SNP Special Needs Plan
& Medi Medi – Cal Medi Connect 

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

Email us [email protected]  for the most current documents or visit Blue Cross’s affiliate website.

No extra charge for our services & expertise.

•  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 * 
      • Sample Pre Enrollment Qualification Assessment
        • Wellcare 
        • Health Net 
  • 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  

• Information about the Medicare Contract

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 *  ^{cms.gov/Special-Need-Plans-SNP-Frequently-Asked-Questions-FAQ  *CMS – Medicare – List of conditions for Special Needs Plans}

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
• 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
• The MOC provides the basic framework under which the SNP will meet the needs of each of its enrollees. The MOC is a vital quality improvement tool and integral component for ensuring that the unique needs of each enrollee are identified by the SNP and addressed through the plan’s care management practices. The MOC provides the foundation for promoting SNP quality, care management, and care coordination processes  ^CMS.Gov *
• Vantage Health Plan Annual Training 
• Cal Broker Magazine
• How Medicare Special Needs Plans (SNPs) work Medicare.Gov
• Provider Service Plan Requirements HHS.Gov
•  

FAQ’s ESRD  – Special Needs Plan for Kidney Failure ”

• if one gets a transplant and no longer requires dialysis, can they stay on a ESRD SNP Plan?
  • Let’s check the Evidence of Coverage – almost 300 pages of plain English to explain just about everything
    • The only time we are allowed to cancel you, is if you no longer have the medical condition required for enrollment in Anthem MediBlue ESRD (HMO C-SNP). Page 238 of 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 end-stage renal disease requiring dialysis (any mode of dialysis).
  • So, hopefully when you no longer require dialysis you’ll have a special enrollment period to pick another Medicare Advantage Plan. Page 7 of eoc
  • Source medicareinteractive.org/SEP-Chart
  • Here’s a definition of how bad ESRD must be to qualify.
  • We can help you enroll in a MAPD plan with Blue Cross, Blue Shield & UHC, no additional charge.
  • There might – it’s a long shot be a way to enroll in Medi Gap – under one of the guaranteed issue provisions?
  • How old are you?
• Might you lose Medicare, and need an under 65 plan if you no longer qualify as ESRD?
  • Nope, you won’t lose Medicare per page 6 of the Medicare Booklet on Kidney Dialysis & Transplant services
    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
• National Kidney registration?  kidney.org/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
• transplant living.org/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:
• 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.
• 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.
  • 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