Background

Special Needs Plans (SNPs) were created by Congress in the Medicare Modernization Act (MMA) of 2003 as a new type of Medicare managed care plan focused on certain vulnerable groups of Medicare beneficiaries: the institutionalized, dual-eligibles and beneficiaries with severe or disabling chronic conditions. These beneficiaries are typically older, with multiple
comorbid conditions, and thus are more challenging and costly to treat.

In early 2008, the Centers for Medicare & Medicaid Services (CMS) contracted with the National Committee for Quality Assurance (NCQA) to develop a strategy to evaluate the quality of care provided by SNPs. This strategy relies on a phased approach, beginning with defining and assessing desirable structural characteristics and followed by assessing processes and, eventually, outcomes. The evaluation approach includes two types of assessment.

• HEDIS® measures
• Measures that evaluate structure and process requirements through submission of documentation (Structure & Process measures)

CMS and NCQA are now publishing the 2010 reporting requirements.

Phased Approach

The first phase of this effort focused on core SNP requirements—those that apply to all SNPs, regardless of type (i.e., dual eligible, chronic care, institutional)—using existing measures. The focus of the second and third phases is on measures that address the special needs of SNP populations and on more mature quality improvement efforts. Phase II (2009) included two additional HEDIS measures, three new Structure & Process measures and two additional elements for the existing Structure & Process measures. Phase III (2010) continues to focus on the HEDIS® and Structure & Process measures introduced in 2009. 

Looking forward to 2011, NCQA is developing new HEDIS® measures to address plan all-cause readmissions and potentially avoidable hospitalizations as well as SNP-type specific measures focusing on the Institutional and Chronic disease and disability SNPs. For the Structure & Process measures, NCQA will focus on evidence of implementation of policies, procedures, processes and programs and use of systems. 

HEDIS® Measures

Specifications are contained in HEDIS 2010, Volume 2: Technical Specifications.

• (COL) Colorectal Cancer Screening* 
• (GSO) Glaucoma Screening in Older Adults 
• (COA) Care for Older Adults
• (SPR) Use of Spirometry Testing in the Assessment and Diagnosis of COPD 
• (PCE) Pharmacotherapy of COPD Exacerbation 
• (CBP) Controlling High Blood Pressure
• (PBH) Persistence of Beta-Blocker Treatment After a Heart Attack
• (OMW) Osteoporosis Management in Older
• (AMM) Antidepressant Medication Management 
• (FUH) Follow-Up After Hospitalization for Mental Illness 
• (MPM) Annual Monitoring for Patients on Persistent Medications 
• (DDE) Potentially Harmful Drug-Disease Interactions
• (DAE) Use of High Risk Medication in the Elderly 
• (MRP) Medication Reconciliation Post-Discharge
• (BCR) Board Certification

* PPOs must submit the Colorectal Cancer Screenung measure using only the administrative specifications.

2010 Reporting Requirements

In 2010 NCQA will collect performance information on all Structure & Process measures. SNP benefit packages that reported in 2009 will be required to submit SNP 4: Care Transitions and SNP 6: Coordination of Medicare and Medicaid Services.  SNP benefit packages reporting for the first time in 2010 will submit measures SNP 1-6. Performance information for the Structure & Process measures will be collected via NCQA’s Interactive Survey System (ISS). All SNPS with 30 or more members as of the February 2009 CMS Comprehensive Report must report all required HEDIS measures.