Insights

Regulatory policy changes finalized by CMS aim to increase the percentage of dual-eligible individuals enrolled in integrated plans 

This week, our In Focus section delves into important and complex regulatory policy changes that affect coverage and services for the 12.9 million individuals who are dually enrolled in both Medicare and Medicaid. These policy changes—which were finalized as part of a broader final rule that the Centers for Medicare & Medicaid Services (CMS) released on April 4, 2023—are designed to increase the percentage of dually eligible people who are enrolled in integrated Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs). The modifications will be phased in gradually, with certain provisions affecting D-SNPs starting in 2025. These adjustments forge a stronger connection between state-level policy and operational decisions, shaping the future landscape of D-SNPs. 

Overview 

Amid rapid growth of D-SNP plan offerings and increased enrollment of dually eligible individuals into D-SNPs, CMS has finalized an interconnected set of regulatory policy changes to increase enrollment in integrated plans while simplifying coverage and plan options for this population.   

By promoting enrollment in integrated plans, CMS seeks to improve the care experience and outcomes for dually eligible individuals, with the ultimate goal of making integrated plan enrollment the standard. Integrated D-SNP plans, which consolidate Medicare and Medicaid services under one managed care organization, offer uniform consumer protections (including unified grievance and appeals process), integrated plan materials, and more coordinated care. 

Key policy changes include:  

• Replacing the current quarterly special enrollment period (SEP) with a monthly SEP for dually eligible and other low-income subsidy (LIS) individuals to enroll into a standalone prescription drug plan (PDP) 
• Establishing a new integrated care SEP that will enable dually eligible individuals to choose an integrated D-SNP plan on a monthly basis 
• Restricting enrollment in certain D-SNPs to individuals also enrolled in an affiliated Medicaid managed care organization (MCO) 
• Limiting the number of D-SNPs an MA organization can offer in the same service area as an affiliated Medicaid MCO to reduce and simplify plan offerings for dually eligible individuals. 

What Issue is CMS Trying to Solve? 

CMS intends to make it easier for dually eligible people make enrollment decisions. Simplified plan options and more integrated care could prevent beneficiaries from inadvertently selecting plans that fail to provide the comprehensive Medicare and Medicaid benefits they need. 

This shift toward aligned enrollment could improve beneficiary experiences, enhance outcomes, and streamline administrative processes for CMS. The introduction of a monthly SEP specifically for dually eligible individuals enrolled in Medicaid managed care plans underscores CMS’s commitment to facilitating enrollment in affiliated D-SNP plans throughout the year. Health Management Associates (HMA) experts expect these changes to affect the sales cycle for dual eligibles and potentially increase member satisfaction, expand access to care, and improve overall health outcomes for this population. 

Timeline of Regulatory Changes 

Considerations for Health Plans  

The impact on individual health plans hinges on state-specific approaches to dually eligible beneficiaries and D-SNPs, as well as each plan’s strategy for integrating Medicare and Medicaid services.  HMA experts identified the following key factors as essential for understanding and monitoring these interconnected dynamics:  

• Does the state administer managed Medicaid, and if so, does it include the dually eligible population? 
• Does the Medicare D-SNP (or an affiliated/ related company) hold a state Medicaid contract that covers dually eligible individuals?  
• What is the state’s vision regarding duals and D-SNPs? 
• Does the state require its Medicaid contractors to offer a D-SNP? 
• Does the state currently or plan to restrict D-SNPs to their Medicaid contractors? 
• Is the state moving toward an exclusively aligned enrollment model? 

What’s Next  

The changes in D-SNPs present opportunities and risks for beneficiaries, MA and Medicaid health plans, and states. Successful navigation of these changes requires proactive planning and anticipation of forthcoming federal and state regulations. Health plans operating within the D-SNP space must actively engage with state Medicaid agencies to understand and potentially help shape this evolving environment. For example, health plan strategies may include: 

• Understanding the state’s priorities and its current and planned approach to integrated care for dually eligible individuals 
• Participating in and/or advocating for stakeholder meetings with the state regarding dually eligible members and D-SNPs to ensure the opportunity to shape regulations 
• Developing internal integration strategies that align product design, operations, quality, clinical, and member experience capabilities for D-SNPs and Medicaid 
• Strategically planning actions, such as participating in Medicaid procurements, to achieve the plan’s objectives 

Connect with Us  

These regulatory changes significantly affect dually eligible beneficiaries, states, and both Medicare and Medicaid health plans. Though some changes may disrupt the duals’ market, others align state objectives with plan strategies. Ultimately, dually eligible individuals with full benefits will gain the most, experiencing improved opportunities to choose suitable plans, access necessary care, and achieve optimal health outcomes and well-being.  

For further insights into these upcoming changes, view the D-SNP Growth and Integration: Key Implications of the 2025 CMS Final Rule webinar, featuring our experts below. Join them and other experts at HMA’s Fall Conference to stay informed about the strategic directions plans and states are pursuing.

As HMA has grown, we have added significant breadth and depth to our Medicare team to better offer our clients comprehensive expertise on Medicare, Medicare Advantage, Dual-Eligibles, payment systems, pricing, and more. When looking for a partner to help navigate the complexities and changes of Medicare, our clients know that by engaging HMA experts they are engaging former CMS officials, former plan executives, payment system and coding experts, policy analysts, and many others. We draw on the resources of experts from our HMA companies to provide comprehensive and end-to-end solutions, including Wakely Consulting Group and Cirdan Health Systems and Consulting for actuarial services, and Leavitt Partners for political and policy engagement. Together we bring considerable expertise in all things Medicare and can leverage our more than 700 consulting colleagues across HMA.

Our world-class Medicare team partners with clients to meet their needs, address their challenges and improve their bottom line. We provide a variety of services such as:

• Significant support for Medicare Advantage (MA) plans and stakeholders seeking to understand MA policy and operational issues including strategy, market assessment, models of care, evaluation, and audit support.
• Support MA special needs plans (D-SNP, I-SNP, C-SNP, etc.) and programs for dual eligible beneficiaries.
• Medicare regulatory, analytics and thought leadership consulting services for MA plans, providers, suppliers, value-based organizations, associations, and foundations.
• Design, implementation, evaluation and analysis of Medicare value-based payment systems and policy issues.
• Program of All-Inclusive Care for the Elderly (PACE) strategy and operations.
• Strategic advice, policy development, and budgetary analysis for clients seeking assistance with Medicare reform efforts.
• Medicare coverage and reimbursement for device, drug and biotechnology manufacturers and other stakeholders in the life sciences community.
• Assistance for clients seeking to commercialize new technologies.
• MA and fee-for-service claims analysis and actuarial services with support from actuaries within HMA plus actuaries from Wakely Consulting Group and Cirdan Health Systems and Consulting.
• Consulting and federal policy analysis, including Congressional Budget Office (CBO) scoring and legislative policy development with our colleagues from Leavitt Partners.

In 2021, HMA acquired The Moran Company (TMC), which provides extensive expertise in the design, implementation, and evaluation of various healthcare payment systems, with a particular focus on the Medicare program. As we approach the 26th anniversary of TMC’s founding and the third anniversary of joining the HMA portfolio, we want to honor the history and contributions of The Moran Company and remember the late Donald Moran who founded TMC in July 1998. He spent almost 50 years in the health policy community, including many years in government service, serving as executive associate director for Budget and Legislation at the U.S. Office of Management and Budget during the Reagan Administration.

Many of our TMC colleagues worked with Moran for more than a decade, benefiting from his mentoring and exhaustive knowledge of the industry. Since joining, TMC consultants have worked closely with our HMA colleagues and the Medicare team in particular.

As of July 1, we are retiring the Moran brand and logo and fully integrating the company into HMA as part of the Medicare team. We may be dropping the Moran brand name, but not the approach and diligence for which TMC is well known. In particular, HMA will continue to use the same methodologies for Congressional Budget Office scores and Medicare data analyses that have characterized Moran’s work for more than 25 years.

View some of our recent work from our combined team:

Case Studies

• Appropriate payment for transformative therapies to secure patient access to CAR Ts
• Patient journey analysis for a new oncology drug
• Helping life science manufacturers navigate Medicare payment systems

Reports

• Medicare Physician Fee Schedule Reform
• Analyzing the Expanded Landscape of Value-Based Entities

Webinar

• D-SNP growth and integration – key implications of the 2025 CMS final rule