SNP Special Needs Plan
& Medi Medi
Anthem Blue Cross
Try turning your phone sideways to see the graphs & pdf's?
Anthem
Summary of Benefits &
EOC Evidence of Coverage
2022
MediBlue Diabetes Care (HMO C-SNP)
MediBlue Heart Care (HMO C-SNP)
MediBlue Lung Care (HMO C-SNP)
MediBlue ESRD Care (HMO C-SNP)
Email us [email protected] for the rest of the State of CA or
visit our affiliate Anthem Website by clicking on the Logo above or below.
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
- 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
- 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 *
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
A 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:
- Chronic Condition SNP (C-SNP)
- Dual Eligible SNP (D-SNP)
- 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.
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
SNP is all the time
#Special, Annual & Initial Enrollment Periods
For MAPD Medicare Advantage aka Part C & Medicare + Choice & Part D Rx
All Special Election Periods (SEP);
- Special election periods constitute periods outside of the usual times when an individual may elect a plan or change his or her current plan election.
- Here's the official technical Medicare Marketing Manual or simple
- plan English, Understanding Medicare C & D enrollment periods Pub # 11219 or see
- our section on materials & guides below, there are 36 various types of SEPs, including SEPs for dual eligibles, and for individuals whose current plan terminates, who change residence and who meet “exceptional conditions” as CMS may provide, consistent with §1851(e)(4) of the Act and §422.62(b) of the MA regulations.
- check with us about special enrollment, like when you turn 65 or lose coverage at work.
- Here's the official technical Medicare Marketing Manual or simple
How the Medicare Advantage Application #typically asks the "Special" Enrollment Period questions:
- I am new to Medicare.
- It's Annual Election Period aka Open Enrollment October 15th through December 7th
- I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).
- I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date) –––––––––––.
- I recently was released from incarceration. I was released on (insert date) –––––––––––.
- I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) –––––––––––.
- I recently obtained lawful presences status in the United States. I got this status on (insert date) –––––––––––.
- I recently had a change in my Medicaid Medi Cal (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on (insert date) –––––––––––.
- I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date) –––––––––––.
- I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.
- I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long-term care facility). I moved/will move into/out of the facility on (insert date) –––––––––––.
- I recently left a PACE program on (insert date) –––––––––––.
- I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date) –––––––––––.
- I am leaving employer or union coverage on (insert date) –––––––––––.
- I belong to a pharmacy assistance program provided by my state.
- My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
- I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on (insert date) –––––––––––.
- I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualifications required to be in the plan. I was disenrolled from the SNP on (insert date) –––––––––––.
- I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster
Medicare Coverage of Kidney Dialysis and Transplants # 10128
Average Billed Charges – 2017 Transplant
Kidney - $414k
click to enlarge and view course CA Health Line.org
Transplant Costs & Insurance - Kidney.org
InsuBuy International Medical Coverage –
Instant Quotes & Enrollment
Coverage for Travel - $50k Emergency under Medicare Medi Gap or MAPD Advantage may not be enough!
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 – 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
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
medicare.gov/special-needs-plans-snp
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 *
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?
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp
7 comments on “ESRD SNP Caremore Medicare Advantage – Special Needs Plan for Kidney Failure –”
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 http://www.medicareinteractive.org/pdf/SEP-Chart.pdf
Here’s a definition of how bad ESRD must be to qualify.
https://medicare.healthreformquotes.com/mapd/snp/can-get-medicare-advantage-plan-end-stage-renal-kidney-disease/end-stage-renal/#comment-25075
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?
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.
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.
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: