By now you know all about our goal of improving integration of care for individuals with a serious mental illness.  In looking more closely at this population, we noticed that about 50% of folks with a serious mental illness who are enrolled with Medicaid (AHCCCS) are also enrolled in Medicare… meaning that they’re “dual eligible.” As part of our recent RFI (see above) regarding a Specialty RBHA with an SMI Health Home we mention that we’d like to explore having a behavioral health authority (RBHA) that’s also a Medicare Part C Special Needs Plan (SNP) because we think that’ll help with care coordination and lower our costs for dual eligible members.

So, what in the world is a Medicare SNP?  To understand a SNP you first need to know a little about Medicare- so here goes.  Medicare and Medicaid were established by the Social Security Act of 1965.  Most folks eligible for Medicare are over the age of 65 or have a disability and receive Social Security Disability Insurance.  The  federal government pays 100% of the costs for Medicare (in other words there is no state matching funds required). Medicare has different benefit packages called Medicare Part A, B, C, and D.

Part A includes coverage for inpatient hospitals, skilled nursing facilities, and hospice care. Everyone enrolled in Medicare is automatically enrolled in Part A and they generally don’t have to pay premiums. Part B provides doctor services, X-rays, occupational therapy and many more medically necessary or preventive services typically provided outside of a hospital or clinic.  Part D was added in 2006 to add prescription drug coverage.

Medicare Part C was established in 1997. Part C Medicare Advantage Plans include both of the Part A and B benefits as well as additional optional benefits the Medicare Advantage Plan wants to offer like eyeglasses. These plans are private companies that are approved by Medicare.  Another type of Part C Plan is a Special Needs Plan… which is like a Medicare Advantage Plan but it’s designed to serve “dual eligibles” (people that qualify for both Medicare and Medicaid) and some people with certain severe and disabling chronic conditions.  A Special Needs Plan must include Part A, B, and D and can also provide other optional services.  Unlike other Medicare plans, this kind of plan coordinates benefits with Medicaid, creating individualized care plans for enrollees.

So, why all the fuss about “dual eligibles” as we craft our plan to better integrate behavioral and regular healthcare?  Two big reasons: lower state costs and better care coordination.   For a “dual eligible” (someone who qualifies for both Medicare and Medicaid) Medicare is the primary payer and is supposed to be billed first.  Remember, the federal government pays 100% of the costs for Medicare, while under Medicaid (read AHCCCS) the state has to pay a chunk of the costs.  Also, Medicare Special Needs Plans coordinate benefits with Medicaid and create individualized care plans for enrollees- which helps with care coordination and results in better outcomes.

So… you can see the potential advantages if our future behavioral health authorities included a Medicare Part C Special Needs Plan because we’d be able to improve care coordination and reduce state costs by making sure that the fed’s pick up the bill (through Medicare) for folks that are “dual eligible”.