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Consumer Protections – Member Rights – Justice in Aging

Consumer Protections – Member Rights – Justice in Aging

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This toolkit provides policymakers, including State Medicaid Agency staff, and advocates, with principles and corresponding template language to develop State Medicaid Agency Contracts (SMACs) that are responsive to the needs of the dually eligible populations they serve. Stakeholders are encouraged to use this tool to advance their priorities by tailoring the components that are most appropriate for their state’s integrated environments.

Parts IV and V of the toolkit provide a robust discussion on consumer protections within D-SNPs, including Member Engagement and Support (e.g., Enrollee Advisory Committees and Ombuds Programs), and Member Rights (e.g., Maintaining Coverage and Appeals and Grievances). Part I of this toolkit covers Eligibility and Enrollment as well as Supplemental Benefits, Part II of this toolkit focuses on Marketing and Communications, and Part III of this toolkit encompasses Care Coordination.

Drawing from Justice in Aging’s D-SNP Issue Brief, we center the experiences of dually eligible enrollees and highlight the challenges faced by this population in navigating their health insurance coverage. To guide the discussion, we reference the Justice in Aging Guiding Principles, a core set of values and goals that call for robust consumer protections, health equity, person-centered care, and more oversight and accountability in integration models. Justice in Aging will release subsequent sections of this toolkit in 2026.

This publication highlights best practices drawn from D-SNP model contracts and Financial Alignment model contracts. For this tool, in instances where existing SMAC language is not publicly available or has not yet been written, Justice in Aging provides suggested template language to help advance key consumer protections and principles.

Maintaining Coverage and Access to Services and Providers

Both deeming and continuity of care protections serve as important strategies to enable enrollees to maintain coverage and access to services and providers.

Deeming Protections

Cycling in and out of Medicaid enrollment or “Medicaid churn” remains a major obstacle to maintaining access to care for people dually eligible. Research demonstrates that people dually eligible most commonly lose Medicaid coverage for administrative reasons rather than changes in financial or categorical eligibility for state Medicaid programs.[1] Medicaid churn can cause enrollees to lose eligibility resulting in their disenrollment from one D-SNP to enrollment in another. To mitigate Medicaid churn and support people dually eligible in retaining their providers and benefits without interruptions during disruptions and transitions, states can leverage SMACs to ensure D-SNPs provide deeming protections.

The Impact of the Budget Reconciliation Act of 2025 (H.R. 1)

The Budget Reconciliation Act of 2025 or H.R. 1 will likely exacerbate Medicaid churn among the dually eligible population. For example, the law halts the Streamlining Medicaid Eligibility & Enrollment Rules for ten years. This will make it harder for older adults to get and maintain Medicaid coverage by allowing states to maintain bureaucratic requirements, such as complex income verification paperwork and frequent renewals that currently prevent eligible people from gaining and maintaining coverage. Older adults who rely on Medicaid to help pay their Medicare premiums and cost-sharing through Medicare Savings Programs will also continue to face this red tape, putting millions at risk of losing critical financial help that makes Medicare affordable.[2] While additional eligibility verifications and work requirement provisions within the law exclude people dually eligible, confusion, misinformation, and system strain may cause eligible individuals to inappropriately lose coverage. In the context of H.R. 1, SMACs are an important tool for states to leverage to secure continuity of care and deeming protections for dually eligible individuals. For more information on the impacts of H.R. 1 on dually eligible individuals, see the Justice in Aging Medicaid Defense series.

Guiding Principle

Integrated models provide robust consumer protections.

Supporting Principle

Integrated models utilize policy levers to minimize disruptions in care.

Federal Requirements

Deeming periods allow D-SNP enrollees to stay enrolled with access to plan benefits and care managements during lapses in Medicaid coverage for a determined period. According to 42 CFR 422.52(d), CMS allows D-SNPs to provide deeming periods from a minimum of 30 days to six months for dually eligible individuals who lose enrollment but are expected to meet the eligibility criteria for Medicaid within a six-month period.

When D-SNPs provide a deeming period, they are required to apply the policy consistently and inform all enrollees. Plans must also provide written notice to enrollees regarding their loss of special needs status within 10 calendar days of learning about the enrollee’s loss of status. If D-SNPs make changes to the deeming policy mid-year, they must follow notification requirements outlined in 42 CFR 422.111(d) and 422.2267(e)(9). According to 42 CFR 422.74, D-SNPs are required to disenroll enrollees who do not reestablish their eligibility within the designated deeming period and provide a minimum of 30 days’ advance notice of disenrollment.

While D-SNPs must provide Medicare related benefits including plan supplemental benefits during the deeming period, plans are not required to provide coverage of Medicaid related benefits.[3] As a result, when members experience a Medicaid eligibility lapse, they may incur cost-sharing for care received during the deeming period.

SMAC Recommendation

States should require D-SNPs to offer deeming protections for six months to prevent plan disenrollment due to temporary loss of Medicaid eligibility.

Template Language

California and North Dakota

To ensure that members retain their D-SNP coverage during temporary lapses in Medicaid coverage, California and North Dakota both require D-SNPs to provide deeming protections for at least three months.

  • For those members who have lost Medicaid eligibility, the D-SNP Contractor is required to maintain enrollment for such members for at least a three-month deeming period following notification that the member lost Medicaid eligibility. This requirement does not preclude the D-SNP Contractor from offering a longer deeming period. The D-SNP Contractor should inform its State Medicaid Agency staff contact of the deeming period that it will provide.[4]
  • As allowed by CMS guidance, MAO shall provide deemed continued eligibility for a minimum three (3) months to maintain the continuity of care of individuals that no longer meet D-SNP eligibility criteria due to a temporary loss of Medicaid eligibility.[5]
Virginia, Indiana, and Pennsylvania

To help members retain their D-SNP coverage during periods of temporary loss of Medicaid coverage, these three states require D-SNPs to offer deeming protections for six months.

Additional SMAC Language

The Contractor shall provide all applicable covered benefits, including Medicaid services, at no additional cost to the enrollee, for the duration of the deeming period. The Contractor will be financially responsible for payment of Medicaid-covered services during the deeming period in order to ensure continuity of coverage and to prevent cost-sharing by the enrollee.[9]

Continuity of Care Protections

People dually eligible often rely on long-standing relationships with primary care, specialty, and durable medical equipment providers, and many are recipients of complex treatments and drug regimens. A transition to a new plan, which may involve changes in provider networks or service coverage, can create serious disruptions in care.

To limit these risks, contract language can be leveraged to safeguard continuity of care through two key protections. First, enrollees should maintain access to existing services and prescription drugs during a defined transition period after enrollment in a D-SNP. Second, enrollees should be able to continue seeing their current providers who are not yet in the plan’s network. D-SNPs must have mechanisms to pay non-network providers during this period and actively work to bring them into the network. If those efforts are unsuccessful, a clear process should allow enrollees to secure approval to continue care with their trusted providers.

Guiding Principle

Integrated models provide robust consumer protections.

Supporting Principle

Integrated models utilize policy levers to minimize disruptions in care.

Federal Requirements

In addition to ensuring access to basic benefits to all enrollees outlined in 42 CFR 422.101, D-SNPs must also abide by the continuity of care requirements in 42 CFR 422.112(b). These requirements include plan approval of prior authorization requests for enrollees undergoing a course of treatment for as long as the treatment is medically necessary, and a 90-day minimum transition period for any active course(s) of treatment when an enrollee has enrolled in a plan after starting a course of treatment, even if the service is furnished by an out-of-network provider.[10]

Additionally, for Part D covered medications, plans must provide enrollees with a temporary transition refill for the first 90 days of the plan year beginning on the enrollee’s first effective date of coverage.[11] Per 42 CFR 422.100(l)(2)(iii), plans must also ensure a 90-day transition period for durable medical equipment (DME) where enrollees are guaranteed the supply and repairs of their DME.

SMAC Recommendation

States can and should implement robust continuity of care protections that go above and beyond the federal minimum. For example, states should implement a 12-month period of transition, from the effective date of the enrollment, requiring D-SNPs to cover out-of-network primary care providers, specialists, DME providers, long-term services and supports, and pharmacies.

To ensure enrollees understand and are fully informed of their continuity of care protections, states should also require plans to provide the plan continuity of care policies in the member handbook and other member notices that meet language and accessibility formats.[12] Additionally, states should require D-SNPs to assign a Primary Care Manager to support enrollees with accessing continuity of care protections.[13]

Additionally, when a new enrollee joins a plan, states should require plans to proactively engage and encourage their non-network providers to join the plan’s network in order to reduce disruptions in care. States should also require plans to consider continuity of care objectives before reducing service access.

Template Language

California

California requires D-SNPs to provide a 12-month continuity of care period from the date of enrollment for primary care providers and specialists with existing relationships with enrollees. Additionally, the state requires plans to ensure enrollees have access to their DME items, supplies, and providers, for more than a 90-day period, and until the plan is able to assess and provide the enrollee with the DME supply or item by an in-network provider.[14]

  • D-SNP Contractor must provide Members with the following:
    1. A 12-month continuity of care period from the date of the Member’s Enrollment in the D-SNP, for primary and specialty providers with whom the Member has a pre-existing relationship and who are willing to work with the D-SNP Contractor; and
    2. Access to Medically Necessary Medicare-covered Durable Medical Equipment and medical supplies.[15]

California requires D-SNPs to accept continuity of care requests from enrollees, authorized representatives, and providers who are eligible for continuity of care. Additionally, the state requires plans to accept continuity of care requests via telephone and according to enrollee preferences and cannot obligate requester to submit requests via paper or electronic form. D-SNPs are also required to accept retroactive continuity of care requests and pay claims accordingly.

  • Members, their authorized representatives, or their providers may make a direct request to a D-SNP for continuity of care.
  • D-SNPs must, at a minimum, accept requests for continuity of care over the telephone, according to the requestor’s preference, and must not require the requester to complete and submit a paper or computer form.
  • D-SNPs must accept and approve retroactive requests for continuity of care and pay claims that meet all continuity of care requirements noted above, with the exception of the requirement to abide by the D-SNP’s utilization management policies.[16]
Massachusetts

To maintain continuity of care for new enrollees, Massachusetts proactively engages with non-network providers to encourage them to become credentialed.

  • The Contractor shall ensure that best efforts are made to contact and contract with non-network providers, including, within the first ninety (90) days of an Enrollee’s Membership in the Contractor’s D-SNP, such providers and prescribers which are providing services to Enrollees during the initial continuity of care period, and provide them with information on becoming credentialed, in-Network Providers. If the provider does not join the network, or if the Enrollee does not select a new in-Network Provider by the end of the ninety (90) day period or after the Individualized Care Plan is developed, the Contractor shall choose one for the Enrollee.[17]

When evaluating LTSS requests, Massachusetts requires plans to consider continuity of care objectives.

  • In evaluating requests for LTSS, the Contractor shall consider continuity of care. If a service, level of service, or equipment has been part of the Enrollee’s life routine over an extended period and is integral to their overall care and independence structure, any denial or reduction in amount, duration, frequency, or scope of that service/equipment/supply must be supported in the ICP to ensure that such changes will not cause diminished ability for independent living and be consistent with the overall goals and needs of the enrollee as expressed in the ICP.[18]

Appeals and Grievances

For people dually eligible and their caregivers, navigating the bifurcated Medicare and Medicaid appeals and grievances processes adds undue stress and confusion, often impeding timely access to care. While integrated models provide some promise with streamlining and simplifying these processes, more oversight is needed to ensure that D-SNPs are not just automatically denying coverage for medically necessary care. Recent data has revealed a concerning trend of high rates of denials of coverage and prior authorization in Medicare Advantage (MA).[19] In order for people dually eligible to access the medically necessary care they need when they need it, D-SNPs should include robust consumer protections and transparency requirements to ensure claims are processed timely and fairly adjudicated.

Integrated Appeals and Grievances Processes

Guiding Principle

Integrated models improve access to care and member experience across the diverse dually eligible population.

Supporting Principle

Members can access their Medicare and Medicaid benefits without delay.

Federal Requirement

MA organizations must follow the federal regulations covering health care and drug related appeals or organization determinations outlined in 42 CFR 422.566 and §423.566. Additionally, MA plans must follow requirements for health care and medication related grievances outlined in 42 CFR 422.564 and §423.564. Per 42 CFR §§ 422.629-634, D-SNPs that operate as applicable integrated plans such as FIDE SNPs, HIDE SNPs, and CO D-SNPs that meet specific requirements, are required to integrate their appeals and grievances processes. This includes providing eligible enrollees who file appeals timely with a continuation of benefits at the first level of appeal while the integrated plan reconsideration is pending.[20] While 42 CFR 422.629(g) requires D-SNPs with integrated appeals and grievances to provide written acknowledgement of receipt of a grievance or appeal, the regulation does not provide set timeframes. Since most D-SNPs are not required to integrate their appeals and grievance processes, the SMAC can serve as a tool to push for enhanced integration.

SMAC Recommendations

States should require all D-SNPs to share appeals and grievances plan level data related to Medicare Part C, D, and where applicable, Medicaid services. States should also work to make this data publicly available to ensure transparency and accountability. Additionally, for D-SNPs not required to integrate their appeals and grievances processes, states can require plans to provide both Medicare and Medicaid appeals and grievances information in the enrollee handbook and other consumer materials.[21]

For D-SNPs with integrated appeals and grievances processes, states should go beyond the federal minimum and require plans to integrate the appeals processes at all levels.[22] Similar to the New York state integrated appeals and grievances model profiled in this toolkit, states can require integrated appeals processes to proceed as follows: if the plan upholds its decision, the appeal would be automatically forwarded to the second level of the appeal through the state office of administrative hearings. Enrollees who disagree with the decision, would be able to appeal to the Medicare Appeals Council and finally the Federal District Court. Each level of appeal would adjudicate both Medicare and Medicaid appeals.[23]

Additionally, states should require D-SNPs with integrated processes to incorporate Part D in integrated appeal and grievance efforts to ensure enrollees who need access to prescription medications can utilize a streamlined process to resolve denials of coverage and utilization management restrictions timely. Under an integrated appeals and grievance process that incorporates Part D, enrollees would initiate one streamlined medication appeal or grievance process, and the responsibility would fall on the D-SNP to address whether the medication is under Part D or Medicaid coverage.

For eligible enrollees, D-SNPs with integrated appeals and grievances processes should be required to provide the continuation of benefits pending the appeal at all levels of the appeals process and allow enrollees to continue receiving coverage for the medical service or item being denied while the appeal is pending.[24] If the plan’s decision is upheld, the SMAC should specify that enrollees will not be held liable for the costs of services received pending the appeal decision.

In addition to requiring D-SNPs to integrate plan appeals and grievances materials at all levels and ensure these meet the language and accessibility requirements outlined in the Justice in Aging Marketing Communications SMAC toolkit, states should work with plans to ensure integrated appeal notices are uniformly timed with scheduled state hearings when applicable. States should also specify the timeframes of when plans are required to provide enrollees with written acknowledgement of the grievance or appeal.[25]

Template Language

Ohio

Ohio requires D-SNPs to report on grievances and appeals data and submit an analysis of trends and any actions taken by the plan. In addition, the state requires plans to report encounter data on Medicare and Medicaid services for dually eligible members.

  • The D-SNP must submit appeal and grievance activity at least monthly in an electronic data file format pursuant to the State Appeal and Grievance file submission specifications stipulated in this contract.
  • As part of the D-SNP’s report submission, the plan must include the analysis of individual and aggregate outliers and trends and identify the plan’s actions taken in response.[26]
  • The D-SNP must collect data on services furnished to members through a claims system and must report encounter data to the state. For dual benefit members, the data must include both Medicare and Medicaid services. The D-SNP must submit encounter data electronically to the state as specified in this contract.[27]
  • The D-SNP must conduct root cause analysis of authorization denials and appeals and develop a targeted plan to decrease inappropriate denials and ensure ease of appeal of medical necessity denials.[28]
New York

The New York Integrated Appeals and Grievances Demonstration requires participating D-SNPs to integrate their appeals and grievances processes and provide the continuation of benefits pending an appeal at all levels.[29]

  • Participating D-SNPs will apply the integrated grievance process described in 42 CFR § 422.630 to all plan-level grievances, whether relating to Medicare or to Medicaid.
  • The plans will also apply the integrated coverage determination and reconsideration process described at 42 CFR § 422.629 and §§ 422.631 through 422.634.
  • For appeals subsequent to the plan level, a streamlined post-plan process will replace the separate Medicare and Medicaid processes. This process will ensure all protections in statute, regulation, and regulatory guidance for both Medicare and Medicaid appeals processes.
  • Continuation of benefits for all prior-approved Medicare and Medicaid benefits that are terminated or modified, pending internal participating plan appeals, second level appeals at Office of Administrative Hearings (OAH), and third level appeals at Medicare Appeals Council must be provided if the original appeal is requested to the participating plan within ten (10) calendar days of the notice’s postmark date (of the decision that is being appealed) or by the intended effective date of the Action, whichever is later.
  • In the case of an appeal to the Medicare Appeals Council, the member must have received continuation of benefits during earlier level of appeals and file the appeal with OAH within ten (10) calendar days of the OAH decision in order to receive continuation of benefits during the appeal to the Medicare Appeals Council. If the participating plan’s action is upheld, the member shall not be liable for the cost of any continued benefits.
California

For D-SNPs required to integrate their appeals and grievances processes, California mandates that plans have procedures to ensure compliance with the acknowledgement of grievances, and the resolution of appeals, within the required timeframes. Additionally, the state requires plans to establish procedures to inform enrollees of their fair hearing rights.

Additional SMAC Language

The state will share information (e.g., Administrative Hearing Contacts, updates about fair hearing scheduling and/or delays, consumer written materials about how to request a fair hearing, etc.) with the D-SNP Contractor about the state hearing procedures. The D-SNP Contractor is responsible for aligning integrated appeal notices to ensure enrollees are provided timely notification about their fair hearing rights for Medicaid state plan covered services and overlapping Medicare and Medicaid services.[31]

More on Continuation of Benefits

The regular Medicare Advantage appeals process does not include a requirement for plans to provide the continuation of benefits while an appeal is pending (also known as “aid continuing” or “aid pending”).[32] D-SNPs with integrated appeals and grievances processes are different. Per 42 CFR 422.632, these D-SNPs are required to provide the continuation of benefits at the plan reconsideration level while the appeal is pending to eligible enrollees who meet the criteria outlined in 42 CFR 422.632(b). While D-SNPs may not pursue recovery for costs of services furnished pending the integrated reconsideration, plans may recover costs for Medicaid services after the integrated reconsideration decision is final.[33]

Appeals and Grievances: Comprehensive Consumer Assistance

Guiding Principle

Integrated models improve access to care and member experience across the diverse dual eligible population.

Supporting Principle

Members can access their Medicare and Medicaid benefits without delay.

Federal Requirement

Per 42 CFR 422.562(a)(5), all D-SNPs are required to assist enrollees in accessing Medicaid benefits and resolving grievances. This includes providing enrollees with reasonable assistance in navigating Medicaid appeals and grievances. Plans with integrated appeals and grievances processes must take additional steps to satisfy this requirement.[34] CMS allows plans to provide assistance in multiple ways including referring enrollees to outside experts such as Ombuds Programs, State Health Insurance Assistance Programs (SHIPs), and others.[35] As Medicare Advantage plans, D-SNPs are required to operate a call center that adheres to the standards outlined in 42 CFR §§ 422.111(h)(1) and 423.128(d)(1).

SMAC Recommendations

States should require D-SNPs to incorporate assistance with accessing Medicare and Medicaid covered services, including carved out and supplemental benefits, as a care coordination responsibility assigned to a specific role such as a Care Manager. The assistance provided by the Care Manager would encompass helping enrollees with navigating the Medicare and Medicaid grievances and appeals processes, whether these processes are integrated or not.[36]

In addition to requiring plans to adhere to the accessibility and language regulations outlined in the Justice in Aging Marketing and Communications SMAC Toolkit, states should require plans to include the contact information of the State and Federal Ombuds Programs and the State Health Insurance Assistance Programs (SHIPs) in all appeal notices.

Template Language

Washington

Washington requires D-SNPs to develop policies and trainings for plan personnel to assist enrollees with Medicare and Medicaid appeals and grievances processes. The state also requires plans to create procedures to work with behavioral health Ombuds in the state and outline how plans will access services from the state and federal Ombuds programs. The state also requires D-SNPs to create a referral mechanism for grievances related to behavioral health services.[37]

  • The Contractor will develop policies and procedures around assisting members in accessing grievance and appeal systems for both Medicare and Medicaid. These shall be provided to the state upon request.
  • Trainings should clearly outline how to assist members with accessing grievance systems.
  • The Contractor will coordinate with all contracted D-SNPs and behavioral health services organizations (BHSO) in the state to develop contact names and a referral process to be used by their Grievance and Appeals teams for directing members and providers for grievances referring behavioral health to the appropriate resources. The referral must include steps for a warm handoff as necessary to ensure prompt review. The Contractor shall prepare and provide a report upon request of all grievances that were received and referred to the BHSO.
  • The Contractor process must include how to access state and federal ombuds services.
  • Where the member is aligned for Behavioral and Physical Health services the Contractor shall track and report all grievances for dual eligible members. This report shall be made available upon request.
Massachusetts

Massachusetts requires D-SNPs to operate a call center helpline specific to “Coverage Determinations and Appeals.” Unlike other plan customer service lines, the SMAC specifies that the Coverage Determinations and Appeals helpline will have trained plan representatives available to discuss Medicare and Medicaid appeal issues and take coverage determination and redetermination requests for both programs.[38]

  • The Contractor shall operate a toll-free call center with live customer service representatives available to respond to providers or enrollees for information related to requests for coverage under Medicare or Medicaid, and Medicare and Medicaid Appeals (including requests for Medicare exceptions and prior authorizations).
  • The Contractor shall provide, via its toll-free call centers, opportunities for enrollees to request for Medicare and Medicaid covered benefits and services, including Medicare coverage determinations and redeterminations.

As part of the requirements for disseminating “Marketing, Outreach and Enrollee Communications Materials,” Massachusetts mandates that D-SNPs provide enrollees with information about how they can access assistance with filing appeals and grievances, the continuation of benefits during appeals, and how to identify representatives to receive written notices regarding denials, terminations or reductions in services.[39]

  • How to file grievances and internal and external appeals, including:
    • Grievance, appeal, and fair hearing procedures and timeframes;
    • Toll free numbers that the enrollee can use to file a grievance or an appeal by phone;
    • How to access assistance in the filing process;
    • The right to file a grievance directly with the State, how to do so, and the State contact information; and
    • A statement that if the enrollee files an appeal or request for state fair hearing within the timeframes specified for filing and when requested by the enrollee, benefits will continue at the plan level for all benefits;
    • How the enrollee can identify who the enrollee wants to receive written notices of denials, terminations, and reductions;
    • How to obtain assistance with the appeals processes through the Enrollee Services Representatives (ESR) and other assistance mechanisms as the State may identify, including an Ombuds;

Massachusetts requires D-SNPs to put in place a mechanism to accept grievances and appeals filed orally.[40]

  • Accept grievances filed either orally or in writing; and
  • Accept internal appeals filed either orally or in writing within 60 calendar days from the notice of Adverse Action specified in this contract provided that if an internal appeal is filed orally, the Contractor shall not require the enrollee to submit a written, signed internal appeal form subsequent to the enrollee’s oral request for an appeal. Internal appeals filed later than 60 days from the notice of adverse action may be rejected as untimely.
  • The Contractor shall send a written acknowledgement of the receipt of any grievance or internal appeal to enrollees and, if an appeals representative filed the grievance or internal appeal, to the appeals representative and the enrollee within one business day of receipt by the Contractor.
Additional SMAC Language

To ensure compliance with regulations at 42 CFR §§ 422.562(a)(5) and 422.629(e), the D-SNP Contractor will assign to the Care Manager role the responsibility to provide members with reasonable assistance with Medicare and Medicaid appeals and grievances including for carved out benefits. If the member accepts the assistance, the Care Manager should assist the member as needed, such as identifying and reaching out to a Medicaid fee-for-service point of contact, providing assistance in filing an appeal or grievance, helping to obtain documentation to support a request for Medicaid appeal or grievance, or completing paperwork that may be needed in filing an appeal or grievance.[41]

Endnotes

  1. For a broader discussion on Medicaid churn and the dually eligible population, see Lakhmani, Erin Weir et al., “Preventing and Addressing Unnecessary Medicaid Eligibility Churn Among Dually Eligible Individuals: Opportunities for States,” Integrated Care Resource Center (March 2022) (Accessed September 4, 2025). ↑

  2. An Act to provide for reconciliation pursuant to title II of H. Con. Res. 14, Pub. L. No. 119-21, §§71101, 71102, 44101 (2025) [“H.R. 1”]. ↑

  3. CMS, “Guidance on Medicaid Unwinding for Impacted Enrollees,” (June 7, 2023) (Accessed September 5, 2025); see also CMS, “Chapter 2-Medicare Advantage Enrollment and Disenrollment,” section 50.2.5 (Rev. August 15, 2023) (Accessed September 5, 2025). ↑

  4. CA Department of Health Care Services (DHCS), Boilerplate 2026 SMAC EAE D-SNP, pg. 14. See also DHCS, Deeming Fact Sheet: In California, Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) are required to maintain D-SNP enrollment for members who have lost Medi-Cal eligibility for a minimum deeming period of three months. This policy ensures that members retain their D-SNP coverage during temporary lapses in Medi-Cal eligibility, allowing time to reestablish Medi-Cal eligibility without losing access to essential Medicare services. D-SNPs may provide a deeming period of three to six months. ↑

  5. North Dakota Department of Health and Human Services, 2025 SMAC Between the State of North Dakota, Department of Health and Human Services, Medical Services Division and Medicare Advantage Organization, pg. 12. ↑

  6. Commonwealth of Virginia Department of Medicare Assistance, D-SNP 2025 Contract. ↑

  7. Indiana Medicaid, Indiana 2024 SMAC, p. 17. ↑

  8. Pennsylvania Department of Human Services, 2025 MIPPA Contract, p. 4. ↑

  9. To encourage D-SNPs to cover Medicaid services during deeming periods, see retroactive coverage suggestions contained in ICRC, Preventing and Addressing Unnecessary Medicaid Eligibility Churn Amongst Dually Eligible Individuals: Opportunities for States, March 2022. ↑

  10. 42 CFR 422.112(b)(8) ↑

  11. See CMS, “Medicare Prescription Drug Benefit Manual chapter 6,” §30.4.4 (Rev. January 15, 2016) (Accessed October 4, 2025). ↑

  12. For a robust discussion of language and accessibility requirements for SMACs, see “Language and Accessibility” in Justice in Aging, “Marketing and Communications for D-SNP State Medicaid Agency Contracts,” (May 5, 2025). ↑

  13. For a robust discussion of the role of the Primary Care Manager, see Justice in Aging, “Care Coordination for D-SNP State Medicaid Agency Contracts,” (August 19, 2025). ↑

  14. California Department of Health Care Services, “CALAIM Dual Eligible Special Needs Plans Policy Guide,” pp. 45 – 50 (2025) (Accessed October 4, 2025). ↑

  15. California Department of Health Care Services, “Boilerplate 2025 SMAC Exclusively Aligned Enrollment D-SNP,” Exhibit A, Attachment 1 at 12, (2025) (Accessed October 4, 2025). ↑

  16. DHCS, supra note 14, at 47. ↑

  17. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” p. 144. ↑

  18. Ibid p. 210. ↑

  19. HHS, Office of Inspector General, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care,” (April 2022) (Accessed August 6, 2025); see also Biniek, Jeannie Fuglesten, et al., “Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023,” Kaiser Family Foundation, (January 28, 2025) (Accessed August 6, 2025). ↑

  20. 42 CFR 422.632 ↑

  21. For a robust discussion on integrated materials and processes, see Justice in Aging, “D-SNP SMAC Template Toolkit: Marketing and Communications,” (May 5, 2025). ↑

  22. This language was adapted from Shyken-Rothbart, Beth and Derek Ayeh, “Integrated Appeals are Essential, But Challenges Remain,” Health Affairs (September 19, 2022) (Accessed August 11, 2025). ↑

  23. This language was adapted from the description of the New York State Integrated Appeals and Grievances Demonstration as outlined in Snow, Kimberly I., et al., “Financial Alignment Initiative New York Integrated Appeals and Grievances Demonstration First Brief Report,” at ES-1 (March 2022) (Accessed August 20, 2025). ↑

  24. Shyken-Rothbart, Beth and Derek Ayeh, supra note 22. ↑

  25. This language was adapted from the challenges of the New York State Integrated Appeals and Grievances Demonstration as outlined in Snow, Kimberly I., et al., supra note 23, at §3.2.2. ↑

  26. This language was adapted from Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Appendix A, p. 56, (Accessed August 13, 2025). Not available online. ↑

  27. Id. at 296. ↑

  28. Id. at 122. ↑

  29. CMS, “Memorandum of Understanding between the Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health to Operate Integrated Grievance and Appeals Processes for Certain Integrated Medicare and Medicaid Plans,” (Accessed August 13, 2025). ↑

  30. California Department of Health Care Services (DHCS), “Boilerplate 2026 SMAC Exclusively Aligned Enrollment D-SNP,” Exhibit A, Attachment 1 at 18-19, (Accessed August 14, 2025). ↑

  31. See Snow, et al., supra note 25. ↑

  32. 42 CFR 422.566; see also CMS, “Parts C & D Enrollees Grievances, Organization/Coverage Determinations, and Appeals Guidance,” (Effective date November 18, 2024) (Accessed September 2, 2025). ↑

  33. 42 CFR 422.632(d); for a review of the Medicaid continuation of benefits regulations, see 42 CFR 438.420(d); and Medicaid and CHIP Payment and Access Commission, “Chapter 2: Denials and Appeals in Medicaid Managed Care,” p. 27 (March 2024) (Accessed September 3, 2025). ↑

  34. 42 CFR 422.629(e). ↑

  35. CMS, “Medicare Managed Care Manual Chapter 16-B: Special Needs Plans,” § 20.2.10.1 at 38, (Rev. 131; Issued: 11-22-24), (Accessed August 15, 2025). ↑

  36. For a robust discussion on the Care Manager role within Care Coordination, see the Justice in Aging, “D-SNP SMAC Template Toolkit: Care Coordination,” (August 2025). ↑

  37. Washington State Health Care Authority, “Amended and Restated State Medicaid Agency Contract,” §1.12 at 44 (Revised March 13, 2024) (Accessed August 18, 2025). ↑

  38. Massachusetts Executive Office of Health and Human Services (EOHHS), supra note 17, §2.11.3 at 231. ↑

  39. Id. §2.12.5. at 236 – 238. ↑

  40. Id. §2.13.1.3. at 243 – 244. ↑

  41. This language was adapted from California DHCS, supra note 32; see more discussion around the Care Manager role in Justice in Aging, supra note 13, at 15. ↑





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