Does Anybody Have Any Experience Selling Medicare Snp's

[Josh]

Care Improvement is actually a regional PPO so here in Atlanta they could use providers in both SC and Georgia. No limit to county or zip code....therefore, wider choices.

But they are more restrictive....must be diabetic or Heart Failure patient.

There are three types of SNP's. The first is for folks on both Medicare and Medicaid. The second is for folks that are institutionalized, like being in a nursing home. The third is the one you are talking about, one that needs special care. The third kind have been getting beat up by policy makers because they aren't usually managing the care any better, they're simply getting higher reimbursements because of the "chronic condition". To use UHC as an example, thousands of agents didn't get paid on business they wrote because CMS told UHC they weren't enforcing the verification of the chronic condition AND they were being too lax in what they called a "chronic" condition. MIPPA pointed that out and laid the groundwork to have those programs reviewed and make the guidelines more stringent and actually set definable goals and specify the degree of medical oversight for each member. As a direct result of that many carriers are stepping away from that market because it was easy money, but not anymore.

 

[Tom Highway]

There are three types of SNP's. The first is for folks on both Medicare and Medicaid. The second is for folks that are institutionalized, like being in a nursing home. The third is the one you are talking about, one that needs special care. The third kind have been getting beat up by policy makers because they aren't usually managing the care any better, they're simply getting higher reimbursements because of the "chronic condition". To use UHC as an example, thousands of agents didn't get paid on business they wrote because CMS told UHC they weren't enforcing the verification of the chronic condition AND they were being too lax in what they called a "chronic" condition. MIPPA pointed that out and laid the groundwork to have those programs reviewed and make the guidelines more stringent and actually set definable goals and specify the degree of medical oversight for each member. As a direct result of that many carriers are stepping away from that market because it was easy money, but not anymore.

Right on! There's a plan near me that got into a little bit of heat with CMS because they had the third kind of SNP, and the criteria to be on it were SO easy. If you had high blood pressure, diabetes, heart disease (ANY), or high cholesterol, you could qualify for that SNP and the special election that comes with it.

They got away with it one year, but not again. They had to include only very specific ICD9 diagnosis codes, which meant a LOT more verification work on the plan, since we all know a vast majority of seniors had those conditions from the first year. This plan is not available anymore.