Hannah Diamond: Welcome everyone. Thank you for joining us for today’s webinar, Dual Eligible Special Needs Plans – What Advocates Need to Know. My name is Hannah Diamond. I’m a senior policy advocate on our health team, and I’m joined by my colleague Samantha Morales, also a senior policy advocate on our health team.
So some logistics before we begin. All participants are on mute. You can use the questions function to ask us questions throughout this webinar. We will try our best to allow for time at the end to answer some questions. And then those that we do not answer today, Sam and I will follow up with you via email. If you’re having problems with getting on the webinar, you can send an email to trainings@justiceinaging.org. And the materials for this training as well as past trainings can be found on our resource library, and the recording for today’s presentation will be posted to our Justice in Aging Vimeo page. And to enable close captioning, you can do so by selecting CC from the Zoom Control Panel.
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Okay, and here is our agenda for today. It’s quite ambitious. We’re going to provide a high level overview of Dual Eligible Special Needs Plans or D-SNPs. Specifically, we’re going to discuss what these plans are, who can enroll, the various categories of D-SNPs and their corresponding levels of integration, and the benefits and coordination requirements that are mandatory for all, and then specific requirements for various categories of D-SNPs. We will also discuss at a high level the impact of H.R.1 or OBBA on people dually eligible, and identify advocacy opportunities for you all to improve integrated care at the state level.
Just some top lines that we wanted to share with you to frame our conversation today. Nearly half of people dually eligible for Medicare and Medicaid receive their care from a dual eligible special needs plan or a D-SNP. Therefore, it’s very important that advocates understand these plans to help individuals make informed decisions about their enrollments, to hold plans accountable to regulatory requirements and to shape policies at the state and federal levels. And we’re going to point out how you can do that as advocates.
Additionally, we want to clearly state that D-SNPs are not for everyone. It’s a very personal decision about whether or not an individual should enroll in a D-SNP. There are specific considerations like health and prescription drug needs, provider networks, prior authorizations and plan offerings, and we’re going to address this question regarding enrollments and some of those considerations throughout the presentation.
So now I’m going to pass it off to my colleague Samantha Morales to walk us through the next section of our presentation.
Samantha Morales: Thank you, Hannah, and thank you all for attending this webinar. So let’s begin our discussion about D-SNPs. As many of you know, Dual Eligible Special Needs Plans or D-SNPs are a type of Medicare Advantage plan specifically designed for people who are dually eligible for Medicare and Medicaid. D-SNPs are intended to address the barriers that dually eligible populations face as a result of having two separate health insurance payers. Medicare and Medicaid were not designed to work together, and this group often reports confusion and barriers to getting needed care. So D-SNPs were intended to address these problems.
So like other Medicare Advantage plans, it is important to remember that D-SNPs are a form of managed healthcare. That means provider networks restrictions for example and utilization management restrictions. Unlike other Medicare Advantage plans, there are some core features that make D-SNPs fundamentally different. So I would like to uplift the core elements that make D-SNPs different from other MA plans.
Number one, enrollment is limited to dually eligible individuals or a subset of this group. States have a lot of power here to limit this further. So for example, states can limit enrollment in D-SNPs to dually eligible individuals who have full Medicaid benefits, also known as Full Duals. The second piece that makes them different is the State Medicaid Agency Contracts or SMACs. Unlike other MA plans, D-SNPs are required to have a SMAC in the state where they operate. So this is where states can really leverage the power with D-SNPs and incorporate more consumer protections, as really the SMAC is a contract between the D-SNP and the state.
Federal requirements for some coordination of Medicaid services also make D-SNPs different than other MA plans. So this again, is unique and unlike other MA plans that do not have to follow this requirement. So when we speak of coordination with Medicaid services, it is important to understand the spectrum of coordination that exists in the D-SNP landscape. So I will be providing more details on this spectrum of coordination as we go through the presentation. Next slide, please. Thank you.
So this is a map of the Medicare coverage options from the Integrated Care Resource Center or ICRC, which is a national initiative of the Centers for Medicare and Medicaid Services, CMS, specifically their Medicare-Medicaid Coordination Office or MMCO. So you can see that D-SNPs are located within the Medicare Advantage Managed Care plan coverage option for people that are eligible for both Medicare and Medicaid benefits. As we will get into later in this presentation, there are some D-SNPs that restrict enrollment to specific populations such as dually eligible individuals with full Medicaid benefits for example. Next slide please.
So here you can see the growth of D-SNPs from a national perspective. So D-SNPs are proliferating across the country with over 5 million people enrolled nationwide. If you work with low-income older adults, you really need to know about D-SNPs because they are growing, and they might be coming to your state if they’re not already in your state already. So these plans were first introduced in 2006 and became permanent options in 2018. So notably, enrollment in D-SNPs have doubled since 2018.
So D-SNPs operate in almost every state as well as DC and Puerto Rico. So there are only five states today who do not have D-SNPs, and those states include Alaska, Illinois, New Hampshire, North Dakota, and Vermont. I will note that Illinois will be offering D-SNP coverage to dually eligible population starting in January of next year.
It is important to uplift this point on demographics. Compared to their Medicare-only counterparts, dually eligible individuals are more likely to have a chronic illness, they are more likely to be admitted to a hospital, and they are more likely to be a person of color. More than half of all dually eligible individuals are people of color, compared with 20% of those who are in Medicare-only. And about one quarter of dually eligible individuals report having five or more chronic conditions. So D-SNPs serve a diverse population, many of whom have high healthcare needs. Next slide please.
In terms of who regulates D-SNPs, both the Centers for Medicare and Medicaid Services, CMS, so the federal government, and the states via the Medicaid agencies regulate D-SNPs. An important point to uplift here is again, the State Medicaid Agency Contract, the SMAC, as this is really the vehicle that states can utilize to impose additional requirements and consumer protections that go beyond the minimum to ensure the needs of dually eligible individuals are met.
So the contracts or SMACs are used to set the criteria for enrollment, plan materials and the level of care coordination between the Medicare and the Medicaid sides that the D-SNPs will be required to offer. So while all D-SNPs enrollees must have Medicare and Medicaid, as I’ve already mentioned states can choose to further limit enrollment to a smaller subset by putting in provisions in their SMACs. So they can limit enrollment, for example, to only dually eligible individuals who require a nursing facility level of care.
On our website, we have several resources available to assist advocates, including a SMAC toolkit that provides template language on various important topics that advocates can use to push for stronger consumer protections in their states. We also have a D-SNPs brief with links to a few SMAC contracts to give you an idea of what SMACs can do. To drive home the point, SMACs have a significant impact in the types of D-SNPs products that are offered in the states. Next slide, please.
Thank you. In this section, we go through who can enroll in a D-SNPs, when people can enroll, and the fundamental choice that all Medicare enrollees have to decide the way they receive their Medicare benefits. Next slide, please. Thank you.
So to recap, Full Duals are people who have Medicare and full Medicaid benefits. Partial Duals are composed of individuals who have Medicare, have a Medicare Savings Program, or MSP, and not full Medicaid benefits. The MSP assists with the Medicare Part B premium. And for folks who are eligible, one of the MSPs called QMB provides assistance with Medicare-related cost sharing, that includes co-insurances, co-payments and deductibles.
So it is important to note that not all D-SNPs allow enrollment of Partial Duals. While federal rules allow enrollment of partial dual eligible individuals in D-SNPs, states can narrow eligibility criteria as I’ve mentioned before. So for example, the more integrated D-SNP products that we will be discussing restrict enrollment to Full Duals. So I will provide, again, more information on enrollment rules later. In this slide. It is important to uplift that dually eligible people may or may not have access to full Medicaid benefits. Next slide please.
In this slide, we want to emphasize the freedom of choice that dually eligible individuals have when it comes to choosing the way they receive their Medicare benefits. So similar to other Medicare enrollees, people who are duals have many options to choose from, and we list some of those options here in this slide. So they can stick with the traditional Medicare fee-for-service program and pick up a standalone Part D plan, or they can decide to enroll in a non-D-SNP Medicare Advantage plan, or they can choose PACE. So even if the state decides to automatically enroll dually eligible people in D-SNPs, duals still have the right to disenroll or opt out, and that’s important to remember. Next slide please.
So people can enroll in D-SNPs in multiple ways. So insurance agents and brokers can market D-SNPs, but there are limits to how insurance agents and brokers directly interact with individuals. And CMS does provide rules on marketing guidance, the dos and don’ts of what agents and brokers can do, how they can communicate with Medicare enrollees. So people can also affirmatively choose to enroll during one of the Medicare enrollment periods.
Individuals may also be enrolled in a D-SNP through a process called default enrollment. In default enrollment, a person is automatically enrolled into a D-SNP when they first become Medicare eligible. And that could be either by turning age 65, or through the receipt of their social security disability benefits, for example, when they meet that 24 month period. But to use this process, D-SNPs must meet certain criteria, quality standards, and have approval from the state and federal government. Default enrollment is not used by every plan or in every state. So there are limits to who is enrolled via default enrollment. And the plan must send at least one notice prior to default enrollment, so individuals always have the right to decline and can choose another path.
There’s also room for advocacy in this space and in states where default enrollment is being contemplated or is already in practice. So advocates can request an additional notice to be mailed before default enrollment takes place so that people have more time to understand what’s happening. Advocates can also ask for stronger continuity of care protections so that newly enrolled individuals do not experience a disruption in care if their previous medical provider, for example, is not in network with their new D-SNP.
I also want to uplift the importance of the State Health Insurance Assistance Programs, the SHIPs, or also they’re called HIICAPs in some states. So the SHIPs are a great resource. They’re also free, they provide free services and they provide objective counseling on Medicare benefits and plan options and can really help people navigate. Next slide please.
So here we have the different periods when dually eligible individuals can enroll and disenroll from a D-SNP. So you all have heard about the Medicare Advantage open enrollment period and the annual election period or fall open enrollment period, so I will not go into more detail there. I would like to bring to your attention that the final Part C and D rule from last year includes two new special enrollment periods that went into effect in January of this year, and these include the monthly SEP for dually eligible individuals and for folks that are enrolled in extra help and a new monthly integrated care SEP.
So starting January 1 of this year, CMS replaced the quarterly SEP with a new monthly SEP specifically for dually eligible individuals and people who only have extra help. So this new monthly SEP allows dually eligible individuals and extra help recipients the ability to switch to a different standalone prescription drug plan or disenroll from a Medicare Advantage plan into original Medicare, and again, pick up a standalone prescription drug plan. It is important to note that while individuals can use this SEP to return to original Medicare and enroll in a Part D standalone prescription drug plan on a monthly basis, the SEP cannot be used to enroll into another Medicare Advantage plan.
So in terms of the new integrated SEP, this also started in January of this year, and it’s meant for full benefit dually eligible individuals so that they can choose to enroll into or switch between integrated D-SNPs on a monthly basis. So this SEP also came out of the Part C and D rule from last year. It’s important to note here that this new SEP is limited and can only be used again, by full benefit dual eligible individuals to enroll into integrated products that aligned enrollment between the Medicare and Medicaid plans.
So at the bottom of this slide, we incorporated links to resources. So for a comprehensive list of SEPs and the scenarios that apply, Medicare.gov provides a good list with explanations. Additionally, we included a link to the Justice in Aging issue brief covering the SEP changes that impact low-income older adults in 2025. Next slide please.
In this section, we will take a deep dive into the different integration levels of the various D-SNPs models. Next slide please.
So when we discuss the levels of integration for D-SNPs, it is imperative to discuss alignment. So here we review important definitions of what constitutes aligned enrollment versus other types of enrollment. So aligned enrollment means that a dually eligible individual is enrolled in a D-SNPs and an affiliated Medicaid Managed Care plan or MMCO. As we state in the first bullet, this alignment between the D-SNPs and the MMCO creates a financial incentive to reduce spending, duplicative services and can even foster more communication between both sides, both entities providing coverage. And exclusively aligned means that enrollment in the D-SNPs is limited to enrollees in aligned enrollment described above, so folks who are in a D-SNPs with a matching MMCO. In terms of unaligned enrollment here, this means the complete opposite of what we just discussed. The individual is enrolled in a D-SNPs without a matching MMCO, or the person may also be in fee for service Medicaid.
So lastly, I would like to uplift the advocacy tip here. So for states that have Medicaid Managed Care, advocates should consider discussing with the state Medicaid agency a SMAC requirement to align or exclusively align enrollment as this will foster the conditions for a much more streamlined integrated health insurance experience for dually eligible individuals. Next slide please.
So to drive home the point on aligned versus unaligned enrollment situations, we have this visual from the Integrated Care Resource Center, ICRC, and the image on the left depicts both the aligned with green arrows and the unaligned situations with red arrows. You can see that alignment is achieved when the D-SNP from company A is matched with the MMCO from company A. So the image on the right depicts complete alignment, where all D-SNP companies on the left are matched with the MMCOs that are under the same parent company on the right. Next slide please.
So here we have the different D-SNP categories and we will discuss how each has varying levels of integration. So the fully integrated or FIDE-SNP offers dually eligible individuals the highest level of integration between the Medicare and Medicaid sides. Because as we list in the slide, FIDE-SNPs must provide almost all Medicaid services to enrollees. Now the highly integrated or HIDE-SNP offers a little less integration than the FIDE in that this D-SNP or its matching MMCO must provide most Medicaid services, but not all.
Now, the Coordination-Only or CO-D-SNPs offer the least integration between the Medicare and Medicaid sides. Now, CO-D-SNPs provide the Medicare services and the Medicaid services are provided by another entity. Now that could be the MMCO that may not be affiliated with the D-SNP, or it could be fee for service Medicaid. Next slide please.
So here, we delve into more detail with the FIDE-SNPs. So FIDE-SNPs offer enrollees coverage of all their Medicare services and almost all of the Medicaid services. FIDEs offer the highest level of integration. So that includes communication materials, appeals and grievances information, and all must be provided in an integrated format at the plan level for the first levels of the appeals processes. So currently, FIDE-SNP enrollments constitutes only 7.8% of all D-SNP enrollments. This means that FIDEs are not the norm across the country.
So starting this year, there are important requirements for FIDE-SNPs. They have to be exclusively aligned, meaning they only allow enrollment to dually eligible individuals who are aligned in a matching MMCO. So they must cover additional Medicaid services such as behavioral health services, home health services, medical equipment, supplies and appliances, and they must cover Medicare cost sharing.
So for folks who would like to review what the D-SNP landscape looks like in your state, we included a link to the CMS SNP data, so you can filter the Excel table for your specific state to see what D-SNPs are offered per county. Next slide please.
So as we discussed previously, HIDE-SNPs offer less integration than FIDE-SNPs in that they provide coverage for most Medicaid services, but not as comprehensively as FIDE. So a few things to uplift about the HIDE-SNPs in this slide. They can carve out behavioral health or long-term services and supports. They can offer Medicaid benefits via the D-SNP or the affiliated MMCO. They are not required to be exclusively aligned unless the state mandates this. They offer a pathway for states to achieve higher levels of integration with the FIDE-SNPs later, for example. So they really build on higher integration levels.
The last note on the slide is important to emphasize. Currently, the majority of D-SNPs are Coordination-Only D-SNPs and do not offer the high level of integration that the FIDEs and HIDE-SNPs offer. Next slide please.
So here, we have Coordination-Only D-SNPs, these plans that offer, again, the most minimal levels of integration. They have fewer requirements than FIDE and HIDE-SNPs and have no clinical or financial involvement on the Medicaid side. Coordination-Only D-SNPs must however provide care coordination of Medicaid services. And this means assisting enrollees to access Medicaid benefits that they’re eligible for, it also means helping enrollees with Medicare and Medicaid appeals and grievances for example. These plans must also notify the state Medicaid agency when certain enrollees who are high-risk are hospitalized or admitted in a nursing facility. Next slide please.
So here we have a visual of the current D-SNP landscape. So this data comes from the ATI Advisory State Data Dashboard. You can see that the majority of D-SNPs available for dually eligible individuals are Coordination-Only D-SNPs. So according to the ATI data, Coordination-Only D-SNPs are about 59% of the D-SNP market compared to FIDE-SNPs which make up about 8%, and HIDE-SNPs which make up an estimated 33% of the market. So as we will discuss with more detail, Coordination D-SNPs offer the most minimal levels of integration. And it is important to note that some states only have Coordination D-SNPs available. Next slide please.
So this is a graph from the Integrated Care Resource Center that depicts the different levels of integration, and really what that means in terms of healthcare coverage for dually eligible individuals. So if we focus our attention in the middle of the graph here, we see that D-SNPs and Medicaid have some interaction compared to the fee-for-service Medicare and other non-D-SNP Medicare Advantage plans.
All D-SNPs are required to provide some coordination of Medicaid services. The FIDE-SNPs and HIDE-SNPs offer the highest levels of integration, and from the graph you can see what that means. They provide all the Medicare coverage and the majority of Medicaid services in the case of the FIDE-SNPs. And in the case of the HIDE-SNPs, as we discussed, these plans must provide the majority of Medicaid services with the possibility of some carve-out benefits such, as the Medicaid long-term care services and supports or the behavioral health benefits. Next slide please.
So there’s one more designation, one more acronym I’m going to cover. It’s called Applicable Integrated Plans or AIPs. And it currently applies to FIDE-SNPs and it can apply to HIDE-SNPs or Coordination-Only D-SNPs. Applicable Integrated Plans or AIPs must implement integrated appeals, which Hannah will discuss later. So AIPs are D-SNPs that operate with exclusively aligned enrollment and cover it least some Medicaid benefits, either through the D-SNP or through an affiliated Medicaid Managed Care plan operated by the same parent company as the D-SNP.
So starting this year, FIDE-SNPs must operate with exclusively aligned enrollment, which means they are AIPs. And in order to be an AIP for HIDE-SNPs, they must have exclusively aligned enrollment, meaning that they will only accept enrollment from individuals also enrolled in a Medicaid Managed Care organization owned and operated by the same parent company as the HIDE-SNP.
Now for Coordination-Only D-SNPs, in order to be Applicable Integrated Plans, AIPs, they must also have exclusively aligned enrollment and cover through the D-SNP or an affiliated Medicaid Managed Care plan, Medicaid primary and acute care benefits, Medicare cost sharing, and at least one of the following Medicaid benefits: home health services, medical supplies, equipment and appliances or nursing facility services.
So our D-SNP Basics Brief, the Appendix B section, goes through each of these categories of FIDE, HIDE-SNPs and Coordination-Only D-SNPs, and also provide a discussion of the AIP status. So for now, I will now turn it over to Hannah, who will begin the discussion on D-SNP requirements.
Hannah Diamond: Thanks so much, Sam. And I know that we just discussed a lot of acronyms, some of which I will repeat in my section, but don’t worry, you have access to this recording after today’s presentation so you can review at your own pace.
So now we’re going to discuss the federal requirements for all D-SNPs. These requirements extend beyond the basic requirements for Medicare Advantage organizations. And as previously noted by Sam, the various categories of D-SNPs that we just discussed, some of those have additional requirements above and beyond these baseline requirements that I’m going to explore on the next few slides.
So all D-SNPs must implement something that’s called an evidence-based model of care. This document demonstrates how the D-SNP is going to tailor its services to the population that it serves. So the model of care outlines how the plan will provide the health services and then coordinate and enroll these Medicare and Medicaid benefits. D-SNPs are required to submit their model of care documents to CMS, the Centers for Medicare and Medicaid Services, as well as the National Committee for Quality Assurance, NCQA, for evaluation and approval.
D-SNPS must also coordinate, not necessarily cover, but coordinate all Medicaid benefits, including Medicaid fee-for-service benefits, to help ensure enrollees can access the healthcare and address their wants and needs. D-SNPs also are expected to assist with grievances and appeals, and we’re going to discuss an integrated appeals process that’s specific to a few categories of D-SNPs later in this presentation. D-SNPS also must screen for housing stability, food security, and transportation needs of members. The results of this assessment are then addressed in each member’s individualized care plan.
And recent rulemaking established that Medicare Advantage organizations offering one or more D-SNPs must establish and maintain one or more Enrollee Advisory Committees, or EACs, to solicit feedback and input from members in the design and delivery of plan offerings. These committees must reflect the plan enrollee population, and plans must solicit member input on a series of things, including improving access to services, coordination of services and health equity for underserved populations.
Communications. So there are no additional communication requirements beyond the Medicare Advantage requirements specific to D-SNPs. That said, many states require D-SNPs to meet additional requirements to assure that materials are accessible and appropriate for the populations that they’re serving. When communications are not integrated, for example, an enrollee’s Medicaid plan might not reference their Medicare offerings and vice versa. This leads to confusion and potentially conflicting information for the enrollee.
So policy levers such as aligned enrollment, what we’re talking about today, can enable streamlined communication, making communication seem like “one plan” as opposed to two separate Medicare and Medicaid offerings. This can look like one list of providers for that individual, or a single drug list that includes both their Part D prescription offerings and also the over-the-counter medications that are covered by the state’s Medicaid plan. So basically integration provides a tool to simplify and streamline communications for the members.
Some tips that we have here to improve communication between plans and members. Sometimes states will have more generous translation requirements for their Medicaid plans than the federal standard for Medicare, meaning that a Medicaid plan must translate materials into more languages than the federal government requires. If this is the case, advocates should use their SMAC, that State Medicaid Agency Contract that Sam talked about earlier, to require D-SNPs to translate their materials into the standard that is most generous. That way the member isn’t receiving communications for their Medicaid benefits in their preferred language, but then when it pertains to their Medicare benefits in English. Ideally, they’ll receive information in their preferred language in an integrated format.
States also should require D-SNPs to test their communications on a subset of members. A great use for this is the Enrollee Advisory Committee, prior to release to their entire member population to ensure intended impact. States can also require plans to submit certain materials specific to marketing and communications to that state for their review and approval prior to member distribution, which gives states greater oversight of plan materials. Additionally, advocates can encourage plans to offer customer service lines to help with answering Medicare and Medicaid questions and improve communication overall.
Okay, the next section, Care Coordination. This is kind of the meat and potatoes of integrated offerings. So as we’ve noted throughout the presentation, D-SNPs are required to coordinate Medicaid services. So all D-SNPs, regardless of type, must develop a comprehensive person-centered care plan known as an individualized care plan for each member, that outlines that individual’s goals and objectives for their care and includes measurable outcomes and specific services and benefits that will be provided.
The D-SNP must utilize an interdisciplinary care team. So this care team has to have demonstrated expertise and training on how to provide care and support to that individual to manage the member’s care and actualize their care plan that we just discussed. D-SNPs also must describe in their model of care documents, so we referenced that earlier, they must describe their transition protocols. So for example, how they’re going to handle nursing facility transitions to coordinate with Medicaid covered services and also maintain continuity of care for enrollees.
Guidance also states that D-SNPs are supposed to help members with maintaining their Medicaid eligibility. This is especially important now in the context of H.R.1 given concerns about loss of benefits. And finally, plans are expected to maintain good data exchange to support care coordination efforts and ensure that members are accessing the care that they need. As previously noted, aligned enrollment can enable more streamlined sharing of data and information about a member’s services, as either one plan or two affiliated entities are administering services. And because they share data systems, that coordination and sharing of data is easier.
Supplemental Benefits. This is a big area, I’ve seen some questions already come in via supplemental benefits. D-SNPs can offer supplemental benefits beyond the benefits that are offered in Medicare Parts A, B and D, also above and beyond Medicaid offerings. So in an attempt to address concerns about access and the utility of supplemental benefits, recent rulemaking has attempted to enhance oversight of supplemental benefits. Specifically, plans must now notify their members mid-year about the benefits they’re likely eligible for but are not using. Plans must document approvals and denials for supplemental benefits. This is really important so that we can understand and identify equity issues. Plans must stabilize supplemental benefit eligibility criteria, meaning that they cannot change the eligibility criteria mid-year. And there are also now new restrictions and how these benefits can be advertised in hopes of improving informed decision making around D-SNP enrollment.
So some tips to improve advocacy in this space. We suggest that states and D-SNPs are publicly posting eligibility criteria for supplemental benefits to make sure that individuals know. It’s also important to advocate for clear information about these benefits, especially in the context of existing Medicare and Medicaid offerings. We have seen at times supplemental benefits duplicating existing benefits that are available to members. They should be adding on top of both Medicare and Medicaid offerings. So it’s really important to make sure that there is no duplication. Instead, they should supplement existing Medicare and Medicaid benefits. And additionally, it’s really important to be gathering data and conducting oversight to see whether or not the plans are abiding by the recent regulatory requirements in this space.
So D-SNPs must conduct something called a health risk assessment, meaning that they must assess each enrollee’s medical, functional, cognitive, psychosocial, mental health needs and social determinants of health needs, including screening for housing, transportation and food needs. And importantly, recent rulemaking requires certain D-SNPs, specifically AIP D-SNPs, to conduct an integrated assessment for both Medicare and Medicaid rather than separate assessments for each program. So the results of this screening will be incorporated into each member’s individualized care plan, and then that plan is expected to use Medicare, Medicaid, supplemental benefits, referrals to community resources and other collaborations and partnerships to meet that member’s holistic health needs.
Appeals Processes. So as we mentioned, plans are expected to help with filing grievances and appeals, and there are some additional requirements for D-SNPs that are AIPs or Applicable Integrated Plans. So just as a reminder, those are FIDE-SNPs, these are HIDE-SNPs operating with exclusively aligned enrollments, and then these are Coordination-Only D-SNPs that are operating with exclusively aligned enrollment and covering some Medicaid offerings.
So at the initial decision that a plan makes and at the first level of appeal, the plan will consider both Medicare and Medicaid criteria in their determinations, and they will send a single notice determination to the member. If the member wants to appeal, then they only have to manage one appeal process as opposed to two separate Medicare and Medicaid processes. Importantly, after this first level, this first level of appeal, the higher levels are no longer required to be integrated, and therefore they will split off into their separate Medicare and Medicaid appeal pathways. Additionally, if a D-SNP is not an AIP, so for example, a Coordination-Only D-SNP that is not operating with exclusively aligned enrollment and not covering Medicaid services, they do not have to offer this integrated appeals process.
And as a tip overall, we would encourage advocates to push for accessible information about plan appeal processes to ensure that members understand the process that is available and can access their rights to appeal decisions.
So now we’re going to discuss the impact of H.R.1 on people dually eligible. So H.R.1, or the One Big Beautiful Bill Act as some people are referring to it or OB3A, this was signed into law on July 4th. It contains nearly a trillion dollars worth of Medicaid cuts that are stemming from changes to Medicaid financing that are really going to shift the burden of costs from the federal government to states. And because states have to balance their budgets, there are concerns about optional benefits, specifically home and community-based services, vision, dental and hearing benefits. The law contains extensive administrative requirements that states will have to implement, which will reduce their capacity overall to focus on integration.
The law also contains significant changes that will impact the Medicaid expansion population, such as work requirements, such as additional eligibility determinations and cost-sharing requirements. And we believe even though people dually eligible are not in the Medicaid expansion population, that people dually eligible could be impacted by these changes. For example, there’s a lot of confusion about what is in this law, there’s a lot of misinformation, and also because this law is so burdensome to implement, it could cost system strain which will impact other populations. Additionally, people dually eligible may use a caregiver or rely on a caregiver that is in the Medicaid expansion population. So if there are negative consequences for them, it could negatively impact people dually eligible.
So we’re uplifting D-SNPs as an opportunity to think about them as a mitigation strategy in relation to H.R.1. And the reason that we’re uplifting them that way is we have such a powerful policy lever via the SMACs at the state level. That said, before I get into some examples, it’s really important for us to state that D-SNPs cannot fill the void that is caused by these Medicaid cuts. It’s really important that in your collective advocacy that yes, you’re considering uplifting D-SNPs as a policy lever, as a mitigation tool, but that you’re also forming coalitions to protect existing Medicaid benefits and expand Medicaid offerings to address gaps in coverage as there is no replacement for investment in HCBS and Medicaid overall.
So some ideas here that we’ve brainstormed and just want to highlight. We’ve talked about, via supplemental benefits, how these plans can offer benefits above and beyond Medicare and Medicaid. So that is something to flag for you as you’re considering mitigation strategies. And also via the SMAC, you can get pretty detailed and robust care coordination requirements that can help to ensure that an individual doesn’t lose their Medicaid benefits, or prevents it to the best extent possible, which is especially important given the changes in H.R.1.
So some advocacy opportunities that we want to flag for you all. First, we just want to acknowledge, like I alluded to in the last slide, the environment that we’re in. We know so many of you were involved in opposing H.R.1 or protecting Medicaid in your state, and now are very involved in mitigation strategies at the state level. So first, it’s important to note that state capacity on behalf of the Medicaid agency is going to be focused on H.R.1, and therefore there might be less focus on integration. Additionally, we just want to state that this is a complicated area of policy, one of the most challenging in health policy arguably, and that it’s important that we’re all learning together, especially in the context of implementing H.R.1. And we also want to acknowledge that depending upon the state, sometimes advocates don’t have an effective method of communicating with their Medicaid agency on integration.
So here are some things that you can do to address some of those concerns that I just stated. First, it’s really important to get up to speed. It’s really important to learn your state’s local D-SNP environments. Each state is very different, various parts of the state differ from one another, so really encourage you to start with learning about what your state’s integration landscape looks like.
It’s also really important to engage your state early and often. So these contracts, these State Medicaid Agency Contracts, they’re finalized in the summer, but actually planning for these contracts starts in the fall. So the fall is a great time to be engaging with your Medicaid agency about SMACs. We also really encourage you to demand to be at the table. When advocates are involved in these conversations and when members are involved in these conversations, it improves the delivery of these plans and their offerings. And we also encourage you to review your state’s SMAC. If it’s not public, that is your first priority with the Medicaid agency, is to get access to your SMAC.
We have some resources for you here that we wanted to outline and highlight. So the first resource, D-SNPs: What Advocates Need to Know, this is our issue brief that covers much of the same content that was included in today’s webinar. We also have an accompanying document that’s a frequently asked questions document. This reflects the questions that we most commonly receive, some of which I’m sure we will cover on today’s webinar during the Q&A section, but encourage you to look there. We also have a principles document that outlines the core values and goals of integration care from Justice in Aging’s perspective.
We also have an integrated care education project, so we run a listserv of advocates nationally that are working on integration. If you are not already a member of that listserv, I encourage you to sign up. We host coalition calls on a quarterly basis. We send out materials specific to integration through that listserv, so encourage you to join. We also have state factsheets that demonstrate the D-SNP landscape in 10 states. And so we would encourage you just to take a look there in hopes that your state is one of those 10 states.
Also, as Sam mentioned, we have a SMAC toolkit. The SMAC toolkit is analyzing publicly available SMACs and uplifting best practices so that you all can take that language to policymakers and try to get that language into your state’s SMAC. So we’ve done toolkits specific to supplemental benefits, marketing and communications, care coordination, and our next toolkit is going to be focused on consumer protections.
And then we have two resources, and I’ve seen some questions about the changes to the special enrollment period. We have some very detailed resources about that as well, so would encourage you to review those two resources that are listed at the bottom of the slide.
And there are some other great resources from partner organizations that we work with. So ICRC, the Integrated Care Resource Center, has a lot of wonderful materials. CMS, the regulatory agency, they release monthly data. It’s very timely about plan offerings in estate and what kind of plan it is, so would encourage you to look there for more information. And then KFF as well has some great resources about people dually eligible and also about D-SNP offerings.
And with that, Sam and I will start to answer some questions. And our email is included on this slide, so please feel free to reach out to us, but we will try to get to as many questions as we can today.
I’ll start us off with the first one. Sam, while you were presenting, someone was asking for a review of a full benefit dual versus a partial benefit dual. Can you go over those definitions again to help us understand?
Samantha Morales: Sure, thank you. So full benefit duals refers to people who both have, again, we’re speaking about the population that’s enrolled in Medicare, which is their primary health insurance coverage of course, and then Medicaid. For full benefit duals, that means folks who have Medicare and full Medicaid benefits. That means the medical, all aspects of the Medicaid program that they are eligible for in their state, the medical portion, everything. So long-term care services, if they meet the criteria for coverage. And that’s unlike Partial Duals who are folks who have Medicare and who may be enrolled in a Medicare Savings Program, but they’re not eligible for the medical portion of the Medicaid program in their state. So that’s what makes them different.
Hannah Diamond: Thank you.
Samantha Morales: Hannah, I do have a question here in the Q&A about D-SNP participants who fall out of the program. And the question really is, is there a way for them to continue with the same Medicare Advantage plan? So essentially the same D-SNP. And I’m happy to take a stab at it, but if you have more that you wanted to expand, I’m also happy to provide that to you as well.
Hannah Diamond: Okay, I’ll start and let’s tag team. So I think that this is a really good question. First of all, let’s talk about maybe why someone is wanting to leave their Medicare Advantage plan or their D-SNP offering. Likely it’s because they can’t access the services that they need. So I think first, I would really emphasize the importance of informed decision-making. So contacting the plan, for example, to find out what level of integration it’s offering. Contacting the plan, not only to look at their provider network, but ask, like I have this really important provider, is this provider covered under this plan? Just making sure that you can access the services and the providers that you need. So doing that vetting on the front end is really important.
And again, the SHIP counselors or the HIICAP counselors that Sam noted earlier are really critical for that process, because they don’t have a bias of wanting to enroll you in a particular plan like a broker. A broker receives an incentive to enroll an individual into a plan. The SHIPs are volunteers, they want what’s best for you. So they can go through those various options with you, so we’d really encourage you to do that. Also, Medicare Plan Finder can help you make this decision. For example, you can put in what prescription drugs you have and it can help you determine whether or not a plan is going to meet your needs. So that’s one thing that I would say.
If the question, and I’m not sure if the question was going in this line of thinking, but I’m going to answer it because it makes me think that way, but for example, what if someone loses their Medicaid coverage and then they’re no longer a dual eligible? What can we do there? And there are some protections that we can advocate for. There’s something called deeming. Deeming can be up to six months, for example, with the understanding and the reason why deeming exists. Someone can maintain their enrollment in a D-SNP and continue to receive D-SNP offerings. And it’s with the understanding that oftentimes people are losing access to their Medicaid benefits, not because they’re not eligible, but because of procedural reasons.
So deeming periods, if they’re written into SMACs, provide that protection to allow individuals to stay enrolled while they are figuring out any concerns regarding their Medicaid coverage, for example.
Sam, are there other things you would add there?
Samantha Morales: No, exactly the deeming part was what I was going to build on. But I think you covered it, Hannah. Thank you.
Hannah Diamond: We had a really interesting question that I saw earlier regarding the benefits, or asking for comment on limiting enrollment to particular populations. For example, limiting enrollment of partial dual-eligibles into D-SNPs. I think that from Justice in Aging’s perspective, we are still watching this space. When it comes to Partial Duals, they do not have Medicaid benefits to coordinate. But at the same time, individuals can access supplemental benefits via these plans, and so those supplemental benefits might benefit a partial dual.
So this is an area where we really want to hear from you all about how you’re seeing D-SNPs provide care and kind of the utility of D-SNPs for Partial Duals.
Samantha Morales: Yeah, and can I add something there, Hannah? I think that is a very interesting question and it gets to a lot of what we have been discussing during this presentation. And it’s again, a reminder that dually eligible individuals like all Medicare enrollees have a choice in the way they receive their Medicare benefits. So all Medicare enrollees, especially during follow-up and enrollment, have to consider their healthcare needs and their prescription medication needs. So if those supplemental benefits are worth getting into a plan that has restrictive provider networks and also networks for pharmacies for example, it’s important for people to consider that. So as Hannah said, it’s a very individual choice and that’s why there are SHIP counselors and other resources that are available to help people navigate those decisions.
Hannah Diamond: Sam, another question that I saw when you were talking about default enrollments, can you remind us of the fact that when it comes to Medicare offerings, individuals always have choice? So even if someone is default enrolled, what their options are regarding default enrollments, maybe when it happens, and then just a reminder of an individual’s options for Medicare offerings.
Samantha Morales: Thank you so much for raising that. Another, I think, important question. So yes, even though a state can impose default enrollment, even though they write it in their SMAC for example, again, dually eligible individuals have a choice, just like all Medicare enrollees, to decide that they do not want to be enrolled in the D-SNP plan. And so the plans have to, they’re required, by federal regulations they are required to provide notices to individuals who are going to be default enrolled so that people have sufficient time to make a decision and to decide what type of Medicare coverage to go into.
So part of the consumer protections that advocates can really ask for with their state Medicaid agency is to make sure that they can go beyond, states can go beyond that required minimum notice of just one notice and ask for more notices to go out to eligible individuals for example, before they are default enrolled. So people have more information, more time to make a decision. And in terms of the choices that people have, they can definitely go back, they can go to original Medicare and stick with their Medicaid coverage separately and pick up a standalone Part D plan. They can go into PACE in their state, or they can go into a different type of non-D-SNP Medicare Advantage plan.
So it all depends again on the person’s individual needs. They should consider their providers, whether their providers are going to be in-network or not, and their prescription medication needs as well.
Hannah Diamond: And we are over time, but there’s one question that I saw that I just have to answer. Where can SMACs be found? So not all SMACs are publicly available. So that’s the first thing. In our resources slide, we linked to a resource that is the equivalent of this webinar, so it’s D-SNPs: What Advocates Need to Know. Within that issue brief, we have provided links to all of the publicly available SMACs. So check out that document as a starting point. And if you can’t find your state there, you go and you ask your state Medicaid agency and that’s a great first opportunity to start working on integration in your state and to get engaged.
So with that, thank you all so much for joining us this afternoon. We so appreciate it. Recording will be posted on Vimeo and Sam and I will answer any questions that we didn’t get to today. Thank you so much.
