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State Efforts to Integrate Care Across Medicaid FFS LTSS and Medicare Advantage D-SNPs

This week, our In Focus section reviews a new paper from Health Management Associates,State Efforts to Integrate Care Across Medicaid Fee-for-Service Long-Term Services and Supports and Medicare Advantage Dual Eligible Special Needs Plans by Sarah Barth, Rachel Deadmon and Julie Faulhaber. Funded by UnitedHealthcare, this paper outlines approaches taken by Medicaid programs seeking to coordinate Medicare and Medicaid services for dually eligible individuals without first implementing standalone Medicaid managed long-term services and supports (MLTSS) programs.

To date, most federal and state government partnerships to create integrated Medicare-Medicaid programs or demonstrations have included some form of Medicaid MLTSS. However, there are opportunities for states that want to keep their long-term services and supports (LTSS) delivery systems under fee-for-service (FFS) to proceed with coordinating and integrating care across the two programs. Some states may prefer to keep successful portions of FFS LTSS systems in place or may not yet be ready to move Medicaid FFS LTSS to managed care.

HMA interviewed Medicaid and Aging agency officials in the District of Columbia, Idaho, Maine, and Washington based upon known exploration and efforts to increase coordination and integration between Medicare and Medicaid. HMA reviewed their Calendar Year 2021 state Medicaid agency contracts (SMACs), as well as the Calendar Year 2021 SMAC for Alabama requiring provision of certain Medicaid benefits. From these interviews and SMAC reviews, HMA identified steps states can take to increase coordination across Medicaid FFS LTSS and Dual Eligible Special Needs Plans (D-SNPs) for dually eligible individuals. Charted paths to better coordinate and integrate Medicaid LTSS FFS and other covered benefits with Medicare services include:

  • HIDE SNPs. Use of Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs) covering behavioral health and other Medicaid services to support coordination with Medicaid FFS LTSS (Washington). HIDE SNP is a designated type of D-SNP. To be considered a HIDE SNP a plan must provide, either directly or through a companion Medicaid managed care plan, either behavioral health services or LTSS in addition to other Medicaid services to its dual eligible enrollees.
  • Medicaid Wraparound. Inclusion of a per member per month payment for certain Medicaid services and benefits, such as the Medicaid agency’s cost sharing obligations in SMACs (Alabama) or the comprehensive set of Medicaid benefits, inclusive of LTSS (District of Columbia)
  • “Benchmark Model” via FIDE SNP. Use of a Medicaid State Plan alternative benefit package with “standalone” fully integrated dual eligible special needs plan (FIDE SNP) (Idaho) and without a standalone Medicaid MLTSS program. FIDE SNP is a designated type of D-SNP. FIDE SNPs provide Medicare and Medicaid benefits under a single legal entity that has a contract with CMS and a Medicaid contract with the state. It must provide coverage, consistent with state policy, of Medicaid benefits, including LTSS and nursing facility services for at least 180 days per plan year.[1]

These innovative pathways to integration can and often do lead to future implementation of MLTSS as a comprehensive approach to provide LTSS to eligible populations.

The paper further outlines approaches taken by these Medicaid programs seeking to coordinate Medicare and Medicaid services without standalone Medicaid MLTSS programs. Their approaches include the following:

  • Identifying and building upon the existing strengths of the state’s Medicaid program to increase coordination and integration of Medicare and Medicaid benefits for dually eligible individuals.
  • Engaging stakeholders, including dually eligible individuals and their families, D-SNP organizations, providers, and others, at the outset of planning for increased coordination and integration between Medicaid and D-SNPs.
  • Establishing strong state staff oversight and understanding of Medicare program benefits and administrative requirements, D-SNP models of care, and MA supplemental benefits.
  • Maximizing the new Centers for Medicare & Medicaid Services (CMS) 2021 standalone D-SNP hospital and skilled nursing facility admission data sharing requirements to support increased coordination around care transitions.
  • Maximizing available CMS Medicare-Medicaid Coordination Office (MMCO) supports and communicating additional supports needed going forward.

Medicaid programs can adapt these approaches to their unique state landscapes, delivery systems, and stakeholders to better coordinate Medicare and Medicaid services for dually eligible individuals.

For further details on these program approaches, please access the following link to the paper.


[1] 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, Centers for Medicare & Medicaid Services, November 17, 2019.

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