMS
would not approve it. In one case, a state Medicaid official reported
that CMS's deadline of July 1, 2012, for 2013 contracts would occur
before the state signed contracts for 2013. Sometimes non-Medicaid
structures conflict with CMS's contracting requirements for D-SNPs. A
representative of one D-SNP told us that Medicaid benefits for
individuals with developmental disabilities were managed through a
contract with the state's family services agency, not the state
Medicaid agency. Therefore, to provide services to this population,
the D-SNP had to become a subcontractor to the family services agency.
The official said that the D-SNP and the state need to work with CMS
to develop a subcontracting relationship that is acceptable.[Footnote
43] State Medicaid officials and D-SNP representatives reported that
they did not always have the resources or the administrative ability
to resolve these types of issues before entering into a contract.
Beginning in 2013, D-SNPs must secure a contract with the state
Medicaid agency in each state in their service area. To do this, D-
SNPs may need to establish new relationships with state officials who,
according to the D-SNP representatives we interviewed, sometimes have
very limited knowledge of Medicare and its requirements. However, some
states have experience with Medicaid managed care and in some cases, D-
SNP representatives had previously worked with the state on Medicaid
contracts, thereby somewhat easing the transition to working with D-
SNPs.
Uncertainty about D-SNPs and Other Initiatives for Dual-Eligible
Beneficiaries:
Plan representatives and state Medicaid officials told us that
uncertainty about the future made them cautious in contracting.
Authority for SNPs to restrict enrollment to special needs populations
(such as dual-eligible beneficiaries) currently expires at the end of
2013; SNPs may not continue as a unique type of MA plan if Congress
does not extend this authority. Were this to occur, states would lose
any advantages they might have gained from investing their resources
to work with D-SNPs to integrate benefits and coordinate care.
Furthermore, uncertainty regarding the future of D-SNPs creates
uncertainty for the states about how to continue to serve dual-
eligible beneficiaries currently enrolled in D-SNPs.
Uncertainty about the implementation of state demonstrations under the
CMS initiative to align Medicare and Medicaid services--financial
alignment initiative--has made some states hesitant to enter into
contracts with D-SNPs. As of June 2012, all proposals had been made
available for public comment but CMS had not finalized agreements with
the states. Medicaid officials from two states told us that if their
proposed financial alignment demonstrations were implemented, D-SNPs
in their states would cease to exist.[Footnote 44] Some states were
moving forward with D-SNP contracts while concurrently preparing to
shift D-SNPs to a different type of managed care plan if their
demonstration proposal is implemented. However, officials from one
state told us that they did not have sufficient clarity about the
direction of the state Medicaid program in relation to its proposed
demonstration to enter into contracts. Even in those states where
demonstrations would not eliminate D-SNPs, contracting challenges as
well as potential financial incentives associated with the
demonstrations from the financial alignment initiatives create
disincentives for states to work with D-SNPs outside of the financial
alignment initiatives and, therefore, leaves the future of D-SNPs in
question in these states as well.
Conclusions:
D-SNPs have the potential to help beneficiaries who are eligible for
both Medicare and Medicaid navigate these two different systems and
receive the health services that meet their individual needs. However,
CMS has not required D-SNPs to report information that is critical to
better holding plans accountable and determining whether they have
realized their potential. Although the models of care D-SNPs must
submit to CMS generally state what these plans intend to do, they do
not all report the number of services they intend to provide. For
example, plans are not required to report the number of enrollees they
expect to designate as most vulnerable, or how many and which
additional services they will provide to these enrollees. Although D-
SNPs are required to collect performance and outcome measures, they
are not required to use standard measures such as existing measures of
hospital readmission or patient health status and cognitive
functioning. Further they are not required to report these measures to
CMS, and, lacking standard measures, it would in any case be difficult
to compare D-SNPs' effectiveness. Standardizing these measures should
have a minimal effect on D-SNPs' administrative efforts, because
additional measures could replace some or all of the measures
currently used as well as much of the narrative in models of care.
Standardizing measures could also reduce CMS's administrative efforts
by streamlining review of D-SNPs. Additional standardized information
would allow CMS to meet its goals for accountability for effective and
efficient use of resources.
Further, CMS has neither evaluated the sufficiency and appropriateness
of the care that D-SNPs provide nor assessed their effectiveness in
integrating benefits and coordinating care for dual-eligible
beneficiaries. Nonetheless, CMS is embarking on a new demonstration in
up to 26 states with as many as 2 million beneficiaries to financially
realign Medicare and Medicaid services so as to serve dual-eligible
beneficiaries more effectively. If CMS systematically evaluates D-SNP
performance, it can use information from the evaluation to inform the
implementation and reporting requirements of this major new initiative.
Recommendations for Executive Action:
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 take the
following four actions:
* 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;
* 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;
* systematically analyze these data and make the results routinely
available to the public; and:
* 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 and Other External Comments and Our Evaluation:
We obtained comments on a draft of this report from HHS and the SNP
Alliance, which represents 32 companies that offer more than 200 SNPs.
CMS provided written comments, which are reprinted in appendix I, and
technical comments that we incorporated where appropriate.
Representatives from the SNP Alliance provided us with oral comments.
HHS Comments:
HHS concurred with our recommendation that CMS should require plans to
explicitly state in their models of care the extent of services they
expect to provide, and agrees that information about the extent to
which D-SNPs provide certain services would increase accountability
and facilitate evaluation. HHS also stated that CMS recently began to
collect information on the completion of health risk assessments, but
has not made it public because the information is relatively new. HHS
did question the usefulness of quantifying the number of members
expected to receive services described in the documents, stating that
the model of care is a framework for indicating how the SNP proposes
to coordinate the care of SNP enrollees. However, as we noted in the
draft report, we believe such information could be useful in later
evaluating whether D-SNPs met their intended goals.
HHS also concurred with our recommendation that CMS should require D-
SNPs to collect and report standard measures relevant to the
populations they serve, and stated that CMS is working to create new
measures that will be relevant to dual-eligible beneficiaries in D-
SNPs. HHS also stated that CMS currently collects a broad range of
standard quality measures, including HEDIS, as well as structure and
process measures. HHS included in its response a recent Health Plan
System Management memorandum that CMS sent to MA organizations,
including D-SNPs, which outlined updated reporting requirements for
2013. HHS also noted that in addition to the data it currently
collects, CMS requires D-SNPs to conduct both a Quality Improvement
Project and a Chronic Care Improvement Project, and asked GAO to note
this in the final report. We did not include these because, as we
noted in the draft report, quality and quality measures were not in
the scope of our work.
HHS also concurred with our other two recommendations.
SNP Alliance Comments:
First, SNP Alliance representatives stated that the benefits D-SNPs
provide most frequently are more meaningful to dual-eligible
beneficiaries than some of the supplemental benefits provided more
frequently by other MA plans. We note in the report that some of the
supplemental benefits offered at lower rates by D-SNPs may be covered
by Medicaid, thereby reducing the need for them to be covered by D-
SNPs. Second, SNP Alliance representatives were concerned with our
definition of FIDESNPs. They explained that CMS's definition, which we
used, limits FIDESNPs to those that integrate all Medicare and
Medicaid benefits without any limits, such as the number of nursing
home days covered. They contended that some D-SNPs may be considered
fully integrated even though they do not include all benefits, such as
nursing home care, and may have some limits. However, in reporting on
CMS activities we have no basis for using different definitions than
those formally applied by the agency. Third, SNP Alliance
representatives stated that the ability of their D-SNP members to
fully integrate benefits through contracting is limited by the
capacity and interest of state Medicaid agencies. We note in the
report that state Medicaid agencies we interviewed acknowledged
limitations in their capacity for contracting. Fourth, SNP Alliance
representatives had some concern with our emphasis on estimating how
many beneficiaries are expected to receive the services described in
the model of care, stating that all dual-eligible beneficiaries would
have access to the services described based on need. However, as we
stated in the draft report, information is not generally available on
the number of beneficiaries that use these benefits. Finally, SNP
Alliance representatives were supportive of the state demonstrations
under the financial alignment initiative. They noted that D-SNPs are
being used as a platform for half of the state demonstrations, with
the remainder being based on a Medicaid model. They considered the
adoption of the D-SNP model by many of the state demonstrations as
evidence of D-SNPs' success.
SNP Alliance representatives generally agreed with our
recommendations. They said that they support better aligning reporting
requirements with the models of care, and stated that D-SNPs need a
set of core measures that are most relevant to the dual-eligible
population they serve.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies to the
Secretary of HHS and to interested congressional committees. In
addition, the report will be available at no charge on the GAO website
at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or CosgroveJ@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix II.
Signed by:
James C. Cosgrove:
Director, Health Care:
[End of section]
Appendix I: Comments from the Department of Health & Human Services:
Department of Health & Human Services:
Office of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
August 27, 2012:
James Cosgrove:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Cosgrove:
Attached are comments on the U.S. Government Accountability Office's
(GAO) report entitled, "Medicare Special Needs Plans: CMS Should
Improve Information Available about Dual-Eligible Plans' Performance"
(GAO-12-864).
The Department appreciates the opportunity to review this report prior
to publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Report Entitled:
"Medicare Special Needs Plans: CMS Should Improve Information
Available About Dual Eligible Plans' Performance" (GAO-12-864):
The Department appreciates the opportunity to review comment on this
draft report.
GAO was asked to analyze the characteristics of dual eligible
beneficiaries in Special Needs Plans that serve dual eligibles (D-
SNPs) and other Medicare Advantage (MA) plans, review the differences
in specialized services between D-SNPs and other MA plans, and review
how DSNPs work with state Medicaid agencies to enhance benefit
integration and care coordination. GAO found that, in order to
increase D-SNP accountability, the Centers for Medicare & Medicaid
Services (CMS) should improve D-SNP reporting of services provided to
dual eligible beneficiaries and make this information available to the
public.
HHS concurs with GAO's recommendations, and the agency is either
implementing or currently taking steps toward implementing three of
the four recommended actions, as described further below. We
respectfully request that the report be revised to include the
information summarized below, so as to provide a more complete and
accurate picture of CMS's oversight of D-SNPs and the agency's efforts
to evaluate the extent to which these plans have provided appropriate
care to dual eligibles.
GAO Recommendation:
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.
HHS Response:
HHS concurs with GAO's recommendation and agrees that information
about the extent to which D-SNPs provide certain services would
increase accountability and facilitate evaluation. Currently, CMS
collects some of the information referenced in the report. For
example, the draft report states (on page 21) that, in its review of
the models of care (MOCs) of 15 D-SNPs, GAO found that the D-SNPs
generally did not state how many of their enrolled beneficiaries were
expected to receive certain services. As an example, while all of the
15 D-SNPs stated that they planned to conduct health risk assessments
(HRAs) within 90 days of enrollment, and an annual reassessment, the D-
SNPs were not required, and thus, in most cases, did not report
information on how many of their members had actually completed an 1-
1RA or reassessment in prior years. However, CMS requires D-SNPs to
report this information separately, via the annual Part C reporting
process. As this data collection is relatively new, CMS has not yet
made information regarding SNPs' HRA completion rates public, but we
have reviewed this data to identify areas of improvement. To that end,
CMS has engaged a contractor to develop a standardized HRA tool (HRAT)
and is testing the feasibility of using this tool once it has been
tested and validated. CMS will also identify approaches for ensuring
that D-SNPs have acceptable HRAT completion rates. HHS suggests that
the report be revised to include this information, so as to provide a
more complete picture of CMS's requirements.
In addition, CMS requires that each SNP describe its target
population, and characteristics of that population in its MOC. D-SNPs
are expected to target plan benefits and services to their specific
population of dual eligibles. The report recommends that D-SNPs also
he required to quantify the number of members who would receive such
services, but it is not clear what purpose that information would
serve, as the purpose of the MOC is to provide a framework for
appropriately coordinating the care of SNP enrollees. CMS is willing
to consider modifications to the MOCs, but would appreciate further
clarification from GAO as to what information would he useful (beyond
the example described above).
GAO Recommendation:
CMS should require D-SNPs to collect and report to CMS standard
measures relevant to the population they serve, including measures of
beneficiary health risk, beneficiary vulnerability, and plan
performance.
HHS Response:
HHS concurs with GAO's recommendation. CMS currently requires D-SNPs
to report a set of standardized measures and is developing additional
standardized measures. CMS collects a broad variety of measures
through the Health Plan Employer Data and Information Set (FIFDISg),
Health Outcomes Survey (FIGS), and Consumer Assessment of Health Plans
Survey (CAHPS®) and via CMS contractors or administrative avenues.
These measures, including readmission rates and other state-of-the-art
outcome measures, are used in evaluating the quality and performance
of contracts that include D-SNPs. In evaluating these MA plans, CMS
relies on consensus building organizations, such as the National
Committee on Quality Assurance (NCQA) and Pharmacy Quality Alliance
(PQA), to identify and specify the appropriate measures for these and
other special populations. Thus, CMS already requires a standard set
of measures for reporting. As additional measures become available
through these organizations, CMS will implement them as appropriate
for these plans. Further, CMS is in the process of determining, as
part of Medicare's star rating system, which measures are
appropriately collected at the plan level (e.g., for a given SNP)
versus at the broader contract level (e.g., across all plans within a
contract). These determinations will need to consider the effect of
small sample sizes (a particularly critical issue for SNPs), as well
as the substantially higher cost for achieving appropriate sample
sizes for a large number of SNPs.
We have attached our recent Health Plan Management System (HEMS)
memorandum, dated August 3, 2012, which outlines updated requirements
for reporting calendar year (CY) 2013 HEMS*, HOS, and CAHPS® measures.
(See Table 2 of the attached memo, which lists required SNP-specific
HMIS measures, including plan all cause readmissions. In addition,
public use tiles containing SNP-specific HEMS measures, from 2008-
2012, arc available on the CMS website at: [hyperlink,
http://www.cms.cov/Research-Statisties-Data-rand-Systems/Statistics-
Trends-and-itcports/MCRAtivPariDEnrolData/SNP-HED1S-Public-Use-
Filcs.html.] GAO acknowledges (footnote 19) that D-SNPs are required
to submit a subset of the HEWS measures hut, given that the title of
the report and its recommendations focus on CMS's publication of a
standard set of quality measures for D-SNPs, HHS recommends that the
report properly reflect CMS's efforts in these areas.
The report also fails to mention that all Special Needs Plans (SNPs),
including D-SNPs, are required to submit both a Quality Improvement
Project (QIP) and a Chronic Condition Improvement Project (CCIP),
which are unique quality improvement initiatives that must be
conducted as part of the plan's Quality Improvement Program Plan in
accordance with regulations at 42 CFR §422.152. For CY 2012, we are
aligning the requirements of these initiatives with broadly-focused
Department of Health and Human Services (I-11-1S) activities. As such,
all plans, including D-SNPs, must conduct a 3-year QIP that is focused
on reducing all-cause hospital readmissions, in accordance with the
Partnership for Patients initiative, an HHSwide initiative that
includes a variety of initiatives focused on improving care and
reducing costs. Plans must also conduct a CCIP that is focused on
reducing risks for cardiovascular disease, in support of the national
"Million Hearts" campaign. Plans are currently submitting their "plan"
section of the "Plan, Do, Study, Act" cycle, and CMS staff, with
contractor support, will review and score this section of the QIP and
provide feedback and technical assistance to plans over the next
several months.
In addition to the SNP-specific HEDIS measures described above, D-SNPs
are required to report their scores on six specific structure and
process measures to NCQA, which then prepares summary reports for CMS.
While these reports are not yet publicly available, CMS is willing to
discuss these results with GAO, and is considering when and how to
make them publicly available. We would also note that CMS continues
its efforts to develop standardized outcome measures to assess
healthcare quality for all Medicare Advantage Organizations {MAO)
products, including SNPs, through a contract with RAND. These outcome
measures are expected to be grounded in evidence-based practices and
feasible to apply at the plan level. A number of potentially-viable
outcomes measures have been identified as a result of a recently-
completed pilot study, and RAND is currently preparing for the
implementation of a validation study. Once standardized measurements
are developed and tested, CMS expects to incorporate the measures
within the MA program.
Finally, we also note that HHS engaged the Measure Applications
Partnership (MAP), a multi-stakeholder group of public and private-
sector organizations and experts convened by the National Quality
Forum (NQF) in May 2011. The MAP's latest report, "Measuring Healthcare
Quality for the Dual Eligible Beneficiary Population," released in
June 2012, recognizes the fragmented and episodic nature of the care
the dual eligible population receives and stated that measurement can
set expectations and provide powerful incentives for change. (The full
text of the report is available at: [hyperlink,
http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Appli
cations_Partnership.aspx]. The report highlights a recommended starter
set of specific measures for immediate use that are sensitive to the
unique needs of dual eligible beneficiaries, including measures of
patient/caregiver experience, hospital readmissions, care transitions,
detecting and treating depression, and screening older adults for fall
risk. In addition, the report also highlighted measures that the
workgroup fell should be expanded or broadened and provided guidance
for further measurement development work as well as measure gaps for
dual eligible populations. HI-IS intends to move forward in assessing
the suggestions within the report, including the modification of these
measures as appropriate for application at the plan level.
GAO Recommendation:
The CMS should systematically analyze these data and make h results
routinely available to the public.
HHS Response:
HHS concurs with the GAO's recommendation, as CMS currently makes
certain D-SNP performance data publicly available. Please refer to
HHS's response to GAO's second recommendation above for more
information.
GAO Recommendation:
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.
HHS Response:
HHS concurs with GAO's recommendation and intends to continue to
evaluate the information described above to examine D-SNPs' overall
performance. HHS is contemplating a more formal, comprehensive
evaluation, but such a review is likely dependent on the program's
continued operation, as the SNP authority currently expires at the end
of 2013.
[End of section]
Appendix II: GAO Contact and Staff Acknowledgments:
GAO Contact:
James C. Cosgrove, (202) 512-7114 or CosgroveJ@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Phyllis Thorburn, Assistant
Director; Ramsey Asaly; George Bogart; Melanie Anne Egorin; Linda
Galib; Giselle Hicks; Corissa Kiyan; Elizabeth T. Morrison; and
Kristal Vardaman made key contributions to this report.
[End of section]
Footnotes:
[1] Medicare is the federally financed health insurance program for
persons 65 years of age or over, certain individuals with
disabilities, and individuals with end-stage renal disease (ESRD).
Medicare fee-for-service (FFS), also known as original Medicare,
includes Medicare Parts A and B. Medicare Part A covers hospital and
other inpatient stays. Medicare Part B is optional insurance, which
covers hospital outpatient, physician, and other services and requires
a monthly premium. Medicare Part B beneficiaries have the option of
enrolling in a Medicare Advantage (MA) plan--a private plan
alternative to Medicare FFS that operates under Medicare Part C--to
receive their Parts A and B benefits. In addition, all Medicare
beneficiaries may opt to receive prescription drug coverage under
Medicare Part D either through a separate Part D plan or through an MA
plan.
[2] Medicare Payment Advisory Commission (MedPAC), A Data Book: Health
Care Spending and the Medicare Program (Washington, D.C.: June 2011).
[3] Kaiser Family Foundation, Dual Eligibles: Medicaid Enrollment and
Spending for Medicare Beneficiaries in 2007 (Washington, D.C.:
December 2010).
[4] Pub. L. No. 108-173, § 231, 117 Stat. 2066, 2207 (codified at 42
U.S.C. §§ 1395w-21(a)(2)(A) and 1395w-28(b)(6)).
[5] This number includes 233,902 dual-eligible beneficiaries in Puerto
Rico.
[6] Throughout this report, "other MA plans" refers to MA plans that
are not SNPs. Enrollment in MA plans, including D-SNPs, is voluntary,
but dual-eligible beneficiaries are allowed to change plans each
month, whereas most other Medicare beneficiaries may change plans only
during the annual open enrollment period.
[7] Throughout this report, "specialized services" refers to services
CMS requires SNPs to provide, such as health risk assessments, as well
as supplemental benefits, which are benefits not provided under
Medicare FFS that may be offered by MA plans.
[8] Risk scores are a relative measure of projected Medicare costs for
each beneficiary--with lower scores indicating lower expected costs--
and are expected to be the same for beneficiaries with the same health
conditions and demographic characteristics. In this report we use
lower risk scores as a proxy for better health status. We report
average risk scores in 2010 because 2010 was the year for which the
most recent risk score data were available.
[9] We excluded enrollees with ESRD, those living outside of the
United States, and new enrollees from our calculations of average risk
scores for each plan type. We adjusted all average risk scores to
account for CMS's normalization factor of 1.041 in 2010; additionally,
we adjusted the risk scores for D SNPs and other MA plans downward by
3.41 percent to account for CMS's estimate of the diagnostic coding
differences between MA and FFS. (This is likely a conservative
estimate. See GAO, Medicare Advantage: CMS Should Improve the Accuracy
of Risk Score Adjustments for Diagnostic Coding Practices, [hyperlink,
http://www.gao.gov/products/GAO-12-51] [Washington, D.C.: Jan. 12,
2012].)
[10] We focused our analysis on the following types of MA plans:
health maintenance organizations, local preferred provider
organizations, regional preferred provider organizations, private fee-
for-service plans, and provider-sponsored organizations. We excluded
one type of MA plan--medical savings accounts--because they are not
allowed to offer mandatory supplemental benefits. Mandatory benefits
must be provided for every person enrolled in the plan, whereas
optional supplemental benefits are available to those enrollees who
elect and pay for them. In addition, we excluded plans that only
provided Medicare Part B benefits and plans that restricted enrollment
to members of an employer group or religious fraternal benefit society.
[11] An individual model of care may cover multiple D-SNPs offered by
a single MA organization.
[12] According to CMS, the most-vulnerable beneficiaries include, but
are not limited to, those beneficiaries who are frail, disabled, or
near the end of life.
[13] For 2012, only new SNPs and those expanding their plan service
areas were required to contract with the state Medicaid program. See
42 C.F.R. § 422.107(d) (2011). Our review may not account for relevant
terms that may have been incorporated by reference into the contracts.
CMS reviewed and approved these contracts for compliance with federal
law and CMS regulations.
[14] The states in our sample were Alabama, California, Massachusetts,
Minnesota, and Oregon.
[15] We excluded D-SNPs and dual-eligible beneficiaries in Puerto Rico
from our analyses because Medicare enrollment, cost, and use in Puerto
Rico are different than in the states, including a far greater
proportion of Medicare beneficiaries enrolling in MA plans. In
addition, the CMS enrollment data we received did not include dual-
eligible beneficiaries in Puerto Rico (they were coded as "low-income
territory beneficiaries" and were not included in the data extracts).
[16] Of these 322 D-SNPs, 17 have been designated by CMS as fully
integrated dual-eligible special needs plans (FIDESNP). A FIDESNP is a
CMS-approved D-SNP that (1) enrolls special-needs individuals entitled
to medical assistance under a Medicaid state plan; (2) provides dual-
eligible beneficiaries access to Medicare and Medicaid benefits under
a single managed care organization; (3) has a capitated contract with
a state Medicaid agency that includes coverage of specified primary,
acute, and long-term care benefits and services, consistent with state
policy; (4) coordinates the delivery of covered Medicare and Medicaid
health and long-term care services using aligned care management and
specialty care network methods for high-risk beneficiaries; and (5)
employs policies and procedures approved by CMS and the state to
coordinate or integrate member materials, enrollment, communications,
grievance and appeals, and quality improvement. 42 C.F.R. § 422.2
(2011). In addition, there are 8 D-SNPs operating in Puerto Rico in
2012.
[17] In 2012, FIDESNPs will be eligible for increased payments when
certain requirements, such as having a similar average level of
frailty as the Program of All-Inclusive Care for the Elderly (PACE)
program, are met.
[18] Under each category of supplemental benefits, plans can provide
coverage for a variety of individual services, such as eye exams,
eyeglasses, or contact lenses under a vision benefit; however, plans
do not have to provide coverage for all individual services under a
supplemental benefit category.
[19] CMS assesses plan quality using a five-star rating scale based on
measures of clinical quality, patients' reported care experience, and
contract performance. Once fully phased in after 2014, the revised
rebates will range from 50 percent of the difference between a plan's
bid and benchmark for plans with the lowest quality ratings to 70
percent of the difference for plans with the highest quality ratings.
See Pub. L. No. 111-148, Title III, Subtitle C, 124 Stat. 442, as
amended by the Health Care and Education Reconciliation Act of 2010,
Pub. L. No. 111-152, § 1102, 124 Stat. 1029, 1040.
[20] MedPAC attempted to analyze the quality of SNPs, but found
isolating results for SNPs is difficult because of the way
organizations that sponsor SNPs report HEDIS quality measures. Most
HEDIS data are reported across all of an organization's plans (i.e.,
both SNPs and other MA plans) rather than reported separately for
SNPs. SNPs do report separately on a subset of 12 of 45 HEDIS
measures. When comparing these measures, MedPAC found in general that
SNP performance was poorer than other MA performance, but there was
wide variation across plans. See MedPAC, Report to the Congress:
Medicare Payment Policy (Washington, D.C.: March 2012), 328-329.
[21] See 42 C.F.R. § 422.152(g)(2)(iii) (2011).
[22] 42 C.F.R. § 422.101(f) (2011).
[23] Social Security Act (SSA), § 1859(f) (requirement for contract);
Pub. L. No.110-275, § 164(c)(2), 122 Stat. 2573 (temporary exemption
for certain SNPs) as amended by Pub. L. No. 111-148, § 3205(d), 124
Stat. 458 (extending temporary exemption through 2012). CMS
regulations require that contracts between D-SNPs and states include
documentation of (1) the MA organization's responsibility, including
financial obligations, to provide or arrange for Medicaid benefits;
(2) the category(ies) of eligibility for dual-eligible beneficiaries
to be enrolled; (3) the Medicaid benefits covered; (4) the cost-
sharing protections covered; (5) the identification and sharing of
information on Medicaid provider participation; (6) the verification
of enrollees' eligibility for both Medicare and Medicaid; (7) the
service area covered; and (8) the contract period. 42 C.F.R. §
422.107(c) (2011). Although such contracts will be required for D-SNPs
to operate within a state, there is no requirement that a state enter
into such a contract.
[24] CMS, Common Contracting Issues and Discussion (Baltimore, Md.:
revised September 2011).
[25] Pub. L. No. 111-148, § 2602, 124 Stat. 315.
[26] In 2011, the Medicare-Medicaid Coordination Office, in
partnership with the Innovation Center, entered into contracts with 15
states for up to $1 million each to design state demonstrations.
Furthermore, in July 2011 CMS issued a letter calling for additional
state Medicaid agencies to submit letters of intent to participate in
the demonstrations to better align Medicare and Medicaid funding.
[27] SSA, § 1115A.
[28] The demonstration may be expanded through rulemaking if (1) the
Secretary determines that the expansion would reduce spending without
reducing the quality of care or improve the quality of care without
increasing spending; (2) the CMS Chief Actuary certifies that the
expansion would reduce or not increase net program spending; and (3)
the Secretary determines that the expansion would not deny or limit
the coverage or the provision of benefits for applicable individuals.
SSA, § 1115A(c).
[29] Data on mental health characteristics are based on the 2010 risk
score data.
[30] Demographic data refer to dual-eligible beneficiaries in July
2011. Mental health data refer to dual-eligible beneficiaries in July
2010 and are based on 2009 diagnosis data. Both sources exclude
beneficiaries in Puerto Rico and those living outside of the 50 states
and the District of Columbia in 2010.
[31] Racial or ethnic minorities include Black, Hispanic, Asian, and
North American Native beneficiaries, and beneficiaries who reported
"Other" race. CMS's enrollment data have limitations in accurately
identifying beneficiary race and ethnicity, resulting in an
underreporting of Hispanics, Asian/Pacific Islanders, and American
Indian/Alaskan Natives.
[32] We report data on health status based on dual-eligible
beneficiaries enrolled in Medicare and Medicaid as of July 2010. These
data are not linked to beneficiaries' demographic characteristics in
2011.
[33] Average risk scores for D-SNP enrollees and dual-eligible
beneficiaries in other MA plans and FFS were even-more similar when
comparing only the risk scores for beneficiaries who lived in the
community in July 2010 (D-SNP=1.27, other MA=1.29, FFS=1.28). This is
true in part because a larger proportion of dual-eligible
beneficiaries who were considered to be long-term institutional (i.e.,
those who resided in an institution for at least 3 months) enrolled in
FFS than in D-SNPs in 2010. CMS calculates the risk scores of these
institutional beneficiaries using a different model than it does for
community beneficiaries, and the resulting risk scores for the two
groups are different. Institutionalized dual-eligible beneficiaries in
D-SNPs, other MA plans, and FFS had similar risk scores in 2010 (D-
SNP=1.95, other MA=1.98, FFS=2.00).
[34] However, when taking into consideration the large proportion of
FFS beneficiaries who lived in institutions compared to D-SNP
beneficiaries, full-benefit dual-eligible beneficiaries in D-SNPs and
FFS had similar average risk scores (1.25 and 1.29, respectively).
[35] We examined a total of 20 supplemental benefits offered by D-SNPs
and other MA plans. In addition to the categories listed in figure 4,
we also examined the following 10 supplemental benefits categories
offered by fewer than half of D-SNPs: (1) podiatry, (2) meal benefits,
(3) chiropractic, (4) acupuncture, (5) point-of-service or out-of-
network option, (6) home infusion, (7) inpatient psychiatric
hospital/facility, (8) U.S. Visitor/Travel program, (9)
cardiac/pulmonary rehabilitation, and (10) outpatient drug benefit. Of
these additional 10 benefits, 5 were offered less frequently by D-SNPs
compared to other MA plans. We limited our analysis to plans with no
premium because 99 percent of D-SNPs have no Part C premium, and in
our interviews with D-SNPs, representatives emphasized the importance
of zero-premium plans for the dual-eligible population.
[36] For 2013, CMS will allow certain D-SNPs that meet integration and
performance standards to offer additional supplemental benefits beyond
those CMS currently allows all MA plans to offer, where CMS finds that
the offering of such benefits could better integrate care for dual-
eligible beneficiaries. Such benefits are subject to CMS approval, but
may include nonskilled nursing services, personal care services, and
other long-term care services and supports designed to enable
beneficiaries to remain in the community. D-SNPs must offer these
additional supplemental benefits at no additional cost to the
beneficiary.
[37] CMS officials told us they plan to conduct a review of how 150
SNP models of care have been implemented in 2012. CMS also asks plans
to collect information on certain measures related to the model of
care as a part of their quality improvement program; however, this
information is only required to be made available upon request and is
not systematically reported to CMS or the public. CMS officials also
told us about several SNP quality initiatives that are in operation or
in planning stages; however, these activities were not equivalent to a
full evaluation of the SNP program.
[38] Improved collection of information allows an agency to meet its
goals for accountability for effective and efficient use of resources,
and is consistent with standards for internal control. GAO, Standards
for Internal Control in the Federal Government, [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.:
November 1999).
[39] The contracts were not required to address these goals. However,
the contracts must document the Medicaid benefits, if any, to be
provided by the D-SNPs. See, 42 C.F.R. § 422.107(c) (2011).
[40] CMS, State Resource Center: State Options for Designing Dual SNP
Contracts with Medicare Advantage Organizations that Adhere to MIPPA
Requirement (Baltimore, Md.: 2009), 5.
[41] CMS stated in its state contract training materials for 2013 D-
SNP-state Medicaid agency contracting that contracts for 2013 must
specify how Medicare and Medicaid benefits are integrated and
coordinated.
[42] For D-SNPs that provided all Medicaid benefits as part of their
plan, coordination with the state Medicaid agency was likely not
needed as the plan provided all benefits.
[43] For 2013, CMS issued guidance specifying criteria under which D-
SNPs and states may enter into such subcontracting arrangements.
[44] As of July 2012, one additional state from our sample had
proposed as part of its Financial Alignment Initiative proposals
shifting D-SNPs into demonstration plans and, therefore, end D-SNPs in
their state. An additional five states not included in our sample
propose shifting D-SNPs into demonstration plans or otherwise ending D-
SNPs in their states.
[End of section]
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