Beginning in 2010, Medicare Advantage Special Needs Plans (SNPs) that serve Medicare beneficiaries with chronic conditions must meet new guidelines issued today by the Centers for Medicare & Medicaid Services (CMS). 

“Based on the panel’s recommendations, we are defining the chronic conditions that certain Medicare special needs plans must use to identify the beneficiary populations eligible for enrollment,” said CMS Acting Administrator Kerry Weems.  “This should help ensure that the specialized services provided by SNPs are being targeted to the appropriate populations.”

Special needs plans are a type of Medicare Advantage plan that serve only beneficiaries living in institutions, eligible for both Medicare and Medicaid, or living with severe or disabling chronic conditions.  The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) directed CMS to convene a panel of clinical advisors to determine the specific chronic conditions that met the MIPAA statutory definition of a severe or disabling chronic condition in regard to SNPs.

The report issued today is based on recommendations from the Special Needs Plan Chronic Condition Panel, which included clinical advisors from three agencies of the U.S. Department of Health and Human Services: CMS, Center for Disease Control and Prevention and the Agency for Health Research and Quality.  The panel identified 15 severe or disabling chronic conditions based on clinical criteria required by statute to ensure that only people who have these conditions are eligible to enroll in a Chronic Care Medicare Advantage Special Needs Plan (CC-SNP).  These changes do not immediately impact Medicare beneficiaries, but become effective Jan. 1, 2010.

The report issued today defines those chronic conditions as being medically complex, substantially disabling or life threatening, having a high risk of hospitalization or other adverse outcomes, and requiring a specialized delivery system across domains of care.  The 15 clinical conditions are:

1.         Chronic alcohol and other drug dependence

2.         Certain autoimmune disorders

3.         Cancer excluding pre-cancer conditions

4.         Certain cardiovascular disorders

5.         Chronic heart failure

6.         Dementia

7.         Diabetes mellitus

8.         End-stage liver disease

9.         End-stage renal disease requiring dialysis (all modes of dialysis)

10.       Certain severe hematologic disorders

11.       HIV/AIDS

12.       Certain chronic lung disorders

13.       Certain chronic and disabling mental health conditions

14.       Certain neurologic disorders

15.       Stroke

The panel’s recommendations were based on public input and panelists’ clinical experience, as well as the prevalence of these conditions among people with Medicare.  The report can be found at www.cms.hhs.gov/SpecialNeedsPlans/.

“The chronic conditions we are defining today are specific to Medicare special needs plans and are being put into place to ensure that SNPs remain targeted to a specific population, and do not expand their services to mirror more generalized Medicare Advantage plans,” said Weems. 

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