U.S. GOVERNMENT PUBLISHING OFFICE

27–071 PDF WASHINGTON : 2018

EXAMINING THE EXTENSION OF SPECIAL NEEDS 

PLANS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

JULY 26, 2017 

Serial No. 115–50 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

SUBCOMMITTEE ON HEALTH

MICHAEL C. BURGESS, Texas 

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOE BARTON, Texas 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

ANNA G. ESHOO, California 

DIANA DEGETTE, Colorado 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 1 

Prepared statement .......................................................................................... 2 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 3 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

prepared statement .............................................................................................. 62 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, prepared statement ........................................................................ 62 

WITNESSES

Chris Wing, Chief Executive Officer, SCAN Health Plan .................................... 4 

Prepared statement .......................................................................................... 7 

G. Lawrence Atkins, Ph.D., Executive Director, National MLISS Health Plan 

Association ............................................................................................................ 11 

Prepared statement .......................................................................................... 13 

Melanie Bella, Independent Consultant and Former Director, Medicare-Medicaid Coordination Office, Centers for Medicare and Medicaid Services ......... 25 

Prepared statement .......................................................................................... 27 

SUBMITTED MATERIAL

Discussion Draft, H.R. lll, the Special Needs Plans Reauthorization Act 

of 2017 ................................................................................................................... 63 

Article of June 29, 2017, ‘‘Fixing the 5 Percent,’’ by Karen Weintraub and 

Rachel Zimmerman, The Atlantic, submitted by Mr. Green ............................ 88 

Joint statement of SCAN Health Plan and Avalere Health, April 2, 2012, 

submitted by Mr. Burgess ................................................................................... 99 

Letter of July 26, 2017, from Joseph White, Interim President and CEO, 

Molina Healthcare, to Mr. Burgess and Mr. Green, submitted by Mr. Burgess ........................................................................................................................ 102 

Memo of March 30, 2012, from Dianne Munevar and Edward Drozd, Avalere 

Health, to Peter Begans, SVP Public & Government Affairs, SCAN Health 

Plan, submitted by Mr. Burgess ......................................................................... 103 

Slide presentation, ‘‘Dual Eligible Population Analysis for SCAN Health Plan: 

Hospitalizations and Readmissions,’’ Avalere Health, March 2012, submitted by Mr. Burgess ......................................................................................... 111 

Statement of the Bipartisan Policy Center, July 26, 2017, submitted by Mr. 

Burgess ................................................................................................................. 135 

Letter of July 26, 2017, from Mary R. Grealy, President, Healthcare Leadership Council, to Mr. Burgess, submitted by Mr. Burgess ................................. 138 

Letter of March 28, 2017, from Christian L. Soura, President, and Judy 

Mohr Peterson, Vice President, National Association of Medical Directors, 

to the Honorable Orrin Hatch, et al., submitted by Mr. Burgess .................... 140 

Letter of July 20, 2017, from AIDS Healthcare Foundation, et al., to Mr. 

Walden, et al., submitted by Mr. Burgess .......................................................... 145 

Statement of America’s Health Insurance Plans, July 26, 2017, submitted 

by Mr. Burgess ..................................................................................................... 147 

Letter of July 24, 2017, from Margaret A. Murray, President and Chief 

Executive Officer, Association for Community Affiliated Plans, to Mr. Walden and Mr. Pallone, submitted by Mr. Burgess ............................................... 152 

Letter of July 25, 2017, from John G. Lovelace, President, Government Programs and Individual Advantage, UPMC Health Plan, to Mr. Burgess, 

et al., submitted by Mr. Burgess ........................................................................ 155 

Page

IV 

Editorial of February 7, 1997, ‘‘Making the Budget Bearable,’’ New York 

Times, submitted by Mr. Burgess ....................................................................... 157 

Excerpt, Congressional Record—Senate, December 22, 1995, pages S19184 

to S19185,submitted by Mr. Burgess ................................................................. 158 

(1) 

EXAMINING THE EXTENSION OF SPECIAL 

NEEDS PLANS 

WEDNESDAY, JULY 26, 2017 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:15 a.m., in Room 

2322, Rayburn House Office Building, Hon. Michael C. Burgess 

(chairman of the subcommittee) presiding. 

Members present: Representatives Burgess, Barton, Shimkus, 

Murphy, Blackburn, Lance, Griffith, Bilirakis, Long, Bucshon, 

Brooks, Mullin, Hudson, Collins, Carter, Green, Schakowsky, 

Butterfield, Matsui, Castor, Schrader, Kennedy, Ca ́ rdenas, Eshoo, 

DeGette, and Pallone (ex officio). 

Also present: Representative Costello. 

Staff present: Paul Edattel, Chief Counsel, Health; Jay Gulshen, 

Legislative Clerk, Health; Katie McKeough, Press Assistant; Jennifer Sherman, Press Secretary; Josh Trent, Deputy Chief Counsel, 

Health; Jeff Carroll, Minority Staff Director; Rachel Pryor, Minority Health Policy Advisor; Samantha Satchell, Minority Policy Analyst; Andrew Souvall, Minority Director of Communications, Member Services, and Outreach; and C.J. Young, Minority Press Secretary. 

Mr. BURGESS. Very well. I will ask all of our guests and Members 

to take their seats. The Subcommittee on Health will now come to 

order. The Chair recognizes himself 5 minutes for an opening statement. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Today the committee moves forward with its work in regular 

order to examine extending and improving the Medicare Advantage 

Special Needs Plans. Special Needs Plans enjoy bipartisan support 

because of their successful record in providing comprehensive coordinated care to two million Medicare beneficiaries. 

This committee is especially interested in understanding how we 

can help improve Special Needs Plans for dual eligibles, since the 

majority of Special Needs Plans 

enrollees are dually eligible beneficiaries who are enrolled in 

both Medicare and Medicaid. Dual-eligible beneficiaries often have 

multiple chronic conditions, physical disabilities, and cognitive impairments. Yet, too often, these very beneficiaries are forced to 

2 

navigate two Government programs with benefit structures, rules, 

and incentives that are often less than simple or intuitive. 

Today, we embark on our process to try to not only extend the 

Special Needs Plans, but improve the tools that States and plans 

have to help these beneficiaries. So in addition to hearing from our 

three experts before us, we also invite stakeholders’ feedback on a 

bipartisan discussion draft recently released. The goal is simple. 

We want detailed feedback from stakeholders on the policies and 

specific language in this draft. We all share the goal of helping improve health outcomes, enhance quality, and improve the patient 

experience for Special Needs Plans enrollees who are some of the 

most vulnerable, high-need beneficiaries in Medicare. 

As a starting place, the discussion draft includes a number of 

provisions including reauthorizing the Institutional Special Needs 

Plans permanently, and extends the dual-eligible Special Needs 

Plans for 5 years. It streamlines Medicare and Medicaid benefits 

through one process so it is easier for duals to navigate their benefits. It improves access to supplemental benefits for patients with 

chronic illnesses through the inclusion of a bipartisan proposal supported by various members, including the gentleman from New 

Jersey, Mr. Lance. It enhances quality by directing HHS actions 

and holds us accountable for results, by requiring a number of 

studies so Congress receives appropriate feedback on policy 

changes. 

I hope members will thoughtfully engage in today’s discussion, 

examine the policies carefully, and provide feedback to committee 

staff as we move forward. 

Thank you to each of our witnesses. We certainly look forward 

to hearing from each of you this morning. 

[The prepared statement of Mr. Burgess follows:] 

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS

The subcommittee will come to order. 

The chairman will recognize himself for an opening statement. 

Today the committee moves forward with its work in regular order to examine 

extending and improving Medicare Advantage Special Needs Plans (SNPs). SNPs 

enjoy bipartisan support because of their successful record in providing comprehensive, coordinated care to about 2 million Medicare beneficiaries. 

This committee is especially interested in understanding how we can help improve 

SNPs for the dual eligibles—since the majority of SNP enrollees are dually eligible 

beneficiaries who are enrolled in both Medicare and Medicaid. Duals often have 

multiple chronic conditions, physical disabilities, and cognitive impairments such as 

dementia, developmental disabilities, and mental illness. Yet, too often, these very 

beneficiaries are forced to navigate two Government programs with benefit structures, rules, and incentives that are often less than simple and intuitive. 

Today, we embark on our process to try to not only extend SNPs, but improve 

the tools that States and plans have to help these beneficiaries. So in addition to 

hearing from our three expert witnesses before us, but we want to invite stakeholder’s feedback on a bipartisan discussion draft we released. Our goal is simple: 

we want detailed feedback from stakeholders on the policies and specific language 

in this bill. We all share the goal of helping improve health outcomes, enhance quality, and improve the patient experience for SNP enrollees who are some of the most 

vulnerable, high-need beneficiaries in Medicare. As a starting place, this discussion 

draft includes a number of provisions, including: 

• Reauthorizes Institutional SNPs permanently and extends D–SNPs and C– 

SNPS for 5 years; 

• Streamlines Medicare and Medicaid benefits through one process so it is easier 

for duals to navigate their benefits; 

3 

• Improves access to supplemental benefits for patients with chronic illnesses 

through the inclusion of a bipartisan proposal supported by various members, including Mr. Lance; 

• Enhances quality by directing HHS actions; 

• Holds us accountable for results, by requiring a number of studies so Congress 

receives appropriate feedback on policy changes. 

I hope Members will thoughtfully engage in today’s discussion, examine the policies carefully, and provide feedback to committee staff as we move forward. 

Thank you to each of our witnesses. We look forward to hearing from each of you. 

Mr. BURGESS. I would yield to the gentleman from Kentucky, but 

he is not here. Let me yield back my time, and I will yield to the 

gentleman from Texas, the ranking member of the subcommittee, 

Mr. Green, 5 minutes for an opening statement, please. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, and thanks to our witnesses for being here this morning. We are here to discuss the extension of the Special Needs Plans that serve some of our most vulnerable and highest need Medicare beneficiaries. The Medicare, 

Prescription Drug, Improvement and Modernization Act of 2003 established a new Medicare Advantage coordinated care plan, options 

specifically for individuals with special needs. This type of MA 

plans known as Special Needs Plans, or SNPs, are authorized to 

target enrollment to one or more types of individuals with distinct 

healthcare needs. Specifically, institutional SNPs, or I–SNPs, are 

largely enrolled beneficiaries who live in nursing homes; dual-eligible SNPs or D–SNPs, enrolled beneficiaries who are eligible for 

both Medicare and Medicaid; and Chronic Condition SNPs, or C– 

SNPs, enroll beneficiaries with certain severe and disabling chronic 

conditions like end-stage renal disease. 

Since the enactment of the Affordable Care Act, all new and expanded D–SNP plans are required to have contracts with the State 

Medicaid agencies to coordinate and deliver benefits and the ACA 

created a subset of D–SNPs known as fully integrated, dual-eligible, FIDE SNPs. 

Mr. Chairman, we have to keep up with all these short-term 

things. 

More than 2 million Americans are enrolled in 600 SNPs nationwide. There is a great amount of variety across SNPs and how they 

work in each State. Since the ACA, SNPs have been extended four 

times, more recently in the Medicare Access and CHP Reauthorization Act or MACRA in 2015. Authorization of the program is currently set to expire at the end of the calendar year. Discussions 

about SNP reauthorization has largely focused on duration of the 

authorization, with a growing number of stakeholders advocating 

for permanent authorization. 

Today, I look forward to learning more about the advantage of 

long-term or permanent authorization of SNPs and I am also interested in how we can address challenges to integrating benefits and 

providing high-quality care for complex patients with health and 

socio-economic needs. The SNP extension is an opportunity to complement other efforts in Medicaid to integrate the delivery of benefits and improve care coordination and quality. 

4 

Finally, I would like to acknowledge the debate going on now in 

the Senate and actions the House took earlier this year will cast 

a shadow on the total discussion. The American Health Care Act 

and the Better Care Reconciliation Act both devastate Medicaid, ultimately cutting funding by 35 percent. Medicaid cuts will harm 

the ability of States to integrate in SNPs and other long-term services and support offering. Cuts in Medicaid will undermine these 

successes and harm our most frail citizens. 

While Medicare provides critical benefits, Medicaid wraps around 

that coverage and fills in the gaps. I hope my colleagues will abandon the pursuit to return to meaningful bipartisan work to improve 

our health system, like improving and extending SNPs. 

Thank you, Mr. Chairman. I look forward to today’s discussion, 

and if anybody on my side wants my last minute and 50 seconds? 

No. I yield back, Mr. Chairman. 

Mr. BURGESS. Will the gentleman yield? 

Mr. GREEN. Sure. 

Mr. BURGESS. So I have been contemplating introducing a bill 

that would modify or perhaps prohibit TLAs of the future. Threeletter acronyms. Does anyone else on the majority—— 

Mr. GREEN. I would be glad to co-sponsor it. 

Mr. BURGESS. Does anyone else on the majority side seek time 

for an opening statement? Anyone else on the minority side seek 

time? 

The Chair apparently concludes with opening statements. The 

Chair would like to remind Members, pursuant to committee rules, 

all Members’ opening statements will be made part of the record. 

We do thank our witnesses for being here today, taking time to 

testify before the subcommittee. Each witness will have the opportunity to give an opening statement, followed by a round of questions from Members. 

This morning, we will hear from Mr. Chris Wing, the CEO of 

SCAN Health Plan; Dr. Larry Atkins, President, National MLTSS 

Health Plan Association; and Ms. Melanie Bella, who has been to 

this committee before, I believe, consultant and former Director of 

the Federal Coordinated Health Care Office, Centers for Medicare 

and Medicaid Services. 

We appreciate all of you being here this morning. Mr. Wing, you 

are now recognized for 5 minutes to give an opening statement, 

please. 

STATEMENT OF CHRIS WING, CHIEF EXECUTIVE OFFICER, 

SCAN HEALTH PLAN; G. LAWRENCE ATKINS, PH.D., EXECUTIVE DIRECTOR, NATIONAL MLTSS HEALTH PLAN ASSOCIATION; AND MELANIE BELLA, INDEPENDENT CONSULTANT 

AND FORMER DIRECTOR, MEDICARE–MEDICAID COORDINATION OFFICE, CENTERS FOR MEDICARE AND MEDICAID 

SERVICES 

STATEMENT OF CHRIS WING 

Mr. WING. Chairman Burgess, Ranking Member Green, and 

members of the subcommittee, thank you very much for the opportunity to testify today. 

5 

When it comes to SNPs, SCAN covers the waterfront. We are the 

only fully integrated dual-eligible SNP in California. We have an 

Institutional SNP in California. We also have three chronic illness 

Special Needs Plans in California. 

Like patient advocates, SCAN supports permanence for all SNPs. 

SCAN does come at the subject from a special vantage point. SCAN 

was a Social HMO for 22 years before the demonstration project 

evolved into SNPs. We have seen over 3 decades how tailoring care 

to meet the special needs of seniors with complex conditions is the 

right approach. The care is better for the beneficiaries and the cost 

is less. 

Let me give you one example. Several years ago, SCAN asked the 

research firm Avalere Health to compare SCAN’s dual-eligible population in California to fee-for-service duals. Using the CMS’ five 

percent sample, Avalere found 5,500 fee-for-service duals in California who had similar risk characteristics as our 5,500 duals. We 

tracked them for over 2 years. We called it a Doppleganger study. 

What did it find? Hospital admissions were 14 percent less for 

the SCAN population. And re-admissions were 25 percent less. Not 

only did the extra care provided by SCAN provide better care for 

the beneficiary by eliminating hospitalizations and re-hospitalizations, but it saved the Government a significant amount of money. 

It is clear that duals, who are the system’s most in need and 

most expensive group of patients, are significantly helped by fully 

integrated D–SNPs. That is why SCAN supports permanency for 

D–SNPs. 

We also strongly support moving all D–SNPs on an expedited 

schedule toward full integration. 

C–SNPs have also succeeded in giving patients better care 

through added benefits and specialized networks. We think C– 

SNPs have also earned permanency. 

We are happy that the committee is proposing to make I–SNPs 

permanent as well. However, let me point out one flaw with the 

current I–SNP structure. 

SCAN runs an Institutional SNP in California, meaning that we 

strive to keep our nursing home eligible beneficiaries in their own 

homes in the community and not in the nursing home. However, 

our plan has shrunk dramatically because we are not allowed by 

law to give beneficiaries the home and community-based services 

they need to stay in the community and lead independent lives. To 

get those long-term services and supports, they have to spend down 

their assets and go on Medicaid and being dually eligible. 

To rectify that, we strongly urge the committee to consider including bipartisan legislation introduced in the last Congress by 

Representatives Leonard Lance and Kurt Schrader, here on Energy 

and Commerce, as well as Representatives Linda Sanchez and Pat 

Meehan on Ways and means. It would create a demonstration 

project to target a limited amount of Medicare funding toward frail 

individuals who are in the cusp of spending down their income and 

becoming dually eligible. It would allow them to receive home and 

community-based services, which is now allowed today. This demonstration would allow these individuals to stay in their homes, 

where they and their families want them to stay, preserving their 

6 

dignity and comfort and would be a first step towards cost savings 

and entitlement reform. 

Finally, we want to strongly support the provision in your bill 

which grants increased flexibility to all plans, not just SNPs, to use 

supplemental benefits for nonmedical services. 

We appreciate you folks very much. Thank you. 

[The prepared statement of Mr. Wing follows:] 

7 


27071.001
8 


27071.002
9 


27071.003
10 


27071.004
11 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. Dr. Atkins, you are recognized for 5 minutes for an 

opening statement. 

STATEMENT OF G. LAWRENCE ATKINS 

Dr. ATKINS. Thank you, Mr. Chairman. Chairman Burgess, 

Ranking Member Green, and members of the subcommittee, thank 

you for the opportunity to testify on reauthorizing the Special 

Needs Plans. 

My name is Larry Atkins and I am the Executive Director of the 

National MLTSS Health Plan Association which I am sure the 

chairman will be happy to know does not fit into a three-letter acronym. Association members are the managed care plans that contract with States to manage long-term services and supports. Member plans are in 18 of the 22 States that have MLTSS and enroll 

nearly a million members in MLTSS plans and 175,000 in duals 

demo MMPS, the Medicare-Medicaid Plans. 

Managing LTSS focuses on helping individuals with functional 

needs and their families, attain their goals by obtaining the assistance they need either in institutions or in their homes and communities. We partner with our States to achieve shared objectives of 

rebalancing from institutions toward more home and communitybased settings and integrating beneficiaries in the community and 

managing Medicare expenditures. 

SNPs, in particular, SNP for dual eligibles, the D–SNPs, improve 

our success with dual eligibles through opportunities to engage in 

fully integrated programs where we can bring Medicare’s medical 

benefits together with the MLTSS benefits that we provide to provide a fully integrated and coordinated care for the individual. 

We fully support SNP reauthorization and urge the committee to 

consider a permanent reauthorization at this time. The cycle of repeated reauthorizations since 2003 has created uncertainty about 

the future of SNPs that deters plan investment and beneficiary enrollment in SNPs. 

D–SNPs, in particular, are a critical building block for integrating plans. 

Why is integration so important? Managing care for people with 

the most complex care needs is the key to controlling healthcare 

spending overall. Only six percent of Medicare beneficiaries use 

LTSS. They account for 43 percent of the spending, much of it medical in Medicaid. 

Providing better support in the home and community can prevent the failures that trigger unnecessary and expensive hospitalizations and institutional admissions that make up a lot of our 

healthcare spending. To do that, plans need to be able to manage 

both medical and nonmedical resources to communicate and share 

information between care managers and LTSS and medical providers and to capture savings on the medical side that can support 

the necessary services on the LTSS side. 

For duals, this means combining Medicare and Medicaid and 

right now, only a small proportion of duals are actually in integrated plans. 

We need an aggressive effort to expand integrated plan availability and enrollment. A barrier to integration is the difficulty of 

12 

aligning Medicare and Medicaid coverage, that is, enrolling an individual in the same organization’s Medicare and Medicaid plan. 

Most States auto-enroll Medicaid participants in their Medicaid 

managed care plan. On the Medicare side, beneficiaries choose. 

And in the SNP program, it allows for monthly decisions about 

election of plans’ coverage. And they often remain in traditional 

Medicare or in another organization’s Medicare plan which limits 

the MLTSS plan’s ability to manage and coordinate care and share 

information among provides. 

The fully integrated dual SNP, the D–SNP, the FIDE SNP, and 

the MMPs, put the two plans together and offer them to beneficiaries as a single package. Only a handful of States have opted 

for either of these models to date. The problem is they use voluntary enrollment or passive enrollment with an opt out, either of 

those two approaches, which is actually acting to keep integrated 

models from reaching a large share of the duals’ population. 

We urge the committee to permanently authorize SNPs. We support the effort to expand FIDE SNPs in more integrated approaches and we recommend that the Congress allow States to require duals that are in an MLTSS plan to be enrolled in an aligned 

MA plan. 

For the future, we propose adopting a common legislative and 

regulatory framework for plans that integrate Medicare and Medicaid to try to get around some of the alphabet soup that we have. 

To this end, we support creating a unified appeals and grievance 

process for integrated plans. We also support expanding the authority of the Medicare and Medicaid Coordination Office to encompass oversight of all integrated plans. 

Finally, we thank the committee for moving quickly on SNP reauthorization. SNPs alone though cannot drive the expansion of 

coverage under integrated plans. We look forward to continuing to 

work with the committee on strategies to bring the benefits of fully 

integrated plans to a larger portion of the population in need of 

LTSS. Thank you. 

[The prepared statement of Dr. Atkins follows:] 

13 


27071.005
14 


27071.006
15 


27071.007
16 


27071.008
17 


27071.009
18 


27071.010
19 


27071.011
20 


27071.012
21 


27071.013
22 


27071.014
23 


27071.015
24 


27071.016
25 

Mr. BURGESS. The Chair thanks the gentleman. Ms. Bella, you 

are recognized for 5 minutes, please, for an opening statement. 

STATEMENT OF MELANIE BELLA 

Ms. BELLA. Chairman Burgess, Ranking Member Green, members of the committee, thank you for having me this morning. My 

name is Melanie Bella. My background is in Medicaid and duals. 

I have been fortunate to serve as a Medicaid Director and more recently ran the Office of Duals within CMS. 

Today, as you know, there are a little over 11 million people who are eligible for Medicare and Medicaid. We spend about $350 billion annually on their care. The majority of those individuals are 

not in programs that integrate their Medicare and Medicaid. However, there are promising models that bring those two programs together. 

Three such models are the Special Needs Plans that we are talking about today; Medicare-Medicaid Demonstration Plans, and the 

PACE program. Of note, PACE is the only permanent program. 

This means that for all of our 11 million dual eligibles, we have 1 

option that is permanent to integrated clinically and financially the 

Medicaid and Medicare programs. 

We need to do more. We have an opportunity to do more and one 

such opportunity is before you today with the permanent authorization of Special Needs Plans. My remarks today will focus on the 

dual-eligible plan specifically. 

There is three things I want to kind of plant in your mind today. 

Number one, is that this takes investment. This is an active choice 

to make an investment of time and resources, and there is an opportunity cost to choosing this path that is pretty complicated over 

others. It is much easier to make investments in things when they 

are stable. So authorizing this, giving permanency to this program, 

allows States, plans, and even beneficiaries who are choosing to be 

in these programs the assurance they need that they are not going 

to worry every few years, that the program might be going away. 

The second is that full integration is really difficult. There is no 

doubt that the bar should be high and that if we want to have Special Needs Plans and dual-eligible Special Needs Plans, we should 

have an expectation that there is full integration of Medicaid and 

Medicare. But what that means is that we have to help State Medicare agencies get their long-term supportive services and behavioral health services into managed and integrated products so we 

can pair those together. So what we should be doing is continuing 

to break down any barriers that stand in the way of doing that. 

In my written testimony, I have included examples of areas 

where the Duals Office within CMS could be given authority to 

break down many of those barriers, largely administrative, that 

make it really difficult for States and plans to bring those two 

worlds together. 

Lastly, we have to talk about States. States have to be our full 

partners in this. They are already resource constrained, and so 

they need incentives and capacity to be able to do these things. 

They also need tools to ensure that if we have these aligned programs that people are actually in them. So today, there are a few 

States where you have fully aligned programs, where Medicaid and 

26 

Medicare are available, say if I am the dual-eligible beneficiary. 

But large numbers of people aren’t in those plans. And so there are 

tools that we could be using to help facilitate those choices. One example where CMS could be very helpful just today would be to lift 

the moratorium on something called seamless conversion which is 

something that allows States and plans to ensure that people are 

getting their services from the same entity. 

So to reiterate an earlier point, States are in the same bucket of 

wanting assurance that this program is going to be stable and it 

is not going away which is another reason in support of permanency for these programs. 

In closing, this is I think my favorite subject in the world, so I 

would like to thank the committee for taking it on. This is a really 

important step. There are many more we could take, but the opportunities here really are ones that lend themselves very well to, I 

think, areas where we could have bipartisan agreement, so I appreciate the opportunity very much. 

[The prepared statement of Ms. Bella follows:] 

27 


27071.017
28 


27071.018
29 


27071.019
30 


27071.020
31 


27071.021
32 


27071.022
33 


27071.023
34 


27071.024
35 

Mr. BURGESS. The Chair thanks the gentlelady. The Chair 

thanks all of the witnesses for your testimony. We will move into 

the Members’ questions portion of the hearing. I want to begin by 

recognizing the gentleman from Illinois, 5 minutes for questions, 

please. 

Mr. SHIMKUS. Thank you, Mr. Chairman, and welcome. This is 

an interesting topic. 

And Ms. Bella, you mentioned, I have listened to all of the testimony, but my first question was going to be on seamless conversion 

which you talk about, but I was going to direct to Dr. Atkins and 

then Ms. Bella, you can follow up. 

The question is on the seamless conversion, can you tell us how 

this helps ensure coordinated care for beneficiaries and whether 

you think or not, I know Ms. Bella thinks this is something we 

should address or will be involved in the legislative fix. 

Dr. ATKINS. The seamless conversion operates on the Medicaid 

side that States can move beneficiaries because the beneficiaries 

are automatically enrolled in Medicaid managed care plans in most 

States. States can reassign them to a different plan, but it aligns 

with a D–SNP. 

Arizona, for example, has had a pretty aggressive program to realign their Medicaid beneficiaries with their D–SNP coverage. The 

problem is that they can still move, the beneficiaries can still 

change their coverage on a monthly basis on the Medicare side. So 

the fact that as long as there is this complete flexibility and freedom of choice on the Medicare side, it is very difficult to achieve 

full alignment. 

Mr. SHIMKUS. So, and I can ask anyone, so is this something that 

you think we should try to address legislatively and fix on the 

Medicare side? 

Dr. ATKINS. Yes. 

Mr. WING. Yes. 

Mr. SHIMKUS. Ms. Bella? 

Ms. BELLA. Yes. 

Mr. SHIMKUS. OK, good. Let me go to, I think Mr. Wing and Dr. 

Atkins again, and of course, Ms. Bella, if you want to chime in. So 

the Medicaid CHP Payment and Access Commission, because I 

don’t like these acronyms, especially, can you imagine somebody 

listening to these opening statements and not knowing what any 

of these terms are? They would be thinking we are talking in a foreign language. 

The Medicaid CHP Payment and Access Commission noted that 

dual eligibles may often be enrolled in up to three health plans, a 

SNP, a Medicaid plan, and a limited benefit plan such as behavioral health or long-term services and supports. While we know 

how that has evolved, I think that the discussion here is that integrated care should be integrated care. And it is kind of silly financially to have to go through, for the individual consumer very confusing. 

Can you speak to the degree to which the committee’s draft legislation addresses this issue of the possibility of three different plans 

and whether there are additional steps the committee should take? 

Mr. WING. We believe in full integration. And we still have a lot 

of work to do. SCAN has been dealing with dual eligibles for 40 

36 

years, as I mentioned. One of the areas, and you mentioned one, 

is behavioral health. Thirty years ago, the industry made a mistake 

about separating the medical component of care from the medical 

component of care and we now have pilots, especially if we have 

permanence, it makes a lot of sense. We are not a not-for-profit, 

but we have to be diligent with our capital deployment. But we 

now have a pilot in anticipation of either a 5-year permanence and 

we have a pilot in Riverside where we are actually coordinating 

bringing a telephonic Skype-based telemedicine that is focused exclusively on behavioral health. So from SCAN’s perspective, we 

need to integrate this so it is totally seamlessly integrated for the 

beneficiaries, for the State and for the plan. 

Mr. SHIMKUS. Dr. Atkins? 

Dr. ATKINS. I think the legislation helps. It creates much more 

of a push toward FIDE SNPs which is really the only full-integrated approach. And then you know, I think the challenge is that 

in many States you don’t have the managed LTSS or you don’t 

have managed behavioral health to be able to integrate with the 

D–SNP. So you can’t get everybody into a FIDE SNP if you don’t 

have the managed LTSS and behavioral health. 

And then I think you spoke to the issue of a managed Medicaid 

plan, just generally, and then often these separate MLTSS or behavioral health plans, but I think if the States can be moving more 

directly to integrating on the Medicaid side, then I think the challenge comes down to trying to find a way to get that alignment to 

happen on the Medicare side. 

Mr. SHIMKUS. Ms. Bella, do you want to add anything to this? 

Ms. BELLA. I would say it is an important incremental step. It 

is taking us one step further. It is still not getting us to a point 

where we have one program fully integrated without all the incentives, but to do that, we have a lot of enrollment and other financing issues to tackle. So it is an important step. It is not the end 

game. 

Mr. SHIMKUS. Thank you very much. I yield back, Mr. Chairman. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from Texas, Mr. 

Green, 5 minutes for questions, please. 

Mr. GREEN. Thank you, Mr. Chairman. Ms. Bella, you noted that 

the clinical and financial integration are both critical to actually 

achieving true coordination between Medicare and Medicaid. As 

part of your testimony, you also highlighted that even in States 

where fully aligned plans are offered, sometimes beneficiaries do 

not enroll in these plans. You mentioned specifically that improved 

enrollment processes and enhanced outreach to promote aligned 

plans could address some of these issues. 

Ms. Bella, can you provide an example of what you mean by improved enrollment processes? 

Ms. BELLA. Sure. I think part of the challenge is these are difficult programs to explain to people who are eligible for them. And 

we make it more difficult with having a different set of requirements for Medicaid and a different set of requirements for Medicare that complicate. 

We also have different processes for reviewing and approving 

those materials, so the end result is to talk to real people. The inVerDate Mar 15 2010 09:47 Oct 11, 2018 Jkt 037690 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\115X50SPECIALNEEDSPDFMADE WAYNE
37 

formation isn’t as clear as it could be. So it is sort of one set of 

things around materials and processes. It is another set of things 

around and this is probably more detailed than we have time to go 

into today, but the Medicaid program looks at people one way and 

has one set of eligibility rules, and the Medicare rules look at that 

exact same person a different way. And so we have conflicts in 

terms of how people are enrolled, how long they are enrolled, when 

and how often they can make enrollment choices and all of those 

things just they create problems for people and they really just 

erode a continuity of care and being able to keep people in a plan. 

Mr. GREEN. Do you have any examples of how we can improve 

that outreach? 

Ms. BELLA. Yes, there are examples. There are examples of how 

you can coordinate member materials, so requirements on the 

Medicare-Medicaid side around summary benefits, annual notice of 

coverage. So some of that is being tested in the demonstration 

States and in Minnesota right now, tested well. 

There are examples of how you can have joint review of those 

materials. What was just discussed about seamless conversion, allowing that to proceed, lifting the moratorium on that would be important. So I would be happy to present some more explicit examples outside of the hearing, but there are definitely concrete things, 

many of which are being tested today. 

Mr. GREEN. If you would give that to us so we could include it 

in the record, I would appreciate it. 

Ms. BELLA. Sure. 

Mr. GREEN. Thank you, Ms. Bella. Finally, there are certain 

States that Congress should look to as models that have been very 

innovative and promoted integration between Medicare and Medicaid. Do any of the panelists have thoughts on certain States that 

we might look at, whether it be Minnesota or someone else? 

Dr. ATKINS. Well, there is certainly, you know, there are the 

States that started first with full integration. Massachusetts, Minnesota, Wisconsin were the early States. And Massachusetts is another State to look at for their FIDE SNP. They have a senior care 

options program for the seniors, and they are in the duals demonstration for the under-65 population. 

But I think a lot of the States now who have gone either to adopt 

MMPs or have pushed more on integration, there are a lot of 

States out there that I think coming at it from very different perspectives have done a great deal in this space. The ones that are 

now sponsoring FIDE SNPs are an example. 

Mr. GREEN. Ms. Bella, I have another question. It seems like 

there is a menu of options available to dual-eligible and chronically 

ill beneficiaries. I think we need a basic review of the system of 

care as it stands for these beneficiaries so that we better understand how the pieces fall together. 

What are the options a dually eligible or chronically ill beneficiary is available to them in any given State? For the record, 

what is a D–SNP, a FIDE SNP, and what is a duals demo and the 

PACE program and how do all these different care options fit together. 

Ms. BELLA. Are you asking what each of them is for the record? 

Mr. GREEN. Yes, for seeing how they all fit together. 

38 

Ms. BELLA. I think of it as sort of menu of integration. So you 

start with sort of—your goal is to get to full integration, which 

means Medicare-Medicaid benefits are delivered by one entity, and 

they have financial integration, too. So the financial alignment 

duals demonstrations integrate the services, the payment. One entity gets a set amount of money every month to provide that care. 

One step down from that are the FIDE SNPs, the fully integrated, dual-eligible SNPs. so they have a contract with Medicare 

as a Special Needs Plans. They have a contract with a Medicaid 

agency for long-term care and behavioral health. They manage 

those two separate contracts. They get two separate funding 

streams, but they are still responsible for everything, just not quite 

as integrated as the Medicare-Medicaid Demo Plan. 

One step down from that is a regular dual-eligible SNP, so they 

have contract with Medicare as a SNP. They may or may not have 

a contract with Medicaid and so they are not quite as integrated 

as the FIDE SNP, because they are not managing the long-term 

care and the behavioral health benefit. 

And then one step down from that would be a regular MA plan 

because there are many duals that are in regular MA plans. They 

have no relationship to Medicaid at all. 

And I erred by saying PACE should be over here beyond the 

MMP plan, because PACE is completely clinically and financially 

integrated with both Medicaid and Medicare. 

Mr. GREEN. Thank you. 

Dr. ATKINS. Is it all right if I comment on that? I think PACE 

has a lot of features that would be beneficial for other integrated 

plans and the other thing is that the MMPs have a three-way contract between the State, the Federal Government, and the plan. 

And that actually is the plans have reported, and I think the State 

and Federal Government feel the same way, that that has enhanced the level of communication that goes on between the three 

entities and it is really moved to a much higher level of coordination. So I think the three-way contract is another interesting piece. 

But we advocate for eventually a single kind of overarching design for integrated plans and to try to allow these different modalities, but to bring them in under a kind of a common architecture 

because I think they are really are there because that is the way 

they have evolved. They are not there because that is the way that 

makes the most sense. 

Mr. GREEN. Thank you. Thank you, Mr. Chairman. I appreciate 

the information as we look at this legislation. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from Pennsylvania, Mr. Murphy, 5 minutes for questions, please. 

Mr. MURPHY. Thank you, Mr. Chairman. This just sounds like 

one of the biggest Rube Goldberg messes the Government could 

come up with. So let me try and peel back a little bit here. 

Mr. Wing, I was fascinated by what you talked about with some 

of these patients through telemedicine. I am assuming you have 

some sort of telepsychiatry consult. We know that people who have 

a chronic illness or acute illness doubles their risk for mood disorder, depression. When that is untreated, it increases their costs. 

39 

Who does that, the work that you talked about in your plan, who 

actually does those teleconsults? 

Mr. WING. Actually, right now we have a pilot. I am under a nondisclosure agreement, but we have a pilot. 

Mr. MURPHY. I don’t mean what the group does, I mean is it a 

psychiatrist, psychologist, social worker? 

Mr. WING. Well, actually, it is everything above. I can discuss the 

intervention. 

Mr. MURPHY. Briefly. 

Mr. WING. I came from a physician group that did a really good 

job, DaVita Medical Group. But diagnosing opioid abuse, substance 

abuse, and depression is easier said than done. So in this modality, 

the primary care physician is given an iPad and when he even suspects that there is opioid abuse, substance abuse, or bipolar disease, put the patient in a private exam room, give them an iPad 

that is connected to Skype to a specialized geriatric nurse practitioner. She is the one that does the better assessment and then she 

can then connect the patient through telehealth through a national 

network in behavioral health. 

Mr. MURPHY. Let me ask a couple of things that would make it 

even worse. Are you aware that even in that, that primary care 

physician because of a regulation put forth in the Nixon administration, if that person is already in treatment or receiving methadone or Suboxone, that doctor may not have access to the records 

and therefore may prescribe an opioid for his pain or the treatment, they don’t even know that person is in treatment because of 

this thing called the 42 CFR Part 2. Are you aware of that? 

Mr. WING. Yes. 

Mr. MURPHY. It is another mess that we have to fix. Plus, we 

also have a strange thing that even those psychologists may do the 

work, they have to bill through the psychiatrist and so which adds 

administrative costs and takes the psychiatrist away from their 

work. So it is another expense that we add to the system. So let 

us continue to build on Rube Goldberg. 

And in this, too, I want to ask all of you, if you are aware, too, 

what we find is that a true coordinated care model is the physician 

can really understand we have a complex case. You have a person, 

dual eligible, so they already are having multiple problems. And we 

even know, when you have got the flu it is hard to manage your 

flu. But when you are dealing with a chronic illness and perhaps 

mental illness on top of that, behavior and physical medicine have 

to be integrated together, but that requires a lot of work. But even 

in that context, I want to make sure I understand, because my understanding is Medicare doesn’t pay for these services that are 

needed. For example, responding to a patient’s phone call about a 

symptom or problem may not be paid for; or communications between the primary care physician and specialists to coordinate a 

care isn’t paid for. Communicating between community physicians 

and emergency room isn’t paid for or providing proactive telephone 

outreach to high-risk patients to say we want to make sure we see 

how you are doing, be aware of these symptoms, etcetera, how is 

your medication going, not paid for. Spending time with a patient 

in shared decision making to map out a game plan for them isn’t 

paid for. Hiring nurses or another staff member to do education, 

40 

patient education on medication, treatments, anything else isn’t 

paid for. Providing palliative care isn’t paid for. And even such 

things as getting the patient to the doctor’s office. I have heard of 

one program in Miami that actually does this. They actually bring 

the patients to the doctor’s office and deliver medication and guess 

what? Patient compliance goes way up. 

So is it your understanding, too, or am I getting this right, in a 

coordinated care plan with these very, very difficult cases, these 

things aren’t paid for, but we know that those things save money. 

Dr. ATKINS. Can I comment on that? I think this is a critical 

issue because Medicare actually is much more restrictive about 

what can be covered and not covered than Medicaid is. Medicaid 

is more flexible, but neither one of them is particularly flexible. 

And when you put the two together, you still have to deal with limitations on coverage, coverage restrictions and things that are built 

in the statute. 

So what we would advocate for is that as we go toward these 

more integrated models, that in the context of an integrated system 

where you are fully capitating across all of these services and supports, behavioral health, long-term services and supports and the 

medical, that you give the plans the flexibility to be able to provide 

the services that make the most sense in the case that they are 

dealing with, understanding that they are financially at risk for the 

overall cost of care for that patient. But if they see the possibility 

of providing a service, whether it is a counseling service or whether 

it is an inhome service that would help to reduce the medical costs 

on the medical side, they have the opportunity to do that. 

Mr. MURPHY. So this goes back to eliminating Rube Goldberg 

and saying if we empower the physicians to work closely with the 

patient and make some determines what they need and work more 

directly with that, and have a system of payment that is designed 

to cover that patient, let the medical practice decide what is best, 

we can actually save a lot of money and it is quite frankly, I believe 

more compassionate and works toward better healthcare. 

Dr. ATKINS. And I would urge you to include the fact that it is 

just not medical because for a lot of these people, the more significant services for them really are the services and supports that 

help to reduce medical expenditures. 

Mr. MURPHY. Yes, I add to that also psychological behavioral 

services. Thank you very much. Mr. Chairman, I yield back. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair recognizes the gentlelady from Florida, Ms. 

Castor, 5 minutes for questions, please. 

Ms. CASTOR. Well, thank you very much for calling this hearing, 

Mr. Chairman. And thank you to our witnesses for your expertise 

here. 

You all, based upon your testimony you say that not enough dual 

eligibles are enrolled in the Special Needs Plans, correct? And you 

have made recommendations to improve that, remove barriers, 

work with States to improve the enrollment there. 

Do you all agree that as we move in this direction, the Government could see substantial cost savings? 

Mr. WING. This is Chris Wing. The answer is yes. In our fully 

integrated D–SNP, we actually have two products. We have more 

41 

of an ambulatory program for the aged, blind, and disabled dual eligible. It is called Connections. 

We have another program in California. These members have to 

meet the California standards for being certified for nursing home 

eligible. In our program, for the seniors that in that Connections 

at home, all of them nursing home certifiable, we keep 96 percent 

of them, 96 percent in the community and outside of nursing 

homes. And if you do the math, this isn’t a DRG where it is 

$12,000 or $14,000. This could be a 7-year length of stay and 

$4,000 or $5,000 a month. The savings to the system are very, very 

profound, coupled with a better quality of life, better quality of care 

for beneficiaries. 

Ms. CASTOR. And I am going to ask you a little bit more about 

that, but do you all agree? 

Dr. ATKINS. Yes, if I could just reinforce that. HHS released a 

study this spring of the MSHIL program in Minnesota which is a 

fully integrated program and it was a comparison of the people who 

were in the MSHIL program to people who were just in MLTSS 

alone without the integration with Medicare. They found a very 

substantial reduction. I don’t know the figure on top of my head, 

but there is a very substantial reduction that is possible. 

Ms. CASTOR. And Ms. Bella, do you agree? And then how do we 

keep track? What measures are in place? How do we keep track of 

cost savings over time so we are investing where we need to invest? 

Ms. BELLA. Well, I do agree there is cost savings, but they are 

not immediate and they accrue more immediately on the Medicare 

side for things like hospitalization, readmissions, better prescription drug management. It takes more time to see on the Medicare 

side and that is part of the problem is that we have a mismatch 

between when the savings happen and how the payers benefit. And 

so that is why you haven’t seen as much take up of some of these 

so that is one of the things we need to address. We track that by 

looking at outcomes, the hard utilization outcomes that are measurable around key utilization areas that are driving costs, around 

all the inpatient buckets. And then on the Medicaid side it services 

all the long term care and how much of that can be moved into 

home and community-based settings and how are we seeing those 

shifts. So there is ways of tracking. 

Ms. CASTOR. And that is the responsibility of CMS? 

Ms. BELLA. It needs to be the responsibility of CMS and the 

States, but also MedPAC and MACPAC also play an important role 

because they can bridge those data together and help do some of 

the academic pieces of that that the governments aren’t necessarily 

staffed to do. 

Ms. CASTOR. So we are really struggling with the escalating cost 

of prescription drugs all across the board and all kinds of insurers. 

Is this a way where we can realize cost savings as well for prescription drugs paid by the Government under Part D and Medicaid and 

how would that work? 

Ms. BELLA. Certainly, prescription drugs is an area that when 

the two programs aren’t talking to each other, the costs can go up 

because there is no coordination, there is no one managing the 

meds, and there are all of those things. So the integrated program 

where you have one entity responsible who is seeing everything 

42 

that that person is getting, yes, they have an opportunity to improve the medication management and presumably drive costs 

down. 

Ms. CASTOR. Are there incentives in place to do so? 

Ms. BELLA. The health plans have incentives. I mean the health 

plans are fully capitated have incentives to make sure that the dollars are being used wisely. Those incentives don’t always flow back 

to the States and the Federal Government, and so again, there is 

sometimes mismatches in where investments are being made and 

where savings are being recouped, but the health plans have incentives across the board when they have responsibility for both pots. 

Ms. CASTOR. Did you want to comment on that, too? 

Mr. WING. The answer is that we have the risk. We are going 

to work with our providers to profile aberrant prescribing patterns 

and also try and work with the patient to make sure we understand what their desires are, what their goals are, we meet their 

desires so they will be more compliant. 

Dr. ATKINS. There is also, I think, an issue of medication adherence which is that very often we have spent a lot of money in this 

country on prescriptions that people either don’t take or don’t take 

properly and they really don’t have the effect that they need to 

have. So one of the advantages of an integrated program is that 

there is a lot of emphasis on medications. 

Ms. CASTOR. And there has also been increased recognition of the 

importance of social determinants, things like social supports and 

an individual’s physical environment and that is how we can help 

create positive outcomes and cost savings and this is something 

that Medicaid has worked on for a while and I am glad to see 

Medicare learning from Medicaid here. 

Mr. Wing, SCAN, I understand, has been very innovative in its 

thinking about social determinants of health and how nontraditional services and interventions can help. Tell us a little bit more 

about that. 

Mr. WING. You know, we were founded to focus on complex seniors especially dually eligible. And it is amazing what small things 

can really make a profound difference. 

I came from DaVita Medical Group, and doctors do a great job, 

but oftentimes they don’t know what is going on in the home. So 

we have a program where we put social workers and care navigators into the home to take stock, do an HRA, but take stock as far 

as the whole social determinants of health, and report back to the 

doctor. We don’t only provide the transportation back to the doctor 

which often is a barrier for dually eligible, but oftentimes we have 

a care navigator go with a patient and make sure the doctor knows 

the social determinants and everything else that is going on in the 

home. 

One case—if I can—about 2 years ago, we videotaped a member 

who was socially isolated, living by himself, a Latino gentleman. 

He already had Parkinson’s, but he had glaucoma. Our community 

health navigator, not a high cost, in the home identified—the member was doing the best he can to put the eye drops in, but couldn’t 

do it. A $12 wrist guard, a $12 wrist guard. The doctor thought the 

member was doing his best, but did not know he couldn’t do it. A 

$12 wrist guard, all of a sudden this patient now can slow the 

43 

delay of the glaucoma and fast forward in 5 years, if he had gone 

blind, had Parkinson’s, if he showed up in ER, he is going to get 

admitted. But that is not the worst outcome. 

The worst outcome is when he was about to be discharged. He 

is not going to be discharged back to the community. He is going 

to go to custodial care the rest of his life. So these social determinants probably predict anywhere between 20 to 80 percent of 

health outcomes. And when you are totally integrated like SCAN 

is for a fully integrated D–SNP, we have all the incentives to work 

with the doctors, but also make sure we are in the home and we 

know everything that is going on with that patient, their care 

givers, and their family situation. 

Ms. CASTOR. Thank you. 

Mr. BURGESS. The gentlelady’s time has expired. The Chair recognizes the gentleman from New Jersey, Mr. Lance, 5 minutes for 

questions, please. 

Mr. LANCE. Thank you, Mr. Chairman. As the chairman indicated, I am one of the sponsors in the bill that would enable expanded supplemental benefits to meet the needs of the chronically 

ill, Medicare Advantage enrollees. 

I want to work with the entire panel on this issue. New Jersey 

has struggled with behavioral health and substance abuse issues. 

Dual eligibles who are in the program, we have in New Jersey, try 

to address the whole person, both physical and mental health. 

In the panel’s opinion, does this kind of dual payment integration 

foster clinical integration? 

Mr. WING. Again, the answer is yes. You know, for our Medicare 

Advantage plan, not for our SNPs, we are prohibited from offering 

nonhealth type of services. Let us take the individual who needed 

a $12 wrist guard, boy, would that make a difference in somebody 

who is in a Medicare Advantage population? Yes. 

We all know about the hip fractures for seniors often lead to bad 

outcomes, whether it is nursing home care, institutional care, but 

if we could provide solid grips in the bathrooms, by the toilets, that 

would make a profound difference. But right now, Medicare Advantage plans cannot offer, by law, Medicare benefits to a Medicare 

Advantage only audience. 

Mr. LANCE. Well, thank you. And I want to continue to work 

with the panel on this and other issues because I think this is an 

incredibly important area and I commend those on the other side 

of the aisle, including Congressman Schrader, who is working with 

me on this issue and it is to be continued. 

Mr. Chairman, I yield back the balance of my time. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from California, 

Mr. Ca ́ rdenas, 5 minutes for questions, please. 

Mr. CA ́ RDENAS. Thank you, Mr. Chairman, Mr. Ranking Member. 

I would to thank you for holding today’s hearing and allowing the 

committee to shine a light on a program that is helping to improve 

the lives of so many medically vulnerable Americans. 

Too often in these discussions, we lose track of the real-world effects of our decisions. The conversation today is not about some obscure policy provision. It is about real people with real needs. 

44 

One of those real people lives in my district. Let us just call her 

Cassandra. Cassandra is 73 years old and has several chronic conditions including congestive heart failure, diabetes, and hypertension. For anyone unfamiliar with diabetes testing, a blood glucose test, or an A1C score above 8 is considered uncontrolled. This 

can lead to range of negative health effects including amputations, 

kidney failure, and loss of vision. 

Before joining the Special Needs Plans, Cassandra had an A1C 

reading of 12. This is dangerously high. This, along with her other 

poorly controlled conditions, led to at least seven hospitalizations 

over the course of just 1 year. Cassandra joined an SNP in 2014 

and today her A1C level is just 7.6. Cassandra has also only been 

to the ER once since her enrollment and has only been hospitalized 

for one scheduled surgery. Cassandra’s care is coordinated by her 

care team and she has regular meetings with her primary care provider and nutritionalist to keep her conditions under control. 

For the first time, Cassandra is getting healthier as she gets 

older, and her quality of life is much, much better. 

Cassandra is just one example of the millions of people benefitting from these specialized plans. We owe it to these patients to 

provide the certainty that these plans will be there for them in the 

future and that is why I believe it is so important to reauthorize 

them permanently to make them more effective and more efficient. 

Bottom line, better quality of care. 

One of the many populations that are treated through Special 

Needs Plans and are end-stage renal disease, otherwise known 

ESRD patients, so I have a question for Mr. Wing. 21st Century 

Cures took the first steps in developing ESRD specific quality 

measures for ESRD C–SNPs. As you know, not all quality measures are applicable to such a specialized patient population due to 

the uniqueness of the ESRD patient population and the type of specialized care they receive. 

So Mr. Wing, do you believe ESRD C–SNPs could better measure 

the quality of care provided if more specialized measures were developed? 

Mr. WING. The answer is yes. And actually we have an ESRD 

Special Needs Plans in Riverside with DaVita Medical— actually, 

DaVita, the parent. And it is amazing here. Not just we have the 

quality metrics. We can always improve quality metrics. We think 

the stars measures have fundamental changed the conversation between health plans’ providers because there is the economic incentives now. We always think there is improvement. Well, boy, when 

you talk to the nephrologists, when you talk to the patients, when 

you talk to the nurses about the care that dialysis patients get, 

ESRD Special Needs Plans, the savings are there, but again, the 

beneficiary satisfaction, the patient satisfaction is there as well. So 

the answer is we do applaud the current measures, but we can always improve upon them. 

Mr. CA ́ RDENAS. Mr. Wing, I have been listening to your answers 

today and I really appreciate you sharing your expertise with us. 

But one of the things that seems to be the common thread in all 

of this that you have been explaining and that is the communication between human beings. I mean we have all been incredibly impressed with the technology and the advances and the efficiencies 

45 

of being able to be more accurate when it comes to seeing what is 

really going on with a patient down to the molecular level, but at 

the same time it seems like every single one of your answers seems 

to point toward we need to make sure that our human beings are 

actually able to communicate with each other and share information and that seems to be the driving factor to having much, much 

better results. Would you agree? 

Mr. WING. I would agree. Hopefully, I am not a one-trick pony, 

but I think there is two tricks, integration and risk-bearing entities 

will always strive to innovate for better care, better quality and 

better financial outcomes. But I am always amazed, when we put 

people into patients’ or beneficiaries’ homes to find out what is 

going on, the doctors, as good as they are, as committed to quality 

as they are, they don’t know what is going on in the home. We 

have to have eyes and ears in the home to translate to the doctors. 

So communication and risk-bearing entities I think are a large part 

of the solution for this type of population. 

Mr. CA ́ RDENAS. And unfortunately, in this modern world, the 

human element seems to be in so many systems that want to get 

eliminated. This one we have to be very careful to understand how 

important that that human touch is. Thank you so much. I yield 

back. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair recognizes the gentleman from Missouri, 

Mr. Billy Long, for 5 minutes for questions, please. 

Mr. LONG. Thank you, Mr. Chairman. And Dr. Atkins, in your 

testimony you discussed fully integrated, dual-eligible Special 

Needs Plans. The uptake by States has been slow and enrollment 

has been relatively low, yet you state Congress should commit to 

advancing models that can fully integrate Medicare and Medicaid 

benefits. 

There is a concern that if we move too quickly, we are trying to 

force rather than facilitate integration. How do you respond to this 

concern? 

Dr. ATKINS. Well, you know, the difficulty with the uptake has 

been just that we have a lot of States that don’t have managed 

MLTSS and behavioral health. So trying to integrate, and you can’t 

really do a FIDE SNP if you don’t have integration—managed care 

on both sides. So that is one of the challenges. 

And then, you know, I think the enrollment issue has been a 

substantial challenge in both the MMP program and the FIDE 

SNP program. It is either voluntary enrollment that people voluntarily choose to enroll as beneficiaries in the combined plan or in 

the case of MMP, there has been passive enrollment with an optout and so people find themselves in the plans, don’t really know 

quite how they got there and often are persuaded either by their 

physician or by an LTSS provider to opt-out of the plan without 

really understanding what the choice has been. 

So I think the challenge has been to address these questions 

about enrollment because what we find is that when people do enroll in these plans, the level of satisfaction goes ways up. So in the 

disability community, for example, in the younger disability community, there has been some resistance to going into managed 

care. So there has been some resistance to going into these inteVerDate Mar 15 2010 09:47 Oct 11, 2018 Jkt 037690 PO 00000 Frm 00049 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\115X50SPECIALNEEDSPDFMADE WAYNE
46 

grated plans, but a lot of that is built on a lack of understanding 

about what is going on in these plans. And when beneficiaries get 

in, they report they are much more satisfied with this experience. 

So I think it is going to be a lot of education. 

I think in many cases, the MMPs were launched in the State 

without adequately communicating in advance what these plans 

were. And then when you look at the beneficiaries who get assigned to these plans, often these are very hard to reach beneficiaries and when they get into an MMP, it is the first time anybody has ever shown up and had contact with them about what is 

going on with their healthcare or what are their services and supports. And so it has been very difficult to kind of get to everybody 

and get the information out there, but I think that we need to have 

some strategies around how do we get more people to enroll in 

these plans. 

Mr. LONG. All that being said and talking about enrollment, 

could this lead to fewer comprehensive plans being offered? 

Dr. ATKINS. I am sorry, I didn’t understand the question. 

Mr. LONG. I said could this lead to fewer comprehensive plans 

being offered, forcing rather than facilitating? 

Dr. ATKINS. If we go to a FIDE SNP, for example? I mean I think 

a FIDE SNP is incredibly—— 

Mr. LONG. Trying to move too quickly, is that going to—— 

Dr. ATKINS. Oh, if we go too quickly, are we scaring people away? 

Well, I think in each State where these products get launched, the 

State has to do the work initially. It may take a year or more to 

work with all of the groups that are affected. 

Just as an example, in Kansas when they brought managed 

LTSS to the IDD population, intellectually and developmentally 

disabled population, which has been carved out of most of these in 

many States, at first blush, there was a lot of resistance because 

the State had not communicated what was going on to the population. The plans had to spend the first year just communicating 

with the advocacy groups, working with the service delivery system 

that was there, getting them to understand what was going on before they actually started to launch services and enroll people. So 

those are the things that just have to happen because there is so 

much lack of understanding. 

Mr. LONG. I have got one more question, it is again for you, Dr. 

Atkins. You also state in your testimony that facilitating full integration will only be possible initially in States that enroll dual 

beneficiaries in Medicaid managed plans, yet enrolling dual eligibles in managed care requires a waiver, and the process of retaining a waiver can often be long, challenging, and uncertain. 

How can we, as a committee, facilitate integration, while not relying on States to get waives from CMS? 

Dr. ATKINS. Do you want to answer that? 

Ms. BELLA. Depending, there are ways that States can have their 

beneficiaries in managed care. They don’t require—they are not 

115 waiver process. They can do it through a State plan process. 

And so, depending on the path the State takes, there are more or 

less complex ways of doing that. 

If you are asking are there ways that we could make it easier 

for States who want to do integrated programs—— 

47 

Mr. LONG. Right, as a committee, how can we assess? 

Ms. BELLA. Yes, there are ways to do that. They are somewhat 

State-specific, depending on how the States structure their program, but there are always ways that we can simplify and making 

these two programs work better together. 

Mr. LONG. OK. 

Dr. ATKINS. But I will say that there is a very strong movement 

in this country right now toward managed LTSS. We have got 

three more States coming in this year. We have a number of States 

lined up starting the process for next year and beyond. And so we 

have expanded the number of States already that are involved in 

MLTSS and that movement is pretty strong because it is really to 

the States’ advantage in trying to manage these costs to do these 

managed care contracts because they can really get their arms 

around trying to figure out how to keep the population that has 

been in institutions or is headed toward institutions really stabilized in the community. 

Mr. LONG. Thank you. Mr. Chairman, I have no time left, but if 

I did, I would yield it back. 

Mr. BURGESS. The Chair appreciates the gentleman’s offer. The 

Chair recognizes the gentlelady from Colorado, Ms. DeGette, 5 minutes for questions, please. 

Ms. DEGETTE. Thank you very much, Mr. Chairman. I want to 

thank Chairman Walden and Ranking Member Pallone for having 

this hearing on SNPs, and you, too. 

I am really happy that the SNP Reauthorization Act includes 

this bill that I have been working on with Representatives Lance 

and Kennedy and also our colleagues on Ways and Means, Congressman Meehan and Congresswoman Sewell. 

What this bill does, H.R. 3044, it expands supplemental benefits 

for chronically ill Medicare Advantage enrolless. What it does, 

under the bill, both traditional Medicare Advantage plans and 

SNPs, would be able to offer individualized benefits that meet the 

specific healthcare needs of chronically ill enrollees. And I know 

you have all been talking about this today. 

Supplemental benefits could include services that are not traditionally covered by health plans like meal delivery, as long as there 

is a reasonable expectation that such services will maintain or improve health. For example, somebody mentioned today that the 

new flexibility would allow plans to purchase air conditioning for 

COPD or asthma patients who couldn’t otherwise afford it. Now 

even though that is not a traditional healthcare service, such a 

change in a patient’s living environment could have huge health 

benefits. I think that this common-sense legislation will lead to better health outcomes and improve quality of life, including in my 

own State, 273,000 seniors. 

And I just really want to thank the committee on a bipartisan 

basis for including our bill in this broader bill that we are considering today. And so I hope we can continue to work in a bipartisan 

basis to reauthorize the SNP program and include this commonsense bill that we have. 

Mr. Wing, I was really struck by your testimony about the gentleman who had Parkinson’s and glaucoma and how all you needed 

to get was a wrist band for him so he could put his eye drops in. 

48 

This is true with so many seniors and what we end up doing, and 

part of it is because Congress doesn’t really know how to look at 

budgeting for prevention and management. And it is very frustrating for our constituents. This is something that Chairman Burgess and I have actually been working on for a long time, trying 

to figure out how to incentivize prevention through the budget 

process, rather than just paying for more and more emergency 

services and whatever. 

And so, I am just wondering, I know in your testimony, you said 

you strongly support provisions in the SNP Reauthorization Act 

that grant increased flexibility to use supplemental benefits of nonmedical services. Do you have some other examples that you can 

share with the committee today? 

Mr. WING. Sure. Thank you for the question. I mentioned that 

the fall often necessitates a hip fracture and a hip fracture necessitates not only a hospital admission, but oftentimes long-term facility admission. Oftentimes, if you have just grips in the toilet, the 

shower, and solid flooring in the kitchen, solid flooring in the bathroom, you can negate the fall that precipitated the hip, and again, 

knowing what is going on in the home. 

Oftentimes, a doctor is going to look for medical solutions, but oftentimes there is a social solution. Maybe a little bit of inhome support, a low-level person coming in and helping with food, with bathing, with activities of daily living for a member that is in a straight 

MA plan. We prevent them from having an ER visit, a hospital 

visit, and since we are at risk for the Medicare benefits want to 

give us the flexibility to prevent that and provide better care for 

the beneficiary and reduce costs for the system. 

Ms. DEGETTE. Doctor, I see you nodding your head. Did you want 

to add to that? 

Dr. ATKINS. I think it is a very important move forward and 

given this flexibility in MA. Because we have to keep in mind that 

the only benefits we provide on long-term services and supports in 

this country are under Medicaid. And so we are serving a very 

small portion of the population that has fairly substantial LTSS 

needs. The more we can do to create more flexibility in the Medicare Advantage program in cases where the services that we are 

going to authorize the plans to provide actually help reduce the 

overall costs of the plan anyway. 

Ms. DEGETTE. Right. 

Dr. ATKINS. So it is really improving outcomes and reducing 

costs. I think that is really important to try to explore as much of 

that as possible. And I know you are familiar with the Bipartisan 

Policy Commission. In fact, Council’s report recently about other 

ways to do that. 

Ms. DEGETTE. Thank you. Thank you very much. I yield back. 

Ms. BLACKBURN [presiding]. The gentlelady yields back. Mr. Carter, you are recognized 5 minutes. 

Mr. CARTER. Well, thank you all for being here, certainly an important subject. 

I want to start off with something that is bothering me. I get the 

SNPs. I get the Institutional in I–SNPs. I was a consultant pharmacist in a long term care setting for over 25 years. And I can understand and see how they work. And I can see the benefit of that. 

49 

I can see the chronic, the C–SNPs. I can see the benefit there. I 

have witnessed that through my practice in retail pharmacy. I have 

seen how they are beneficiary. 

What I struggle with and I have always struggled with is the 

dual eligible. Explain to me why we have to have dual eligible? Explain to my why we can’t introduce legislation that says you have 

to be one or the other. You are not going to be both. I mean just 

simplify it for me. 

Dr. ATKINS. Well, one of the critical things is that Medicare 

doesn’t really cover anything but medical expenses and for many 

of the people we are talking about who have very complex care 

needs, being able to address their nonmedical needs can have more 

impact on their overall health than the cost of care for them than 

spending the money on the medical side. So Medicare is limited in 

its capacity to serve this population completely. 

For those people who are in Medicaid and have the long-term 

services and supports covered in the Medicaid program, they have 

those services available to them. Where you have dual coverage—— 

Mr. CARTER. Then why don’t you just let them be Medicaid? Say 

you are going to be Medicaid. You are not going to be Medicare. 

Ms. BELLA. In 1965, the then Congress created two programs 

with two separate titles. These folks qualify under both title. So the 

only way to get rid of it is to have a new title that encompasses 

the medical—— 

Mr. CARTER. OK, I want to introduce a new title, and it is going 

to be you are one or the other. Just explain to me. I just struggle. 

I have always struggled with it. 

Ms. BELLA. The challenge with this population is they, right now, 

they are eligible to get their medical needs met through Medicare 

and their long-term supports and behavioral health and wraparound services met through Medicaid. So you can’t really put 

them in one or the other because they—right now, the system gives 

them both. And so if you want to make a choice, then you have to 

make them ineligible for one or the other because today, they are 

eligible for both and they need both types of services, medical and 

nonmedical. 

Are they delivered in the right way? No. Is it efficient to have 

them delivered this way? No. Do we need a new title? Yes. Are 

these things that we are talking about today, are they important 

steps? They are, if we can align incentives which is part of what 

we are talking about today to put things together, give the money 

to one entity and start to fix some of these problems that have kept 

having accountability. 

Mr. CARTER. Is that what your PACE program is? 

Dr. ATKINS. Yes, that is what PACE is. 

Mr. CARTER. So that is the answer I am looking for here. Is we 

need PACE. 

Dr. ATKINS. Well, PACE needs to be—— 

Ms. BELLA. They are two separate titles. 

Mr. CARTER. So we are just going to create another title. 

Dr. ATKINS. The only thing I would suggest, I think there should 

be a category of integrated plans and they should have their own 

statutory and structure and regulatory structure. But to get away 

50 

from having two sources of money coming into these programs, one 

from the Federal Government and one from the combination Federal and State government, the Federal Government would have to 

be willing to essentially take the Medicare money for these people 

and give it to the States to serve that population. 

Mr. CARTER. And what would be wrong with that? 

Dr. ATKINS. Nothing. 

Mr. CARTER. Listen, the source remains the same. 

Dr. ATKINS. Right. 

Mr. CARTER. Whether it is Medicare or Medicaid, guess where it 

is coming from originally. It is coming from here, whether it is administered through the State. 

Dr. ATKINS. Right. In the MMP program we have a three-way 

contract with the Federal Government and the State and the plan 

all work together. If the Congress so chose, they could take that 

Medicare money and just essentially hand it to the States and let 

them run the contract, if that was what people wanted to do. But 

that would be a major shift from where we are today. 

Mr. CARTER. I can’t imagine. I just have struggled with this for 

many years to understand this, why we can’t simplify to it where 

you are on one or the other. And I get it. I know that people who 

are eligible for Medicare who are lower incomes need that safety 

net program to help them because there are services that are not 

covered, but still, I don’t understand why and maybe I need to understand the PACE program. I have got 20 seconds left. Can you 

tell me how it is going to benefit and how it would help with this? 

Ms. BELLA. Both PACE and what he is referring to as the MMP, 

which is Medicare-Medicaid Plan, give an entity the payment for 

both Medicaid and Medicare services. There is one contract. So you 

are not kind of fighting two different regulators. You attempt to 

align the administrative requirement. So they are the closest 

things we have to sort of having it be seamless that there is really 

two programs behind it. So they are the models that you would use 

if you were trying to get away from having two separate programs 

that are constantly at odds with each other. 

Mr. CARTER. OK. My time is up. I yield back. Thank you. 

Mr. BURGESS [presiding]. The Chair thanks the gentleman. The 

gentleman yields back. The Chair recognizes the gentleman from 

Oregon, Mr. Schrader, 5 minutes for questions, please. 

Mr. SCHRADER. Thank you very much, Mr. Chairman. I appreciate that. Dual eligibles is really the absolute gold standard by 

which I think healthcare delivery in this country will be judged if 

we are going to make improvements. They are the most expensive 

population, require the most attention, to my good colleague’s comments earlier, the fact that we have got two different programs 

dealing with a complex population with many needs is confounding. 

I would take a slightly different approach. I like what I was 

hearing from Mr. Atkins about, you know, starting over, an integrated model with overarching rubric that the States could play 

into that combined the better aspects with one set of criteria, not 

two, with Medicaid having one set of eligibility requirements and 

Medicare having another. It seems like the time has come with the 

SNP programs, the MMP programs, come up with some sort of way 

that we could have a common standard by which the monies get 

51 

delivered to one spot, however much money that is, and then the 

States again, under some overarching rubric, come up with a better 

way, more efficient, more coordinated way that would be maybe up 

front a little costly, but over the long haul yield measurable, better 

outcome results that would decrease the cost for these very difficult 

patients going forward. 

That would be fun to work on. I think based on the testimony 

I have heard so far, I think you would find a lot of willing participants, both sides of the aisle, across the political spectrum to do 

that. 

Currently, the money that comes into these MMPs or the SNP, 

the dual SNP programs, is it the—I am a little ignorant here also 

in terms of how the money flows. Is it always a case that the full 

Medicaid payment and the full Medicare payment come into these 

programs and are utilized by whatever program delivery system is 

there, Mr. Atkins? 

Dr. ATKINS. Well, yes, I would defer to my colleague who actually 

ran the program to be a little bit better informed on how the mechanics work. But go ahead. 

Ms. BELLA. Sure. The Medicare-Medicaid rate, the MedicareMedicaid Plans, the Federal Government and the States set the 

rate, and they give Medicare and Medicaid money to the plan, and 

it encompasses the full set of Medicare and Medicaid benefits. 

In the arrangements where you have Medicare managed care 

and a SNP or a FIDE SNP, it varies by State. In the most integrated products, the same plan is getting capitated amount for all 

the Medicaid benefits and Medicare benefits? 

Mr. SCHRADER. So how does the overall amount of dollars compare to the two separate payments that are out there? 

Ms. BELLA. In the MMP products, the two payers, we took those 

factors into account and assumed benefits of coordination and reduced duplication and took cost savings off the top of that. 

Mr. SCHRADER. I think that has a lot of appeal to members on 

both sides of the aisle. Instead of having two big payments that 

add up to X plus, we have one that adds upto X or X minus because of that coordinated care. I think you a lot of willing participation. 

Dr. ATKINS. Yes, and one of the other issues is just when you are 

dealing with a very frail or a population with a lot of very complex 

care needs is the risk adjustment that goes into the payment to 

make sure that it adequately reflects the social factors that are 

binding on these populations as well. 

Mr. SCHRADER. And risks gaming the system a little bit, not that 

anyone would do that, but everyone then would be compensated for 

the degree of risk that they are incurring given the complex needs 

of their particular people going forward. 

I guess the other point I would make that Mr. Wing touched on 

a little bit is that there is a very fantastic bill out there that Mr. 

Lance and myself have to keep people from falling into, hopefully, 

the dual-eligible situation, i.e., making sure low income Medicare 

patients can access some of the advantages of this integrated approach and I would hope that there is an opportunity as we go forward to include this type thing. Again, we are thinking of cost savings rather than having someone have to spend themselves down 

52 

into Medicaid to be able to take advantage of the dual-eligible 

MMPs or PACE or whatever the program is. We could start giving 

some of these inhome, community-based services earlier on and 

save a ton of money from having to pay for these very same people 

on a more institutionalized or more expensive setting going forward. 

So I would hope the Chair and ranking member would look forward to working with us on this, maybe going forward and see if 

we can’t continue to improve a very good system that seems to be 

developing here. With that, I yield back. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair recognizes the gentleman from North Carolina, Mr. Hudson, 5 minutes for questions, please. 

Mr. HUDSON. I thank the chairman and thank you, panel, for 

being here today. It is very helpful helping us grapple with this 

very complex issue. You have touched on this in your testimony a 

little bit, but I have a question, sort of about the deadlines and 

time frames under our discussion draft. Do you think these time 

frames and deadlines for integrating benefits and providing services is realistic to States that need more time? I just ask if anybody 

has a comment on that. 

Dr. ATKINS. I think the way it is structured for States that 

haven’t been able to do managed care on the LTSS and behavioral 

health side, there is a way to get around that and kind of be able 

to do it even with a fee-for-service kind of structure in place there. 

So I think that is an important carve-out because a lot of States 

aren’t yet in the position to be able to have aligned Medicare and 

Medicaid managed care plans. 

But I think the time frames, as far as what I have seen, in the 

legislation seem reasonable. 

Mr. WING. SCAN also believes that the movement to full integration for the D–SNPs is mission critical. Unless we have integration, 

there is no hope for savings, long-term savings, keeping people out 

of nursing homes for the State which is a big burden for the State. 

So I think it is 2021 and legislation and we support that. We think 

if there is a FIDE SNP at any stage, there is a lot of FIDE SNPs 

like SCAN in the United States, we think a 4-year time frame is 

very, very doable and essential. 

Mr. HUDSON. Great. I appreciate that. Dr. Atkins, in your testimony, you know, what we have also heard from the GAO that 

there are not standardized measures for long-term services and 

supports that have been widely adopted or broadly used. However, 

it sounds like your association has initiated an effort to adopt quality measures that can meet the State requirements or yet not burdensome for plans. This sounds great to me, but I am wondering 

if you could tell me more about when you think the association will 

have more to report to us. Obviously, the more data points we have 

to deal with, the better. 

Dr. ATKINS. Thank you for that question. I will say that we have 

adopted a quality framework which is a list of the indicators that 

we would feel we were able to report in a reasonable time frame. 

We will hay to put all of this into effect, all the companies who participate will agree to put all of this into effect. 

53 

These are measures that we did not create. These are measures 

that have gone through the NQF process or are being developed by 

Mathematica for CMS or are generally out there in the home and 

community based consumer survey. 

So there are existing measures that we believe that we can actually produce now out of our databases. So the process we are going 

through right now is to do what is called specification. We are actually digging down into each of our plans to see where the data is 

going to come from and how consistent we can get it to be across 

all of these. 

Our purpose is not to do it unilaterally by ourselves, but to work 

with our States to encourage the States to essentially accept these 

measures that we would report as measures that are used in overseeing the quality, integrating with the quality reporting systems 

that they are going to have in place because it is a State function 

to report this. 

Mr. HUDSON. Right. I think that is critical for being able to determine the impact on the beneficiaries. 

Dr. ATKINS. We would be glad to come back and talk to you in 

a couple of months with some much more detail about where we 

are with it. 

Mr. HUDSON. I think it would be great, Mr. Chairman. I hope we 

can encourage that and I will yield back the balance of my time 

if anybody else would like to use it. Thank you. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentlelady from California, 

Ms. Eshoo, 5 minutes for questions, please. 

Ms. ESHOO. Thank you, Mr. Chairman for holding this hearing 

and to the witnesses, thank you for your wonderful testimony. You 

bring enormous expertise to the hearing room and we all appreciate it. 

I am fascinated by the question of our colleague from Georgia 

about why does it have to be this way? Do we need a new title? 

Why do we have part of Medicare? Why is it in Medicaid? And I 

can’t help but think of the President saying ‘‘Whoever knew that 

healthcare could be so complicated.’’ So we are dealing with the 

complications here and these hearings are targeted to specific 

areas, but they also broaden and deepen our understanding of the 

system that we have and how we want to improve it and what is 

important to do. 

What stands out to me today is how important Medicaid is, I 

mean how essential it is. And so the broader context in terms of 

what we are dealing with, whether some of us like it and some of 

us don’t like it is that the House passed a bill that fundamentally 

restructures the Medicaid program by implementing per capita 

caps and block grants and the Senate is debating a lot of things, 

but we know that Medicaid is on the chopping block. 

Now this discussion about reauthorizing, I think we should reauthorize. I think that we need to make some changes and you have 

brought some very good ideas to the table, but the reality is that 

I think anyway, Medicaid is hanging by a thread. I think it is 

hanging by a thread. Forget the ACA. Medicaid itself as an entitlement is hanging by a thread. 

54 

So my question, I guess I will start with Ms. Bella, is what would 

that do to dual eligibles? I mean it is my understanding that 70 

percent of the SNP plans have dual eligibles in them, so can you 

talk about what if there is, in fact, an implementation of per capita 

caps or block grants in the Medicaid program, how does that affect 

what we are talking about today? We are talking about improving 

it, but the larger picture is that it is up to a 35 percent gouge of 

Medicaid itself. 

Ms. BELLA. So I guess a couple of things. One, we are talking 

about improving it and improving it means we can put a full kind 

of cadre of Medicaid-funded services along with the medical piece. 

Ms. ESHOO. I understand what those are. I worked on this years 

ago when I was a county supervisor for the dual eligibles. And we 

developed a capitated plan in the county. 

You know what? I took care of my parents and they were blessed 

with a long life. And I know what is needed in the home. They are 

better off at home if, in fact, you can bring the kinds of services 

that they—the particular services that they need. So while they 

weren’t enrolled in Medicaid, they were Medicare beneficiaries, 

they had the beneficiary of their daughter, too. But in terms of the 

care, I understand it. 

Ms. BELLA. Right, so those services—— 

Ms. ESHOO. And the care for each one of them was unique. 

Ms. BELLA. Right, those are the services that are at risk with a 

per capita or some sort of Medicaid block grant. And it is those 

services that are keeping people in these integrated programs out 

of the hospital and out of other places. 

Ms. ESHOO. See, thank you for saying that. I hope everyone is 

listening to this. Because we are dealing with frail, elderly people 

that are far more vulnerable. I have always thought—I remember 

saying to the doctor when he said I think we need to take your father to the hospital and I said well, what are they going to do at 

Stanford Hospital that I can’t do here at home for him? He said, 

you know, you have got a good point. So we kept him at home and 

in three and a half days, he was much better. But I think that in 

some ways we have got our heads in the sand here, because we are 

talking about how to do this, what it is, reauthorizing and meanwhile in the larger bubble, there is a wrecking ball that is going 

up against Medicaid. So we have got some choices here and I think 

we need to tell the truth about what is going on which is so frustrating to me. I am glad we are having the hearing, but you know 

what, we are pretending that everything is all right. And it is not 

because what is at hand is going to take a wrecking ball to what 

these people have come here to testify about. Thank you, and I will 

yield back. 

Mr. BURGESS. The gentlelady’s time has expired. The Chair recognizes the gentlelady from Indiana, Mrs. Brooks, 5 minutes for 

questions, please. 

Mrs. BROOKS. Thank you, Mr. Chairman, and I, too, thank you 

for providing your expertise to all of us. 

I have heard a lot of discussion today about the need for more 

integration coordination, but one policy area I know there is often 

typically a lot of bipartisan interest in is the issue of telehealth and 

it is something that—I represent a district that is urban, suburban, 

55 

but very rural as well. I know that one school in a smaller community of Elwood, Indiana, has begun some telehealth with the school 

nurse and I know that this is something that I think could have 

tremendous benefits to citizens throughout the country. 

So I am interested in each of you commenting on the policy idea 

that many Medicare Advantage plans have expressed an interest 

in, and that is to allow Medicare Advantage plans to offer telehealth as part of their bid, so they don’t have to use rebate dollars 

to provide it. They have an incentive to be efficient in their bids 

and this flexibility could be particularly helpful with the frail, disabled, or homebound beneficiaries and beneficiaries in rural areas 

that I just discussed. 

So I wondered if you could please share with us, if you think it 

would be useful to give special needs plans this authority, at least 

for the next 5 years, and to see how this tool could boost the health 

outcomes for patients and what each of your thoughts are on telehealth and these types of plans. 

Mr. Wing? 

Mr. WING. I will start. I mentioned earlier that we have a pilot 

of behavioral health telehealth which we think is mission critical. 

And when you are dealing with the fully integrated D–SNPs, we 

are talking about a very vulnerable population and a lot of them, 

as you mentioned, are homebound. And so we need to figure out 

how do we bring the delivery system into their home? 

In telehealth, the technology is there. The funding isn’t, but the 

technology is there. And we are using it for telehealth, but for truly 

homebound members who don’t have the financial wherewithal to 

go to a doctor, don’t have the transportation to go to the doctor. 

They either have cognitive impairment or other reasons why they 

can’t go to the doctor. We need to bring the delivery system there. 

Now you can bring doctors to the home, but that is a very expensive proposition. Telehealth seems to hold the hope of bringing 

medical physicians, psychologists, psychiatrists, and other providers into the home at a fraction of the cost in real time. And oftentimes, these frail duals, they can’t wait 15 days to get in to see 

a specialist. They need to see them now. So we are very supportive. 

Mrs. BROOKS. Any particular reason why you are only focused on 

behavioral health? 

Mr. WING. No. We are a small company. We happen to find this 

company out of Nashville and know that behavioral health, opioids 

is a really big issue of the senior population in aggregate. When 

you take the duals, it is a very pressing issue. I think 48 percent 

of our dually eligible have a clinical diagnosis of depression, 48 percent. When you see those numbers, you have to do something about 

it. And we can’t bring a psychiatrist, a psychologist in a home. 

First of all, we don’t even know the diagnosis yet. So we think telehealth is the right modality for behavioral health, but probably for 

a lot of other type of specialties. 

Mrs. BROOKS. Thank you. Dr. Atkins? 

Dr. ATKINS. I think Mr. Wing spoke earlier about the importance 

of eyes and ears in connecting the medical and nonmedical parts 

of the delivery system and that is critical. I think that we have to 

explore a lot of technology solutions that are going to enable us to 

be better connected in people in their homes who have these very 

56 

complex care needs. Telehealth certainly is going to be a major part 

of that. 

Mrs. BROOKS. Ms. Bella, do you see any impediments to us advancing telehealth in Medicare Advantage plans? 

Dr. ATKINS. No, especially if it is part of a broader push to recognize supplemental benefits generally that plans could be given 

more flexibility around when they are taking the financial risk. 

Mrs. BROOKS. Actually, building on that issue regarding supplemental benefits, could you give us examples of supplemental benefit plans, benefits that plans provide and how they improve patient outcomes, other supplemental benefits? 

Ms. BELLA. Sure, I think—Chris, do you want to answer? 

Mr. WING. Well, again, if you take the FIDE SNP where we can 

provide these Medicaid type of benefits, you know, I mentioned I 

wrist card, solid flooring in the bathroom, solid flooring in the 

kitchen, guard rails in the toilet area and the shower that prevent 

the fall, a home- and community-based services, having a home 

health aide to help with bathing, cooking to prevent nursing home 

viable people being placed in custodial care. It is really being able 

for a Medicare Advantage plan to offer Medicaid-like benefits to 

prevent the reason for necessity for acute admission or even more 

importantly, going into long-term custodial care where they are 

never going to come back from. These are really demonstrated long 

time demonstrated benefits that really curtail costs, but they radically improve the quality of life for beneficiaries. 

Mrs. BROOKS. Thank you. Thank you for those examples. I yield 

back. 

Mr. BURGESS. The Chair thanks the gentlelady. The gentlelady 

yield back. The Chair recognizes the gentlelady from California, 

Ms. Matsui, 5 minutes for questions, please. 

Ms. MATSUI. Thank you, Mr. Chairman, and I want to thank the 

panelists here today. We are learning an awful lot and realize that 

there is so much more to learn here. 

I have got to say that the future of special needs plans is so very 

important as we move forward because since their creation I guess 

in 2003, we have seen success in managing complex populations 

across Medicare and Medicaid, such as those dually eligible for programs and seniors with chronic conditions like diabetes and dementia and so forth. 

But as we see the increase in population and look to see the 

quality of care that the individuals have gotten, I think it is important because sometimes it is not as successful and we really need 

to be very clear as we move towards full integration in Medicare 

and Medicaid options for the chronically ill and dual-eligible beneficiaries. The protection of beneficiary rights and the quality of care 

that beneficiaries receive should be the first consideration when 

evaluating any policy change. To that end, I think one of the most 

important things that could impact a beneficiary’s experience is a 

unified appeals and grievance process. 

Now I know that for many individuals, it can be overwhelming 

to understand how to appeal, doubly so if you are a person who 

happens to have both Medicare and Medicaid benefits. 

57 

All of our witnesses have highlighted the importance of a consistent and understandable appeals process for our beneficiaries, 

but I would like to dig a little deeper into this. 

Mr. Wing, can you discuss how appeals and grievances work in 

the FIDE SNP, and how this is different from other types of SNPs? 

Mr. WING. Well, I will talk about one of the solutions is we do 

suffer from the different rules for Medicare and Medicaid. We have 

to deal with that. I think Melanie Bella has been talking about 

that for years. It is very complex. It is confusing for the members, 

for the family, for the doctors and that confusion leaves people to 

go, I am not going to join. 

Ms. MATSUI. Right. 

Mr. WING. At SCAN, we have what we call for our fully integrated D–SNPs, we have basically concierge care. We want these 

people to stay with us, but when they are having a problem with 

an appeal or a referral or anything, we want them to have a oneon-one relationship with somebody in our call center that is not a 

bank. So everyone of our fully integrated D–SNP members have 

what we call a PAL, personal assistant line, where they develop a 

unique relationship with someone at our call center. If they have 

got a problem with coordinating appeals and grievances we are 

there for them. If they have got a problem with the delivery system, we are there for them. If they have got a problem with how 

we deliver care or home health aide services at home, we are there 

for them. And that is mission essential. These people, they have got 

a lot of special needs, complex needs. They need the system to come 

alongside them as opposed to them coming along aside the system. 

Ms. MATSUI. OK. Ms. Bella, can you talk about this issue from 

the perspective of your former role as Director of Medicare and 

Medicaid Coordination Office? What barriers did you encounter? 

Ms. BELLA. In the grievances and appeals specifically? 

Ms. MATSUI. Yes. 

Ms. BELLA. There are some legislative barriers and then there 

are some administrative barriers and so part of the—the language 

that is in the House bill will go a long way toward fixing, so in the 

Medicare-Medicaid programs there are different requirements 

about time frames, for example, and what level you have to go to, 

for example. 

And so in CMS, in the demonstrations, we were able to integrate 

some of those things, but we just couldn’t go quite far enough and 

we were still doing it under demonstration authority. Again, the 

language that you are considering today makes a huge step forward and then there are some administrative pieces where we can 

continue to wrap around that. That would streamline it even better 

and make it both protective of the beneficiary, but also make it 

easier for all parties to operate under. 

Ms. MATSUI. OK. Thank you. Dr. Atkins, even with your associations, why diversity in membership? It seems like this is an important recommendation that has been agreed upon. Can you discuss 

why unified appeals are so important from the beneficiary perspective? 

Dr. ATKINS. Well, certainly. I mean one of the more confusing aspects of the system is the different routes and different time frames 

and things that are involved in appeals and grievance under the 

58 

different programs. So I think it is critical that we work toward 

getting a single set of uniform set of rules. 

We would, of course, love to see a common architecture in the 

program, a common architecture for integrated plans that would 

address a lot of these kinds of issues. 

Ms. MATSUI. Right, right. I think it is really important as we 

talked about the unification of—and I think it is very, very difficult, as we know, in Medicaid and Medicare. But there is aspects 

here that I think I could see having some sort of unifying aspect 

of it where people aren’t as confused as to what to do as we move 

forward. I see my time is gone. I yield back the balance. 

Mr. BURGESS. The gentlelady yields back. The Chair thanks the 

gentlelady. The Chair observes that the Chair has actually delayed 

his time for questions to the end. We also have been joined by Mr. 

Costello, who is not on the subcommittee, but I believe the gentleman would like to seek time for questions. Is that correct? 

Mr. COSTELLO. Yes, thank you, Mr. Chairman. 

Mr. BURGESS. I will recognize the gentleman for 5 minutes for 

his questions. 

Mr. COSTELLO. As a follow-up, to a line of inquiry that Mrs. 

Brooks had to you, Mr. Wing, could you share with me the certain 

types of specialty providers, be they medical or nonmedical, that 

you see most likely to begin or most likely to have the capacity to 

offer telehealth services? 

Mr. WING. I thought you were going to go a different direction. 

I appreciate the question. 

Mr. COSTELLO. You can take another direction. 

Mr. WING. I thought you were going to ask me what is the specialty or type of provider that is going to make the most profound 

difference in the future. 

Mr. COSTELLO. That was going to be my next piece of it. 

Mr. WING. I like that question. I think it is going to be community health navigators. These people are $14 or $15 an hour, but 

going into the people’s home, assessing what is going on with the 

social determinants. This is a low-cost, high-impact intervention. 

We would like to flood the market, especially for those who are 

nursing home certifiable, and make sure we are identifying the social determinants of health quickly, make sure the doctor knows. 

But I see no greater innovation. I don’t think this is a medical 

problem that requires medical intervention. This is a social problem that requires a social solution and I think having an army, if 

you will, covering fully integrated D–SNPs or seniors who have 

Chronic Special Needs Plans, I think is going to be one of the most 

pronounced interventions, the most impactful interventions to improving quality and reducing costs that we are going to see over 

the next 5 to 10 years. 

Mr. COSTELLO. Thank you. Ms. Bella, your testimony comments 

on how there are things that CMS and States can do to improve 

the coordination of benefits and delivery of services for dual eligibles, including those with disabilities. You know that State Medicaid manuals should move toward capitation of their LTSS and behavioral health benefits. 

You also said though that they need assurance that if they go 

down this path, the future of D–SNPs is not uncertain. So to conVerDate Mar 15 2010 09:47 Oct 11, 2018 Jkt 037690 PO 00000 Frm 00062 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\115X50SPECIALNEEDSPDFMADE WAYNE
59 

firm, you are effectively saying that a longer extension would allow 

more planning and investment in infrastructure and policies that 

would better serve individuals with disabilities? Is that correct and 

could you expound upon that a little bit? 

Ms. BELLA. Sure. I am actually saying that permanency would go 

the furthest because these have been sort of in limbo since 2003, 

meaning every few years people are wondering do we have to come 

back and argue for their case. And so Pennsylvania is a great example. Your State just spent several years putting together a managed LTSS program. They put in their Community HealthChoices 

Program. They have required all those participants to be D–SNPs. 

Tremendous amount of work. Tremendous amount of progress. And 

we want them to keep investing in that with already limited resources. They can’t feel like it is at risk of going away. So if we 

want to get States to continue building these programs, they need 

the assurance of knowing that this program is permanent and stable. 

Mr. COSTELLO. Thank you. 

Dr. ATKINS. Could I add one thing to that which is that the MMP 

program, which is the demonstration program, has a time limit on 

it and we have a lot of people enrolled very successfully in MMP 

programs. It would be helpful for those people to know where they 

go when that demonstration ends. 

Mr. COSTELLO. Thank you for your thoughts and thank you, Mr. 

Chairman. 

Mr. BURGESS. Does the gentleman yield back? 

Mr. COSTELLO. I do. 

Mr. BURGESS. The Chair thanks the gentleman. The Chair recognizes himself for the balance of the time. Just checking to see if 

you are paying attention. Ms. Matsui, apparently not. 

First off, thank you all for the very intriguing discussion this 

morning. 

Mr. Wing, let me just start with, you mentioned right at the end 

here of this, something that I have thought for a long time, which 

is—you even used the term—‘‘concierge medicine.’’ Yes, navigators 

are important. Yes, the home health aides are important. But you 

can have all the fingers in the world, but if you don’t have a palm, 

it doesn’t do you any good. 

So I remember having this discussion with Dr. Berwick when he 

was CMS Director, many, many years ago, that when I voiced some 

of the same frustration that the gentleman from Georgia voiced 

this morning about not understanding why we have these programs that are sometimes difficult to comprehend and navigate, 

why there wasn’t just one place and that, to me, would have been 

that position of the concierge or direct primary care or whatever 

you want to call the model. 

So I was grateful to hear you mention that this morning. I do 

think that that is a direction that this subcommittee should explore. I have felt that for a long time. 

And Ms. Bella, even the agency that you used to head up when 

we look at the enabling language in the Affordable Care Act, the 

establishment of a Federal coordinated healthcare office, that was 

the goal. And when I talked to Dr. Berwick and I said why don’t 

we do a concierge doctor for these poor folks and actually take care 

60 

of them, his answer was we are going to set up a new Federal 

agency. I wasn’t thrilled when he told me that. I probably had a 

reaction much like Buddy Carter voiced this morning, but at the 

same time I will also say that as your former office has matured 

over time, it does seem to be providing a valuable service to patients. 

The reports that you generate at the end of every fiscal year— 

and I guess the most recent one I have is for Fiscal Year 2015, and 

you were probably involved in the generation of that report, were 

you not, Ms. Bella? So it is helpful. It is not just a recitation of 

things that were done. It actually has some meaningful insights 

and perhaps legislative direction that the legislative branch could 

pursue, so I think that is a good and positive development. 

But again, Mr. Wing, when you mentioned the word concierge 

medicine, yes, I think that is right. When Don Berwick would complain, I got 20 percent of my folks spending 80 percent of my bucks 

and I need to do better with that. It seemed to lend itself in that 

direction. So I would be happy to hear your thoughts on that because this is the first time in all of these years of having these 

hearings that I have heard anyone actually mention that. 

Mr. WING. Well, we believe the center of the universe really 

should be the doctor. 

Mr. BURGESS. That is the right answer. Thank you. 

Mr. WING. Well, it should be, but often again doesn’t know what 

is going on in the community, so our people in the community are 

integrating via a laptop into the EMR with the doctor and we are 

trying to do the same thing through or provider integration efforts 

so that any encounter that we have with our PALS unit gets right 

back with the primary care physician. Primary care physicians 

armed with complete data will make complete decisions. Without 

complete decisions, they won’t. And we need to arm them to do a 

better job. 

Mr. BURGESS. And are you utilizing, of course, the day the Affordable Care Act was written the smartphone was in its infancy. 

The ability now that people have to connect even absent a navigator in the home, the fact that their smartphone can electronically 

transmit a daily weight, a blood pressure, a blood sugar, to some 

central facility. 

Mr. WING. We are piloting—actually, some of our medical groups 

on their own are piloting, having a smartphone, but really, it is not 

really doing telemetry of health outcomes or bioreadings, but if you 

have a problem, here is a number to call. So they have a 

smartphone. Just call here. If you think you need to go to the ER, 

if you are uncertain, call us. 

However, we spend a lot of time on the fully duals and these people have a lot of cognitive impairment. Oftentimes, they are socially isolated. Oftentimes they have multiple ADLs and multiple 

chronic conditions. Smart anything, I don’t think this is going to 

solely a technology answer. It is going to have to be a high touch. 

We need to have people there to come alongside to help them. 

Mr. BURGESS. I don’t disagree, but even as the gentlelady from 

California mentioned taking care of her parents, when I was in a 

similar situation, the ability to get that information to someone to 

help you make a decision. 

61 

Mr. WING. We are very supportive of that. We are very supportive of that. 

Mr. BURGESS. Let me, again—fascinating panel, and I really appreciate all of you being here this morning. I am sorry Ms. Eshoo 

has already left. I am obligated to answer some of the charges that 

she made, so I have some stuff for the record, and I want to offer 

for the record an op-ed from February 7, 1997. The op-ed is almost 

old enough to vote itself. An op-ed from February 7, 1997, from the 

New York Times, ‘‘Making the Budget Bearable.’’ This was back in 

the Clinton administration. Part of the op-ed says, ‘‘The President 

offers an important reform of Medicaid, proposing to control future 

spending by placing a cap on the amount of Federal spending per 

enrollee and allowing States to place enrollees in managed care 

without going through the frustrating process of begging for Washington’s approval.’’ The New York Times recommending the per 

capita cap. That was an idea of a Democratic administration back 

in the 1990s. 

Further evidence, Senator Murray from Washington State. Senator Murray speaking on the Congressional Record December 22, 

1995: ‘‘Mr. President, I hold in my hand today a letter to President 

Clinton that is signed by all 46 members of the Democratic Caucus. 

This letter urges him to hold firm in our commitment to basic 

healthcare for children, pregnant women, and the elderly, and the 

disabled... . This letter supports a per capita cap approach to finding savings in the Medicaid program.’’ This was a problem 22 years 

ago. It is no less a problem today. 

As Margaret Thatcher once aptly observed, you can eventually 

run out of other people’s money. And that is a concern that, although this is an authorizing committee, not an appropriations 

committee, it is a concern that we should have as well. And I think 

one of the things that this panel helps us with today is understanding we need to be spending dollars wisely. It is not that we 

are not going to spend dollars, but we need to spend them wisely. 

This is not a new concept of what is being debated in this committee this year and over in the Senate, even as we speak, not a 

new concept, one that was embraced by a Democratic administration 21 years ago, Democratic Senators 22 years ago, the New York 

Times 20 years ago. So it has been an interesting panel this morning. I want to thank you for being here. 

Seeing that there are no further Members wishing to ask questions, I again want to thank our witnesses. We have received outside feedback from a number of organizations on these bills, so I 

would like to submit statements from the following for the record: 

Molina Healthcare, Avalere, the Healthcare Leadership Council, 

the National Association of Medicaid Directors, AHIP, the Association for Community Affiliated Plans, Bipartisan Policy Center, 

UPMC, and a letter from 12 advocacy groups on Special Needs 

Plans. 

Additionally, I want to submit the New York Times editorial 

from 1997 and the Congressional Record statement from 1995. 

Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Pursuant to committee rules, I remind Members they have 10 

business days to submit additional questions for the record. I ask 

62 

the witnesses to submit their response within 10 business days 

upon receipt of the questions. Without objection, this subcommittee 

is adjourned. 

[Whereupon, at 11:59 a.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

PREPARED STATEMENT OF HON. GREG WALDEN

This morning we have a distinguished panel of witnesses to discuss the ways the 

committee can improve Special Needs Plans in Medicare Advantage as Congress 

looks to extend the authority for this program in the coming months. Special Needs 

Plans, or SNPs (pronounced ‘‘SNIPS’’) are private healthcare plans providing Medicare benefits to some of our most vulnerable beneficiaries. These are elderly beneficiaries who are in care facilities, who have chronic conditions or diseases, and who 

are low-income and are enrolled in Medicaid. 

As a committee with jurisdiction over both Medicare and Medicaid, we have a special obligation to thoughtfully examine this unique opportunity to not only extend 

the SNPs’ authority, but to make refinements to policy which can improve the ability of States and plans to provide needed care to millions of beneficiaries. As we 

embark on our effort, we recognize and appreciate the good bipartisan committee 

work that has preceded us—efforts by our colleagues in the Senate and in the House 

Ways and Means Committee. 

Today, we complement previous efforts by hearing from experts and releasing 

draft legislation. Our bipartisan goal is to extend and enhance the program in a 

manner that encourages integrated, coordinated healthcare coverage. 

We want to ensure healthcare plans and State Medicaid programs have the right 

incentives and proper tools to offer the best care to vulnerable patients. We also 

want to help ensure patients have the needed protections and help when navigating 

healthcare benefits and accessing care. 

We welcome and need stakeholders’ feedback on how we can move forward on 

SNPs in a manner that improves care, enhances quality, and best serves millions 

of patients. I’d like to thank our witnesses for being here with us today, and I look 

forward to a productive discussion that will help us move forward on this critical 

issue. 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Thank you, Mr. Chairman, for calling this hearing to consider the extension of 

Special Needs Plans, an important subset of Medicare Advantage plans for some of 

our highest-need Medicare beneficiaries. 

It is so important that our committee consider the extension of SNPs, as they are 

often called, and any related policy changes with the program closely. These types 

of plans serve some of our most complex and vulnerable patients: those that are institutionalized or have serious chronic illnesses, and those that are dually eligible 

for Medicare and Medicaid. 

It is undeniable, also, that these types of Medicare plans have a unique interaction with Medicaid. And, as the chairman has heard me say so many times, the 

Energy and Commerce Committee has the critical responsibility and privilege of 

overseeing and protecting the Medicaid program. First and foremost, we should ensure that people who are dually eligible for both Medicare and Medicaid or living 

with a chronic illness have a seamless experience—regardless of what plan or combination of benefits they may elect to receive. 

At times, this goal has been challenging, but I know that we have a good opportunity before us with the reauthorization of SNPs to continue to further that goal. 

Today, I look forward to discussing how we can best continue to integrate benefits 

and provide high quality care to people that have chosen a SNP plan to provide 

their care. Our colleagues on the Ways and Means Committee and the Senate Finance Committee have both done excellent work over the past several months to 

further the growth and development of SNPs in the Medicare program. And now, 

I look forward to adding the voice of the Energy and Commerce Committee to that 

important work. 

63 


27071.025
64 


27071.026
65 


27071.027
66 


27071.028
67 


27071.029
68 


27071.030
69 


27071.031
70 


27071.032
71 


27071.033
72 


27071.034
73 


27071.035
74 


27071.036
75 


27071.037
76 


27071.038
77 


27071.039
78 


27071.040
79 


27071.041
80 


27071.042
81 


27071.043
82 


27071.044
83 


27071.045
84 


27071.046
85 


27071.047
86 


27071.048
87 


27071.049
88 


27071.050
89 


27071.051
90 


27071.052
91 


27071.053
92 


27071.054
93 


27071.055
94 


27071.056
95 


27071.057
96 


27071.058
97 


27071.059
98 


27071.060
99 


27071.061
100 


27071.062
101 


27071.063
102 


27071.064
103 


27071.065
104 


27071.066
105 


27071.067
106 


27071.068
107 


27071.069
108 


27071.070
109 


27071.071
110 


27071.072
111 


27071.073
112 


27071.074
113 


27071.075
114 


27071.076
115 


27071.077
116 


27071.078
117 


27071.079
118 


27071.080
119 


27071.081
120 


27071.082
121 


27071.083
122 


27071.084
123 


27071.085
124 


27071.086
125 


27071.087
126 


27071.088
127 


27071.089
128 


27071.090
129 


27071.091
130 


27071.092
131 


27071.093
132 


27071.094
133 


27071.095
134 


27071.096
135 


27071.097
136 


27071.098
137 


27071.099
138 


27071.100
139 


27071.101
140 


27071.102
141 


27071.103
142 


27071.104
143 


27071.105
144 


27071.106
145 


27071.107
146 


27071.108
147 


27071.109
148 


27071.110
149 


27071.111
150 


27071.112
151 


27071.113
152 


27071.114
153 


27071.115
154 


27071.116
155 


27071.117
156 


27071.118
157 


27071.119
158 


27071.120
159 

Æ 


27071.121