SNP Special Needs Plan

Anthem 

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What is a Medicare MAPD Special Needs Chronic Condition SNP – C-SNP Plan?

 

Medicare SNPs  Special Needs Plans are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. Medicare.gov

special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals.

A SNP may be any type of MA CCP, including either a local or regional preferred provider organization (i.e., LPPO or RPPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan.  There are three different types of SNPs:

  1. Chronic Condition SNP (C-SNP)
  2. Dual Eligible SNP (D-SNP)
  3. Institutional SNP (I-SNP)  cms.govSpecialNeedsPlans  *

Can I get my health care from any doctor, other health care provider, or hospital?

You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).

Are prescription drugs covered?

Yes. All SNPs must provide Medicare prescription drug coverage (Part D).

Do I need to choose a primary care doctor?

Generally, yes.

Do I have to get a referral to see a specialist?

In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.

What else do I need to know about this type of plan?

A plan must limit membership to these groups:

1) people who live in certain institutions (like nursing homes) or who require nursing care at home, or

2) people who are eligible for both Medicare and Medicaid, or

3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia).

Plans may further limit membership.

Plans will coordinate the services and providers you need to help you stay healthy and follow doctors’ or other health care providers’ orders.

Diabetes C SNP

If you have Medicare and diabetes you can enroll in chronic condition special needs plans (C-SNPs).   Surveys show members experience better outcomes than you would in regular Medicare Advantage (MA) plan.  The survey used a claims-based approach to compare member outcomes on five clinical and utilization  measures, Avalere found that enrollees in a diabetes-focused C-SNP were:

• 22 percent more likely to have a primary care visit,
• 10 percent more likely to receive appropriate diabetes testing,
38 percent less likely to have an inpatient hospital admission,
• 32 percent less likely to have a readmission, and
• 6 percent more likely to fill (and refill) a prescription for an antidiabetic medication.

These findings held true when controlling for expected differences in enrollees’ demographics and health status. The analysis suggests that C-SNPs can improve outcomes for beneficiaries with diabetes compared to non-SNPs.   AnthemInc.com * Avalere.com

Los Angeles & Orange  County

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  •  Summary of Benefits
  •  Evidence of Coverage 
    • See page 7 of the EOC Special eligibility requirements for our plan Our plan is designed to meet the specialized needs of people who have certain medical conditions. To be eligible for our plan, you must have diabetes mellitus.   NIH.Gov *
      • To determine eligibility for a special needs individual to enroll in a C-SNP, CMS requires that the C-SNP contact the applicant’s existing provider – doctor to verify that the enrollee has the qualifying conditions. C-SNPs must reconfirm a beneficiary’s eligibility at least annually.  CMS.gov
    • The Coverage chart is on page 50 of the EOC.  If it changes with annual revisions, just use the table of contents or search feature.
    • SNP FAQ’s from CMS Site  

SNP Benefits
Click to enlarge

Chronic Condition Special Needs Plans  C SNP

Scan Foundation Summary on Chronic Care Act 

Forbes  * Commonwealth Fund - Social Services

home-delivered meals, transportation for nonmedical needs, pest control, indoor air quality equipment (e.g., air conditioner for someone with asthma), and minor home modifications (e.g., permanent ramps, widening of hallways or doorways to accommodate wheelchairs).    Listening

telehealth is  the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services. 

Learn More

 Part C & D Enrollment Periods

SNP is all the time
Part C & D Enrollment Periods

Special Needs Plans * #11302 Outdated 11.2011  *

Special Needs Plans #11302

Medicare Coverage for Diabetes # 11022

Medicare Coverage for Diabetes # 11022

VIDEO's  

Diabetes  Official Medicare VIDEO 

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Posted by Anthem Blue Cross on Tuesday, September 4, 2018

Medicare Coverage of Kidney Dialysis and Transplants # 10128Medicare Coverage of Kidney and Dialysis

Average Billed Charges – 2017 Transplant
Kidney - $414k
Average Transplant Charges

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7 comments on “ESRD SNP Caremore Medicare Advantage – Special Needs Plan for Kidney Failure –”

  1. Anonymous says:
    if one gets a transplant and no longer requires dialysis, can they stay on a ESRD SNP Plan?
     
  2. us says:
    I live in Los Angeles and I’m on a transplant waiting list in Washington State. Will a Medicare Advantage Plan pay my expenses out of state?
     
    • Steve Shorr says:
      Excellent Question and it’s beyond our pay grade.

       

      For one, isn’t there a National Kidney registration?

      https://www.kidney.org/atoz/content/transplant-waitlist
      The United Network for Organ Sharing (UNOS) manages the list of all the people across the US waiting for an organ transplant. UNOS ensures that deceased donor organs are distributed fairly using a transparent system

      https://transplantliving.org/kidney/how-could-i-get-a-transplant-sooner/
      There are different kinds of donated kidneys – some with shorter wait times. It will be your job to choose which of these kidneys you’re willing to take – being open to more than 1 kind may make your wait shorter.

      On the other hand:

      http://www.organjet.com/
      OrganJet provides an information service, as well as options for timely and affordable air transport, for patients who are multi-listed or distant listed for organ transplants in the U.S.

      (Did you know that 500+ kidneys are wasted every year while 90000+ people wait on the list? We believe that we can improve the system and are working towards it.)

      In the meantime, you can likely get a transplant earlier by listing smartly.

       
    • Steve Shorr says:
      Excerpt from Evidence of Coverage

       

      What are network providers?

      Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals and other health care facilities that have an agreement with us to accept our payment, and any plan cost sharing, as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The most recent list of providers and suppliers is available on our website at https://shop.anthem.com/medicare/ca.

      Why do you need to know which providers are part of our network?

      It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan, you must use network providers to get your medical care and services.

      The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services and cases in which the plan authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical and other covered services) for more specific information about emergency, out-of-network and out-of-area coverage.

      If you don’t have your copy of the Provider/Pharmacy Directory, you can request a copy from Customer Service (phone numbers are printed on the back cover of this booklet). You may ask Customer Service for more information about our network providers, including their qualifications. You can also see the Provider/Pharmacy Directory at https://shop.anthem.com/medicare/ca or download it from this website. Both Customer Service and the website can give you the most up-to-date information about changes in our network providers.

      Getting an exception is pushing the limits of our pay grade. See also our webpages on medical necessity and appeals.

       
    • Steve Shorr says:
      I checked with “my people” at Caremore and they advise that you NOT change plans as it may put in at the bottom of the waiting list!

       

      Thus, I think your “battle” would be with Medi Cal to pay the 20% that Medicare doesn’t pay.

      Medi-Cal pays out of state when:

      540-1 (a) (5) When an out-of-state treatment plan has been proposed by the beneficiary’s attending physician and the proposed plan has been received, reviewed and authorized by the Department before the services are provided; and the proposed treatment is not available from resources and facilities within the State.

      https://www.law.cornell.edu/cfr/text/42/431.10

      Medi Cal Treatment Authorization Request

Chronic Conditions List

  • Chronic alcohol and other dependence
  • Autoimmune disorders
  • Cancer (excluding pre-cancer conditions)
  • Cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
    • Our webpage on getting coverage
  • Severe hematologic disorders
  • HIV/AIDS
  • Chronic lung disorders
  • Chronic and disabling mental health conditions
  • Neurologic disorders
  • Stroke  cms.gov/C-SNPs *  Medicare.gov *

Chronic care management services

If you have 2 or more serious, chronic conditions (like arthritis, asthma, diabetes, hypertension, heart disease, osteoporosis, and other conditions) that are expected to last at least a year, Medicare may pay for a health care provider’s help to manage those conditions. This includes a comprehensive care plan that lists your health problems and goals, other health care providers, medications, community services you have and need, and other information about your health. It also explains the care you need and how your care will be coordinated. Your health care provider will ask you to sign an agreement to provide this service. If you agree, he or she will prepare the care plan, help you with medication management, provide 24/7 access for urgent care needs, give you support when you go from one health care setting to another, review your medicines and how you take them, and help you with other chronic care needs. You pay a monthly fee, and the Part B deductible and coinsurance apply.  medicare.gov/10050-Medicare-and-You

Links & Resources

Blue Cross Explanation

Nolo.Com

CA Health Advocates.org

CA Dept of Aging – HICAP (Local SHIP) – Center for Health Care Rights – 1-800-434-0222

CMS – Medicare – List of conditions for Special Needs Plans

Medicare Managed Care Manual – SNP  Chapter 16 B 

better medicare alliance.org/IssueBrief

Wikipedia

medicare.gov/special-needs-plans-snp

Management Services 

Aetna.com Model of Care

Vantage Health Plan Annual Training 

Cal Broker Magazine

Medicare covers the substantial costs associated with End Stage Renal Disease (ESRD) for the vast majority of kidney patients. How will this coverage change under the newly implemented Affordable Care Act, also known as Obamacare?

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