This week, our In Focus section provides a high-level overview of the new Medicare Advantage Dual-Eligible Special Needs Plan (D-SNP) integration requirements in the Centers for Medicare & Medicaid Services (CMS) April 16, 2019, final rule[1] for calendar year (CY) 2021. CMS recently released two publications providing guidance and technical assistance to assist with the implementation of these new opportunities: the November 14, 2019, CMCS Informational Bulletin[2] and Integrated Care Resource Center technical assistance tool Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans.[3] Both identify steps to ensure that states’ Medicaid agency contracts (SMACs) with D-SNPs comply with the new 2021 requirements, and further encourage states and D-SNPs to work together to address the often fragmented care provided to the Medicare-Medicaid dually eligible population.
CMS outlined three ways D-SNPs may meet CY 2021 integration requirements which must be reflected in D-SNP SMACs. D-SNPs must do at least one of the following:
- Meet CMS requirements to be designated as a fully integrated D-SNP (FIDE SNP) by providing coverage of Medicaid long-term services and supports (LTSS)[4] and behavioral health, consistent with state policy, under a single entity (Note: Complete carve-out of behavioral health coverage by the state Medicaid agency is permitted.);
- Meet CMS requirements to be designated as a highly integrated D-SNP (HIDE SNP) by providing coverage of Medicaid LTSS and/or behavioral health services, consistent with state policy, under a capitated contract with the Medicare Advantage organization, or its parent company, or another entity owned by the Medicare Advantage organization/parent organization; or
- Notify the state, or its designee, of hospital or SNF admissions for at least one group of high-risk, full benefit dually eligible individuals.[5]
See Appendix A – CMS Attributes of FIDE SNPs and HIDE SNPs for further detail.
For CY 2021, D-SNPs and affiliated Medicaid managed care plans with exclusively aligned enrollment,[6] referred to by CMS as “applicable integrated plans,” must also implement unified appeals and grievance procedures outlined in 42 CRF 422.629-634.
CMS further clarified that states and D-SNPs have opportunities to work together to identify D-SNP designation tailored to individual state readiness and capacity to coordinate and integrate Medicare and Medicaid benefits. D-SNPs may partner with states to:
- Establish data sharing for D-SNPs without HIDE or FIDE SNP designation – States and health plans may work together to develop the process for sharing information with the state, or its designee, on hospital and SNF admissions of one or more groups of high-risk individuals enrolled in the D-SNP. This data sharing includes the notification process, timeframe and methods by which notice is provided, and criteria for identifying the one or more groups of high-risk full-benefit dually eligible individuals for whom the notice is provided.[7] States and D-SNPs can identify entities well-positioned to effectively use the data to support coordination of transition planning to ensure needed services and supports are in place for individuals upon hospital or SNF discharge. (e.g. Medicaid managed care organizations, Medicaid home and community-based waiver care managers)
- Identify and execute SMAC provisions reflecting new requirements, as well as additional policies to support the most integrated care possible for dually eligible individuals – States and health plans can look to CMS sample SMAC contract language Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans to identify provisions that implement policies required of all D-SNPs and those applicable to HIDE SNPs and FIDE SNPs, including those that are applicable integrated plans. CMS permits states the flexibility to adopt additional contract language options that go beyond 2021 minimum integration obligations. For example, optional language may:
For all D-SNPs
- Require coordination with unaffiliated Medicaid managed care plans, the state Medicaid agency, and/or specialized Medicaid benefit contractors
- Describe coordination in D-SNPs with integrated benefits and exclusively aligned enrollment
- Require D-SNP to inform providers of verified enrollee eligibility and plan enrollment
- Require D-SNP to report changes in enrollee status that may impact enrollee eligibility
- Establish “evergreen” [8] contracts with D-SNPs beginning January 1, 2021
For different types of D-SNPs (i.e. those without and with HIDE SNP or FIDE SNP designation, and those with exclusively aligned enrollment)
- Require enhanced D-SNP coordination and discharge planning
- Require D-SNPs to operate affiliated Medicaid managed care plans in the same service area(s) as their D-SNPs
- Require Medicaid managed care organizations to operate affiliated D-SNPs in the same service area(s) as their Medicaid managed care plan(s)
- Require integrated approach to beneficiary marketing materials and including of State Medicaid Agency in review of marketing materials with Medicaid information
- Require use of a single enrollee ID care for Medicare and Medicaid benefits[9]
States have started to request information from stakeholders for planning for more integrated programs. For example, in October 2019, the District of Columbia released a Request for Information – Highly Integrated Dual Eligible Special Needs Plans and Enhanced Coordination for Care for Enrolled Dually and Eligible Beneficiaries and Maine release an RFI – Related to Managed Care Service Delivery for Dually Eligible Members.
Submission of SMACs for CY 2021 are due to CMS July 6, 2020. D-SNPs and states can plan for required contract updates and additional policies to support coordinated and integrated care now.
For more information, please contact Sarah Barth, Principal, HMA
Appendix A – CMS Attributes of FIDE SNPs and HIDE SNPs
Attributes of FIDE SNPs and HIDE SNPs | ||
| FIDE SNP | HIDE SNP | |
| Must have a contract with the state Medicaid agency that meets the requirements of a managed care organization as defined in section 1903(m) of the Act. | Yes | No |
| May provide coverage of Medicaid services via a prepaid inpatient health plan (PIHP) or a prepaid ambulatory health plan (PAHP). | No | Yes |
| Must provide coverage of applicable Medicaid benefits through the same entity that contracts with CMS to operate an MA plan. | Yes | No. The state Medicaid contract may be with: (1) the MA organization offering the D-SNP; (2) the MA organization’s parent organization; or (3) another entity owned and controlled by the MA organization’s parent organization. |
| Must have a capitated contract with the state Medicaid agency to provide coverage of LTSS, consistent with state policy. | Yes | No, if the capitated contract otherwise covers behavioral health services. |
| Must have a capitated contract with the state Medicaid agency to provide coverage of behavioral health services, consistent with state policy. | No. Complete carve-out of behavioral health coverage by the state Medicaid agency is permitted. | No, if the capitated contract otherwise covers LTSS. |
| Must have a capitated contract with the state Medicaid agency to provide coverage of a minimum of 180 days of nursing facility services during the plan year. | Yes | No |
Source: Medicare-Medicaid Integration and Unified Appeals and Grievance Requirements for State Medicaid Agency Contracts with Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) for Contract Year 2021, CMCS Informational Bulletin, November 14, 2019.
[1] Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021.
[2] Medicare-Medicaid Integration and Unified Appeals and Grievance Requirements for State Medicaid Agency Contracts with Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) for Contract Year 2021, CMCS Informational Bulletin, November 14, 2019.
[3] Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans, Technical Assistance Tool, Integrated Care Resource Center, November 14, 2019.
[4] Including nursing facility services for at least 180 days per plan year.
[5] Medicare-Medicaid Integration and Unified Appeals and Grievance Requirements for State Medicaid Agency Contracts with Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) for Contract Year 2021, CMCS Informational Bulletin, November 14, 2019.
[6] Exclusively aligned enrollment is when a state limits FIDE SNP or HIDE SNP enrollment to membership in a Medicaid managed care plan offered by the same organization.
[7] Information Sharing to Improve Coordination for High-Risk Dual Eligible Special Needs Plan Enrollees: Key Questions for State Implementation, Technical Assistance Tool, Integrated Care Resource Center, September 2019.
[8] An “evergreen” contract is a contract that remains in effect continuously, rather than solely for a single year. Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans, Technical Assistance Tool, Integrated Care Resource Center, November 14, 2019.
[9] Ibid.