snp surveyor update training june 17, 2013. 2 snp: surveyor update training objectives of snp sut...

SNP Surveyor Update Training

June 17, 2013

2SNP: Surveyor Update Training

Objectives of SNP SUT Training

• Review NCQA’s year-to-year approach to the project and reporting requirements for SNPs

• Describe the changes in the S&P measures for the 2013 SNP Assessment

• Explain how to assess performance with individual elements in the S&P Measures


Objectives of SNP Assessment Program

• Develop a robust and comprehensive assessment strategy

• Evaluate the quality of care SNPs provide

• Evaluate how SNPs address the special needs of their beneficiaries

• Provide data to CMS to allow plan-plan and year-year comparisons


SNP Assessment: How did we get here?

• Existing contract with CMS to develop measures focusing on vulnerable elderly

• Revised contract to address SNP assessment

2008 - rapid turnaround, adapted existing NCQA measures and processes from Accreditation programs

2009 - focused on SNP-specific measures

2010 - refined existing measures

2011 - clarified requirements in SNP 1 thru 6

2012 - added elements/factors, removed factors, refined measures and documentation requirements


Who Reports

• HEDIS measures– All SNP plan benefit packages with 1 or

more members as of February 2012 Comprehensive Report (CMS website)

• S&P measures– All SNP plan benefit packages– Plans with zero enrollment as of April

2013 Comprehensive Report are exempt for certain elements


SNP Reporting

• Returning SNPs— all SNPs that were operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted.– SNP 1 A-F, SNP 2A-C, SNP 3-6

• New SNPs — all SNPs operational as of January 1, 2012 AND renewed for 2013 AND are reporting for the first time.– SNP 1 A-D, SNP 2A-C, SNP 4-6


Project Time Line – 2013-2014

• June 2013 through September 2013- Training for SNPs

• June & July 2013 - Release S&P Measures in hardcopy and ISS Data Collection Tool

• October 15, 2013 - S&P Measure submissions due to NCQA

• October 15, 2013 to April 30, 2014 – S&P reviews conducted by NCQA and surveyors

• June 2014 - NCQA delivers SNP Assessment Report to CMS

Structure and Process Measures

SNP 1: Care Management and Coordination


Changes since 2012• Replaced elements of Complex Case

Management with new ones for Care Management that assess whether SNPs have appropriate programs to coordinate services and help all members access needed resources

• Better align with CMS MOC requirements for assessment and care plans

SNP 1- Care Mgmt. and Coordination


Changes continuedCare Mgmt. and Coordination consists of

ElementsA: Care Management Program DescriptionB: Population DescriptionC: Care Management ProcessD: Individualized Care PlanE: Satisfaction with Care ManagementF: Analyzing Effectiveness/Identifying

OpportunitiesG: Implementing Interventions and Follow-up Evaluation



Definition - Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing coordination of care, eliminating duplication of services and reducing the need for expensive medical services.



Element A - Program DescriptionThe SNP has a description for its Care

Mgmt. program that includes:1. Evidence used to develop the

program2. Criteria for identifying members who

are eligible for the program3. Services offered to eligible members4. Defined program goals

Data source: documented process



Care Mgmt. program focuses on member-specific activities and the coordination of services; it involves:

• Comprehensive assessment of member’s condition

• Determining benefits/resources• Developing and implementing a

care plan that includes performance goals, monitoring and follow-up



A SNP must have a Care Mgmt. Program

• Based on the subpopulations within its membership SNPs may have the following within a larger Care Mgmt. Program:–Complex case mgmt–Transitional case mgmt–High-risk/high utilization

programs–Hospital case mgmt



• Factor 1 requires the SNP to describe the evidence it used to develop the program.– E.g., clinical practice guidelines;

scientific evidence from clinical or technical literature or government research; or literature reviews for nonclinical aspects of the program like dealing with or promoting behavioral change.

• Program description must also detail the criteria SNP uses to identify eligible members for factor 2



• SNP’s description includes the services it provides to members.

• Org that stratifies members based on risk or level of need must include eligibility criteria, services to be provided and goals for each tier.

• Program description also needs to include goals that reflect specific objectives and targets.



Element B – Population Assessment• Annually SNP must:

1. Assess the characteristics and needs of member population and pertinent subpopulations

2. Review and update Care Mgmt. processes to address member needs

3. Review and update Care Mgmt. resources to address member needs

Data source: Documented process



• Population assessment includes SNP’s covered population not just members in specific programs like CCM

• Documentation must show how:– SNP considers specific member

characteristics when designing and revising program e.g.,• Medicaid eligibility categories• Nature and extent of carved out benefits• Type of SNP• Race/ethnicity and language preferences



• Population assessment procedures also need to include consideration of program characteristics and resources e.g., staffing ratios, clinical qualifications, job training, external resources and cultural competency

• SNP’s documentation needs to be dated after 10/15/12



Element C - Care Mgmt. Assessment Process

• Includes all info for SNP to assess members’ needs and develop interventions for them

• A SNP’s documentation must address all 8 factors

• It may submit assessment tools or screenshots as evidence, if these documents demonstrate the system has all required functionality


Data sources: Documented process and reports or materials


SNP’s evidence must include:• Documentation of clinical history and

meds– e.g., disease onset, inpatient stays,

treatment history• Initial assessment of:

– health status & comorbidities– activities of daily living– mental health status and cognitive

function• both aspects are required



• Evaluation of:– cultural and linguistic needs

• review of language needs meets factor 5

– visual & hearing needs, preferences/limitations

– caregiver resources• e.g., family involvement in decision making

– available benefits• covered by SNP, carved out for supplemental

services such as community behavioral health or national and community resources



Element D - Individualized Care Plan• SNP uses info from assessment e.g.,

HRAs and other sources to develop a comprehensive care plan

• Care plan includes info on actions or interventions and their duration a SNP’s Interdisciplinary Care Team (ICT) takes to address members’ medical, BH, functional and support needs.


Data sources: Documented process and reports or materials


• A SNP’s documentation shows that the ICT develops a care plan for each member that includes:– prioritized goals that reflect member’s

or caregiver’s preferences and involvement

– self-management plan– schedule for follow-up/identify barriers– process to assess member progress



• Based on the member’s specific needs the care plan also identifies:– resources to be utilized and

appropriate level of care• CMs as members of the ICT often facilitate

referrals to other providers as part of member’s benefits

– planning for coordination of care including transitions and transfers• identifying how and when ICTs follow up

with a member after referral to a health resource

– collaborative approaches to be used



Element E - Satisfaction with Care MgmtIntent is for SNP to obtain feedback on its Care Mgmt. program from a broad sample of members, not just those that contacted it• SNP must submit a report showing it

performed an evaluation of satisfaction by:1) Obtaining feedback from members2) Analyzing member complaints and

inquiries


Data source: Reports


Factors 1 and 2 require SNPs to use:• focus groups or satisfaction surveys that

are specific to Care Mgmt program– e.g., assess satisfaction with--program

staff, the usefulness of info received, member’s ability to adhere to recommendations.

• analysis of complaint and inquiry data after 10/15/12 to identify patterns or trends– quantitative and qualitative



• Factors 1 and 2 focus on satisfaction with the Care Mgmt. Program not satisfaction with the SNP’s overall operations

• Reports with data obtained from CAHPS or general surveys will not meet the intent

• Results from satisfaction surveys administered across multiple SNPs must be stratified at individual plan level for analysis



• Score factor 2 NA if SNP provides evidence (e.g., tracking mechanism) showing it did not receive any Care Mgmt. complaints and inquiries after 10/15/12

• Score factors 1 and 2 NA for SNPs that did not have any members at the start of the look-back period. Confirm this with CMS April 2013 Comprehensive Report.



Element F - Analyzing Effectiveness/Identifying Opportunities

• The SNP measures the effectiveness of its Care Mgmt. program using three measures. For each measure, it:1) Identifies a relevant process or outcome 2) Uses valid methods that provide quantitative results 3) Sets a performance goal 4) Clearly identifies measure specifications 5) Analyzes results 6) Identifies opportunities for improvement, if

applicable


Data source: Reports


SNP’s report must contain appropriate measures

likely to have significant and demonstrable bearing on all or a subset of Care Mgmt. members

– Outcomes based– Relevant to target population– Valid methodology

• Contains info on sampling (if used) and sample size calculation

• Measurement periods reflect the effects of seasonality

– Denominator specific to Care Mgmt. population



Report shows appropriate analysis – goes beyond simple reporting or data display– Comparison to goal or benchmark

• Measure must not have exceeded goal from outset – Quantitative and qualitative– Opportunities for improvement

• SNP can use 3 patient experience measures• e.g., improved quality of life, pain

management and health status• May only use 1 satisfaction measure with

Care Mgmt. program operations



• Scoring is based on an average for all 3 measures

• Analysis of measures must be SNP-specific. Org can present aggregate analysis if it breaks out data and results for individual SNPs

• SNP must have performed analyses of measures after 10/15/12

• SNPs that submit Care Mgmt. worksheets also need to provide actual reports



• Score factor 6 NA if your assessment of the SNP’s documentation confirms it does not have any opportunities for improvement

• Score factors 1 thru 6 NA for SNPs that did not have any members at the start of the look-back period. Confirm this with CMS April 2013 Comprehensive Report.



• Examples of measures– HEDIS measures of effectiveness for

chronic conditions• e.g., controlling high blood pressure,

persistence of beta blocker treatment after a heart attack

– SF-36 or SF-12 results– Use of service measures for which

consensus indicates improvement – e.g., reduced ED visits

– Readmission rates– Ambulatory-care sensitive admissions



Element G - Implementing Interventions and Follow-up Evaluation

• Based on the results of its measurement and analysis of Care Mgmt. effectiveness, the organization:1) Implements at least one intervention for

each of the three opportunities identified in Element F to improve performance

2) Develops a plan for evaluation of the intervention and re-measurement


Data source: Documented process and Reports


• Scoring is based on an average for all 3 measures

• Interventions must have been implemented after 10/15/12

• A SNP’s documentation needs to show that it developed a plan to evaluate the effectiveness of its interventions; this evaluation includes re-measurement using methods consistent with initial measurement.



• Factor 1 may be NA if no opportunities

• Factor 2, re-measurement, must be completed whether there are opportunities or not.

• Score factors 1 and 2 NA for SNPs that did not have any members at the start of the look-back period. Use the CMS April 2013 Comprehensive Report to confirm this.



Questions?

SNP 2: Improving Member Satisfaction


• SNP 2 Element A and B– Now applicable to both initial and returning

SNPs• SNP 2 Element C

– Added new example for factor 2 that emphasizes continuing the intervention and then re-measuring when an organization does not meet its initial goal

Summary of Changes for 2013


• Who reports?– Initial and returning SNPs are

responsible for reporting all of SNP 2. This includes Elements A, B and C

– SNPs with no members at the start of the look-back period are exempt from SNP 2• Surveyors will need to confirm with CMS

April 2013 SNP Comprehensive Report.

SNP 2: Overview


Assessment of Member Satisfaction• a SNP must supply BOTH a documented

process and a report explaining how it performed the assessment and an analysis of member satisfaction data that shows it: – identified the appropriate population– selected appropriate samples from the

affected population, (if used)– conducted an quantitative and qualitative

analysis annually• The SNP will receive credit for factor 2 if it

collects data for its entire population

SNP 2 Element A


• A SNP’s complaint and appeal data must relate to at least the four major categories– Quality of Care– Access– Attitude and Service– Billing and Financial

• It must submit a report that shows the quantitative and qualitative analyses was performed after 10/1/12.

• Complaint, grievance and appeal data or satisfaction survey data collected 12 months prior to the start of the look-back period--(4/15/12) will not meet the intent

SNP 2 Element A


• All SNP complaint/appeal data must be at the PBP level. The SNP should receive a score of: – 50% for data only identified as

“Medicare”– 0% if data source is not specified at all

• SNPs must perform their own analysis of CAHPS results, not just attach a vendor’s report to meet the intent of Element A.

SNP 2 Element A


• If the SNP has no complaints, appeals or grievances, it must still show a table, spreadsheet or other documentation that demonstrates it collected appropriate data for an analysis and found no complaints or appeals for its members

SNP 2 Element A


• The analysis must be SNP-specific; plans must break out the data at the PBP level for an aggregate analysis of complaints and appeals across multiple benefit plans

SNP 2 Element A


Opportunities for Improvement• Element B requires a SNP to show:

– How it identifies opportunities for improvement of member satisfaction (documented processes)

– At least 2 opportunities for improvements based on its data and analysis for SNP 2A (reports)

– It identified opportunities after 10/1/12.• Analysis should indicate reasons for

opportunities identified– May be lesser priorities

SNP 2 Element B


• Element B is NA if:– a SNP’s analysis does not result in the

identification of one or more opportunities for improvement.

• Reasons for no improvement opportunities may include: – no or very low enrollment – no trendable data available – very low number of complaints/appeals

SNP 2 Element B


Improving Satisfaction• Element C requires a SNP to show that it is

actively working on implementing interventions and measuring their effectiveness.– Plans must provide BOTH documented

processes and reports• The interventions must relate to those

opportunities identified in SNP 2B, or from other opportunities identified from the analysis of member satisfaction data in SNP 2A

• Do not have to show improvement on interventions, but a SNP must show it measured intervention effectiveness.

SNP 2 Element C


• Timeframes– Interventions must be implemented

within one year of the submission date (October 15, 2012 – October 15, 2013)

– Analysis of intervention effectiveness or remeasurement for those that do not have opportunities must be performed within the look-back period (April 15, 2013 – October 15, 2013)

SNP 2 Element C


• When evaluating intervention effectiveness for factor 2 - SNPs must perform remeasurement against an original goal, or a targeted intermediate measurement of specific interventions

SNP 2 Element C


• If a SNP has no members as of the start of look-back period, score the element “NA”. – Confirm with CMS April 2013 SNP

Comprehensive Report. • Initial SNPs with no opportunities

for improvement get an “NA” for factors 1-2

• Returning SNPs with no opportunities for improvement get an “NA” for factor 1 only

SNP 2 Element C

SNP 3: Clinical Quality Improvement


• Methodology has been revised to calculate statistically significant improvement. The new methodology better addresses the “small numbers” issues related to low enrollments and denominators for many of the HEDIS measures and more accurately reflects year-to-year improvement without penalizing plans SNPs that do not have at least one member as of the CMS February 2012 SNP Comprehensive Report are exempt from reporting this measure and receive a score of “NA”.

• Surveyors do not score this measure

SNP 3 Element A


• What is statistical significance?– 0-59: At least a 6 percentage point change – 60-74: At least a 5 percentage point change – 75-84: At least a 4 percentage point change – 85-92: At least a 3 percentage point change – 93-96: At least a 2 percentage point change – 97-99: At least a 1 percentage point change

• This applies to measures where both higher and lower percentages are better

SNP 3 Element A


• Which SNPs must demonstrate clinical improvement?– Only returning SNPs will be scored– Initial SNPs and plans with no

members (as of Feb 2012 CMS Comp. Report) are exempt

• Plans are not required to submit anything in ISS. NCQA will score this element internally.

SNP 3 Element A


Questions?

SNP 4: Care Transitions


• No major content, documentation or scoring changes

• Element E—Added a new factor that requires plans to take actions or interventions related to the opportunities identified in factor 2.

• Element E—clarified that plans may use their existing CMS QIP related to reducing hospital admissions to satisfy factor 3 requirements

What’s Changed?


SNP 4 Element A: Managing Transitions

• Managing & coordinating planned/unplanned transitions from one care setting to another– Factor 1 focuses on planned transitions

to and from a hospital• Requires SNP to show it is aware that a

transition is about to take place—before it happens and provide support throughout the transition process, not just after discharge

• A preauthorization policy included in documentation must show how it triggers clinical action. Cannot solely pertain to a coverage or payment decision.


SNP 4 Element A• Factor 2 specifies requirements for

planned and unplanned transitions to and from a hospital

• Sending setting must share care plan with receiving setting within 1 business day of transition notification– Care plan consists of patient info that

facilitates communication, collaboration and continuity of care across settings

– Org determines what info care plan includes– Must specify practitioner to receive care plan

for planned transitions to hospital—must show evidence SNP shared care plan with practitioner w/in specified timeframe


SNP 4 Element A

• Factor 3: Notifying member’s usual practitioner of transition

– planned and unplanned transitions to and from all care settings

– must specify a timeframe for completion of transition activities, e.g., • 24-48 hours prior to member movement to

receiving setting• within 1 business day of member’s

discharge• at least 2 calendar days before the

scheduled procedure


SNP 4 Element B

Supporting Members Through Transitions

• Communications with members/caregivers within specified timeframes regarding:– the transition process and what to

expect– changes in health status and their care

plan– who will support them through the

process• Factors 1 thru 3 pertain to planned

andunplanned transitions to and from all care settings


SNP 4 Element B

• A SNP’s documented process for factors 1 thru 3 must specify a timeframe for completion of required transition activities– The following do not qualify as

timeframes• during the encounter ….• upon identification of transition needs ….

• regular contact and review ….• on an ongoing basis ….• during discharge ….


• An aggregate analysis of transitions should contain:– Measures that directly assess the

frequency a SNP performs the functions assessed in factors 1-3 of Elements A & B

– A description of:• how the SNP collects the data• who performs the functions assessed• the timeframe for the analysis• Universe of planned & unplanned

transitions included and care settings involved

SNP 4 Element C


SNP 4 Element C

• The intent of the aggregate analysis for this element is for plans to assess how well they are managing transition activities.

• Factors 1 and 3 need to show: – data collected; – a quantitative and qualitative analysis; and – the opportunities for improvement

• Factors 2 and 4 must describe:– the universe of members in the sample– sampling methodology– how the SNP drew at least 3 months of data


What is an Analysis?• An evaluation of aggregate performance

that includes:– quantitative data – number of transitions in

the denominator for a factor and the number of transitions where the SNP performed the activity specified by the factor within any pertinent timeframes

– qualitative data – notations on results, trends, anomalies, assessment of causes/reasons for findings» identification of opportunities and

recommendations for further action

SNP 4 Element C


Identifying Unplanned Transitions• A SNP must show that it:

– has a documented process and reviews reports of hospital admissions within 1 business day of the admission• Must show at least 3 admissions

– reviews reports of long-term care facility admissions within 1 business day of the admission • Must show at least 3 admissions

SNP 4 Element D


SNP 4 Element E• Focus of element is on minimizing

unplanned transitions and keeping patients in least restrictive setting

• Factor 1 requires an analysis of patient-specific data to identify those at risk− E.g., claims, UM or provider reports,

predictive modeling


SNP 4 Element E

• A SNP’s documentation for factor 1 needs to show:– data collected—must monitor all

members– members targeted– areas where it acts to minimize the

risk of unplanned transitions and keep members in the least restrictive setting


SNP 4 Element E

Factor 2 requires SNPs to analyze data and identify areas where avoidable, unplanned transitions can be reduced• Analyze member admissions to all

hospitals and ED visits– Population focus (aggregate data)– Actual analysis to identify areas for

improvement


SNP 4 Element E• SNP’s documentation for factor 2

must show:1) data collected2) quantitative and qualitative analysis3) opportunities for improvement.

• SNP must include in-network and out of network facilities and EDs in this analysis for factor 2. If it only includes in-network facilities, it does not receive full credit for this factor (cannot score >50%).


SNP 4 Element E

• SNP must provide evidence of 1 analysis performed w/in the look-back period (April 1-October 15, 2013). – Data for analysis can go back to April

2012 • Analyses must be SNP-specific;

organizations that perform an aggregate analysis of multiple benefit plans must break out the data for each individual plan


• Factor 3—implementing interventions

• New for 2013– The SNP must implement at least one

intervention from the opportunities identified in factor 2.

– Do not have to show improvement or effectiveness of the intervention

– SNPs can use their existing CMS QIP related to reducing hospital readmissions

SNP 4: Element E


SNP 4 Element F

Reducing TransitionsFactors 1 and 2 require a SNP’s documentation to show that it:• Coordinates services for at-risk

members

• Educates these members or their caregivers on how to prevent unplanned transitionsActions must relate to findings from

monthly analyses in SNP 4:E, factor 1


SNP 4 Element F

• Factor 1—Care Coordination may be done through Case Mgmt or other programs; SNP must maintain special procedures if all members are not in CM

• Factor 2—Educational opportunities must be related to specific, targeted populations, not just general health education

SNP 5: Institutional SNP Relationship with Facility


SNP 5 Element A

Monitoring Members’ Health Status• Institutional SNPs only

– Focus is on communications with facilities to monitor member needs and services provided

– Facilities include contracted nursing facilities and assisted living facilities

• The SNP must show that it monitors information on members’ health status at least monthly– Communication should include information that may

indicate a change in health status or no change


• Scoring• 100% or full credit

– Institutional SNPs who monitor at least monthly

• 50% or partial credit– Institutional SNPs who monitor at least

quarterly• 0% or no credit

– Institutional SNPs who monitor less often than quarterly

SNP 5 Element A


SNP 5 Element A

• Monitoring methods a SNP can use: – data derived from MDS or other reports on member

health status it requires from the institutional facility– reports from its staff who visit members in facilities– data on members’ health status it collects through

care management if collected on a monthly basis• Status reports may include:

– Functional status assessments– Medication regimen– Self-reported health status– Reports on falls, socialization and depression


• Documentation – a SNP must provide a documented

process and one additional data source or it does not receive full credit for this element

• Element is NA for:– An Institutional SNP that shows it does not have

contracts with nursing facilities or assisted living facilitiesall members reside in the community

• Dual Eligible and Chronic Care SNPs are exempt– Score all elements in this measure “NA”

SNP 5 Element A


Monitoring Changes in Members’ Health Status

• Organization monitors and responds to triggering events and changes by:

1. Setting parameters for the types of changes and triggering events contracted facilities must report within 48 hours, 3 calendar days and 4 to 7 calendar days

2. Identifying who will act on that information and should be contacted

3. Identifying how the member’s care will be coordinated with appropriate clinicians or the clinical care plan

4. Identifying one monitoring or data collection method it uses to assess changes in all members’ health status

SNP 5 Element B


• An organization must submit evidence that shows it has identified specific conditions or early warning signs and symptoms that facilities must report within a minimum of:

48 hours3 calendar days4-7 days

• The SNP must submit a documented process and reports or materials showing how and when facility staff must report a list of triggers such as:

changes in vital signschanges in the member’s behaviorchanges in their functional statuscomplaints of pain

Factor 1 Details


• Explanation of scoring• 100% or full credit

–The organization meets all 4 factors• 50% or partial credit

–The organization meets 3 factors including factors 1 through 3 (critical factors)

• 0% or no credit–The organization meets 0-2 factors or

does not meet factors 1, 2 or 3

SNP 5 Element B


SNP 5 Element B • The SNP must demonstrate it monitors

members through one of the following methods:– Reports from facilities to the organization such as

Minimum Data Set (MDS)– Reports from organization staff who visit the

members– Oversight of facility monitoring and reporting

changes to treating practitioners rather than to the organization

– A combination of the processes above


SNP 5 Element C

Maintaining Members’ Health Status• Organizations use the information from

SNP 5 Elements A&B to identify at-risk members and work with facilities/practitioners to arrange for necessary care and adjust care plans as needed to prevent declines in member health status

• Scoring is 100% or 0% (all or nothing element)


SNP 5 Element C

Methods of providing care: • SNPs may have differing models of

relationships with facilities to address these monitoring functions– Facility oversight: relies on facilities to

modify/carry out care plans– Staff practitioners: SNP staff practitioners

visit facilities and order care plan modifications

– Other models of care: SNPs may use a combination of above models or different one


SNP 5 Element C Documentation• A SNP must submit:

– Documented Processes; AND• Policies describing increases in frequency of visits

to member by the organization’s nurse managers to assess, revise the care plan and monitor his or her condition after a health status decline and resulting inpatient stay

– Reports• Screenshots from the organization’s care

management system documenting monitoring visits, assessments and care plan changes the nurse managers discussed with the member’s treating practitioner and notes confirming the practitioner’s agreement


QUESTIONS?

SNP 6: Coordination of Medicare and Medicaid Coverage


No Major Changes for 2013 !!!

What’s Changed?


SNP 6 Element A

Coordination of Benefits for Dual-Eligible Members

Dual-eligible SNPs coordinate Medicare & Medicaid benefits/services for their members by:

• Giving members access to staff knowledgeable about both programs

• Providing clear explanations of rights to pursue grievances/appeals under both programs

• Providing clear explanations of benefits and any communications they receive re: claims, cost sharing

Not Applicable for C-SNPs & I-SNPs


• For all factors — SNP must provide information to members for Medicare AND Medicaid per the requirements of the factors.

SNP 6 Element A


• Documentation must show:– SNP’s reports cover the details of

members’ specific benefit plans– It gives members information on staff

who can answer questions regarding both programs in lieu of written documents

– SNP staff can answer questions about Medicare benefits and the state’s payment cost-sharing as well as Medicaid eligibility and cost-sharing for services where the member is liable.

SNP 6 Element A


• Documentation - SNPs must provide reports and may provide documented processes or materials– Reports:

• Evidence of Coverage (EOC) documentation– Documented processes:

• Evidence of Coverage (EOC) documentation• Processes describing how coordination occurs

– Materials:• Scripts or guidelines for staff who help members

with eligibility

SNP 6 Element A


SNP 6 Element B

Administrative Coordination of Dual-Eligible Benefit Packages

The organization coordinates services by:

• Identifying changes in members’ Medicaid eligibility

• Coordinating adjudication of Medicare/Medicaid claims for which it is contractually responsible

Not Applicable for C-SNPs & I-SNPs

100

SNP: Surveyor Update Training

SNP 6 Element B

• SNPs must demonstrate that they monitor instances where members are losing and regaining Medicaid eligibility for factor 1

• SNPs without a contract for Medicaid adjudication can meet the intent of factor two if they show they help members understand the state’s adjudication of claims submitted by providers for factor 2

101


SNP 6 Element B

Documentation• SNPs must provide (1) documented

processes and (2) reports OR materials– Documented processes:

• Procedures used to determine changes in Medicaid eligibility

• Procedures used to coordinate adjudication of Medicare and Medicaid claims

– Materials:• Scripts or guidelines for staff who help members

eligibility, benefits, and claims for both programs

– Reports:• Redacted reports on Medicaid eligibility used by

organization

102


SNP 6 Element C

Administrative Coordination for Chronic and Institutional Benefit Packages

• SNP shows it coordinates Medicare/Medicaid benefits for C-SNP& I-SNP members by:– Using a process to identify changes in members’

Medicaid eligibility– Informing members about maintaining Medicaid

eligibility– Giving members information about benefits they are

eligible to receive under both programs– Giving members access to staff who can advise them on using both programs

Not Applicable for D-SNPs

103


• Factors 1, 3 and 4—SNP must supply documentation that shows it provides information to members for Medicare AND Medicaid. The SNP cannot receive credit for factors 1, 3 and 4 if it provides the required information only for Medicare.

SNP 6 Element C

104


• To receive credit for factor 2:– I-SNPs’ documentation must address

changes where members gain Medicaid eligibility;

– C-SNPs’ documentation must show that they monitor instances where members are gaining and losing Medicaid eligibility.

SNP 6 Element C

105


• C-SNPs and I-SNPs are exempt from this element if less than 5% of the members in their SNP population are dual eligibles as of the start of the look-back period

• Score each factor “NA” if they meet this criterion.– This can be confirmed using the

surveyor resource guide.

SNP 6 Element C

106


• Documentation - SNPs must provide

• Documented processes AND;• Procedures used to verify changes in Medicaid

eligibility– Reports or Materials:

• Sample benefit summaries provided to members

SNP 6 Element C

107


SNP 6 Element D

Service Coordination• Organization coordinates delivery of services

covered by Medicare/Medicaid through the following:– Helping members access network providers that

participate in both programs or accept Medicaid patients

– Educating providers about coordinating benefits for which members are eligible and about members’ special needs

– Helping members obtain services funded by either program when needed

* C-SNPs and I-SNPs are exempt from this element if less than 5% of the members in their SNP population are dual

Applicable for all SNPs*

108


For factor 1• SNP must publish a directory that

shows:– providers that participate in both

programsor– providers that accept Medicare for

services covered by Medicare and– providers that accept Medicaid for

dual-eligible members

SNP 6 Element D

109


SNP 6 Element D

Factor 2 requires SNPs to educate network practitioners and providers about their role coordinating Medicare/Medicaid benefits and members’ special needs.

– Alert their providers to the range of benefits or services for which members are eligible, as well as responsibility for cost-sharing, if any, and the members right to reimbursement

– Inform providers who is responsible for coordinating services for both programs

110


SNP 6 Element D

Factor 3 requires SNPs to help members obtain services funded by either program when assistance is needed.

– Referring members to non-contracted facilities

– Assisting members in scheduling services or directly providing the services

111


SNP 6 Element D

• Documentation - SNPs must provide:

– Documented processes; AND• Policies and procedures for arranging

services for members– Reports or Materials

• Reports detailing how members were assisted in obtaining services from Medicaid when needed.

• Materials such as the provider directory or provider manuals.

112


SNP 6 Element E

Network Adequacy Assessment• Organization assesses the adequacy of

the network of practitioners and providers by:

- Establishing standards of the number and geographic distribution of each type of practitioner and provider

- Conducting an annual analysis of performance against numeric and geographic standards

* Element is NA for C-SNPs and I-SNPs w/less than 5% dual eligible members and D-SNPs with no enrollment at the start of the look-back period.

Applicable for all SNPs*

113


• Review the organization’s documented process for factors 1 and 2 and reviews reports for factors 3 and 4.

• The SNP’s documentation must include the geographic and numeric standards for practitioners and providers and a description of its methodology used to perform the analysis.

SNP 6 Element E

114


• A SNP’s analysis must include a network access indicator (ratio of member to practitioner availability based a number of miles/minutes). A plan that uses:1) Access data (appointment availability)2) Data on members’ cultural or linguistic

needs or 3) Satisfaction data (surveys, complaints and

appeals)

must supplement its assessment with another network access indicator

SNP 6 Element E

115


• Organization must determine adequate access for members for the following types of providers– Primary care practitioners (e.g. general

practitioners, internal medicine specialist)

– High volume specialist (e.g. cardiologist, neurologist, gynecologists, psychiatrists)

– Providers (e.g. hospitals, skilled nursing facilities)

SNP 6 Element E

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• GEO Access analysis for a SNP’s Medicare practitioner network only is insufficient to meet this element. The GEO Access or other analysis must include practitioners and providers that accept coverage for services paid for by Medicare and Medicaid.

• GEO Access maps must be accompanied by an assessment of quantitative data

• If the plan can show all of its providers accept Medicaid and Medicare then GEO Access or other access reports are sufficient

SNP 6 Element E

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SNP 6 Element E

• The SNP’s methodology must include: direct measurement of results against standards, info about sampling (if used), and analysis of causes of any deficiencies

• Analysis can be aggregate if org breaks out data and results for the individual SNP PBP

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SNP 6 Element E

• SNPs must provide the following documentation:– Documented processes; AND

• P&Ps for assessing network adequacy– Reports

• Reports on availability of Medicare and Medicaid practitioners and providers

• Reports on access indicators such as percentage of in-network and out-of-network use; rate of ED use compared to norms in area; or member surveys of satisfaction with access

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Questions?

snp surveyor update training june 17, 2013. 2 snp: surveyor update training objectives of snp sut...

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