As lawmakers break this month from contemplating the future of the Affordable Care Act, Congress has another pressing health care issue to address: the permanency (or lack thereof) of Medicare Advantage Special Needs Plans (SNPs). At the same time the Senate was heatedly debating repeal-and-replace scenarios, a subcommittee of the House Ways and Means Committee on July 26 held a hearing to examine the extension of SNP authorization and ways to improve integration and coordination of care for dually eligible Medicare-Medicaid beneficiaries. Experts interviewed by the panel expressed support for extending the plans, but also urged Congress to permanently authorize all SNP types and offered suggestions for additional enhancements to the program, such as allowing seamless conversion to boost enrollment into aligned plans.

SNPs were authorized under the Medicare Modernization Act of 2003 to serve institutionalized, dual-eligible or severe/disabled chronically ill patients through 2008, and have since gone through a series of brief reauthorizations, most recently with a provision in the Medicare Access and CHIP Reauthorization Act of 2015 that allows them to operate through 2018. Parallel bills have been introduced this year that address SNP reauthorization. One is the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 (S. 870), which was approved by the Senate Finance Committee on May 18 and — in addition to expanding telehealth and other benefits for chronically ill patients — would permanently authorize SNPs (MAN 5/25/17, p. 1).

The other proposed legislation is H.R. 3168, which would grant a five-year extension to SNPs in addition to requiring dual eligible SNPs (D-SNPs) to become integrated by 2022, meaning the MA plan sponsor would have to integrate the product with the state Medicaid program and take all the Medicare and Medicaid risk on that plan. In the version discussed on July 26, only institutional SNPs (I-SNPs) would be made permanent.

Approximately 11 million people are eligible for Medicare and Medicaid coverage, but the majority of dual eligibles are not in programs that integrate both benefits, pointed out Melanie Bella, former director for the CMS Medicare-Medicaid Coordination Office (MMCO), during the hearing. More than 2.3 million individuals are currently enrolled in SNPs, and the bulk of that enrollment is in D-SNPs. Bella testified that permanently extending D-SNPs is a “critical piece” of advancing toward true clinical and financial integration of the two programs, and that plans and other stakeholders “need the assurance of stability to continue to invest both time and resources on increasing the number of aligned plans and Medicare-Medicaid enrollees in those plans.”

Stakeholders Ask for Seamless Conversion

Furthermore, states and plans need mechanisms to ensure that dual eligibles are enrolled in aligned plans, she argued. These include seamless conversion of Medicaid enrollees who become eligible for Medicare into an aligned D-SNP, which is not currently allowed. And MMCO could be given expanded authority to align and simplify administrative requirements by working with states to, for example, coordinate enrollment processes and conduct joint review of marketing and enrollment materials, she added. The discussion draft contains language establishing MMCO as a “dedicated point of contact for States to address misalignments that arise with the integration of specialized MA plans for special needs individuals,” and to establish a unified grievances and appeals process for items and services provided by such plans.

Chris Wing, CEO of California not-for-profit SCAN Health Plan, also testified at the hearing in support of SNP extension and other possible enhancements to the program. SCAN serves about 185,000 seniors in California and operates the state’s only Fully Integrated Dual Eligible (FIDE)-SNP, a subset of D-SNP through which Medicare and Medicaid benefits are offered by a single managed care organization. “If you’re not sure a program is going to be around for more than a year, you really don’t want to invest too heavily in it, so this is a big deal,” Wing remarks in a follow-up interview. “Even if we got a five-year extension, that’s a totally different timeframe than a one- or two-year extension.”

SCAN also welcomes a provision included in H.R. 3168 that would provide new flexibility to MA plans to offer certain non-health care-related services. Wing during the hearing gave an example of a $12 “wrist guard,” which could enable a patient with both glaucoma and Parkinson’s Disease to administer his eye drops from home and ultimately stay out of the emergency room and/or long-term care. “It’s crazy that we can’t offer these Medicaid type of benefits that could help improve care and radically reduce system costs for a Medicare Advantage population,” he tells AIS Health.

Also testifying at the hearing was Larry Atkins, Ph.D., executive director of the National MLTSS Health Plan Association, whose health plan members serve about 70% of the managed long-term services and supports market and about half of Medicare-Medicaid Plan membership through CMS’s Financial Alignment Incentive demonstration. As part of the D-SNP integration requirement in the proposed legislation, MCOs would have to enter into a capitated contract with the state Medicaid agency to provide LTSS or behavioral health services, or both. The coordination of care “across medical and non-medical sectors” not only helps achieve higher care quality but manages spend effectively for states and the federal government, Atkins stressed. Integrating medical and LTSS coverage allows individuals to stay in their homes and communities for as long as possible; avoid unnecessary ER visits, hospital admissions and readmissions; and avoid or defer institutionalization, he added.

MLTSS Plans Argue for More Flexibility

Atkins said his association urges the committee to “permanently reauthorize SNPs rather than continue them for another five years, necessitating Congress to revisit and reauthorize the program yet again another five years from now” and advocated for enhanced state flexibility to “require that dual beneficiaries enrolled in an MLTSS plan be enrolled in an aligned MA plan” (e.g., a FIDE-SNP or a D-SNP offered by the organization providing their MLTSS coverage). He also cited challenges with states auto-enrolling their Medicaid beneficiaries into managed care while Medicare beneficiaries can opt to stay in traditional Medicare or in MA plans that do not align with their Medicaid coverage, and agreed that the moratorium on seamless conversion should be lifted.

Wing says he was “very encouraged” by the meeting and was impressed with the “bipartisan enthusiastic support” that it demonstrated. “I walked away feeling that this is actually going to happen, that we’re going to get something done in Congress that will be helping truly the neediest Americans when it comes to the health care system,” he adds.

View a replay of the hearing at