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 second phase of 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 includes two additional HEDIS measures, three new Structure & Process measures and two additional elements for the existing Structure & Process measures.

HEDIS Measures

Specifications are contained in HEDIS 2009, Volume 2: Technical Specifications.

• Colorectal Cancer Screening*
• Glaucoma Screening in Older Adults
• Use of Spirometry Testing in the Assessment and Diagnosis of COPD
• Pharmacotherapy Management of COPD Exacerbation
• Controlling High Blood Pressure*
• Persistence of Beta-Blocker Treatment After a Heart Attack
• Osteoporosis Management in Older Women Who Had a Fracture
• Antidepressant Medication Management
• Follow-Up After Hospitalization for Mental Illness
• Annual Monitoring for Patients on Persistent Medications
• Potentially Harmful Drug-Disease Interactions in the Elderly
• Use of High Risk Medication in the Elderly
• Board Certification
• Care for Older Adults**
• Medication Reconciliation Post-Discharge**

Structure & Process Measures

• SNP 1: Complex Case Management
• SNP 2: Improving Member Satisfaction
• SNP 3: Clinical Quality Improvements
• SNP 4: Care Transitions**
• SNP 5: Institutional SNP Relationship With Facility**
• SNP 6: Coordination of Medicare and Medicaid Benefits**

*SNP benefit packages under PPO contracts do not have to report this measure because it relies on medical record review.
**Phase II measure, required for the first time in 2009.

NCQA developed these measures under the direction of CMS and with guidance from NCQA’s Geriatric Measurement Advisory Panel (GMAP). The development process included interviews with plans and stakeholders; field-tests; Public Comment; and oversight by the GMAP, which includes clinical, consumer, plan and purchaser representatives.

Reporting Requirements

In 2009 NCQA will collect performance information on both Phase I and Phase II Structure & Process measures. SNP benefit packages that reported in 2008 will be required to submit the new elements in SNP 2 and 3 (Elements 2c and 3b), and all of SNP 4–6. SNP benefit packages reporting for the first time in 2009 will submit all measures except SNP 2C and 3B. Performance information for the Structure & Process measures will be collected via NCQA’s Interactive Survey System (ISS). All SNPS must report all required HEDIS measures.