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.
Enrollee Advisory Committee
Too often, policy and services are designed without input from care recipients. Enrollee Advisory Committees (EACs) provide integrated models with a structured platform to incorporate the lived experience and expertise of members into the design and delivery of plan offerings, improving the ability of plans to provide services that are responsive to the wants and needs of members.
Guiding Principle
Integrated models provide robust consumer protections.
Supporting Principle
Integrated models incorporate members in model design, implementation, and oversight processes.
Federal Requirement
Under 42 C.F.R. § 422.107(f), any Medicare Advantage (MA) organization offering one or more D-SNPs must establish and maintain one or more Enrollee Advisory Committees (EACs) to serve the D-SNPs it offers in the state.[1] EAC membership must reflect the plan’s enrollee population to provide input on ways to “improve access to covered services, coordination of services, and health equity for underserved populations.”[2]
SMAC Recommendations
To enable meaningful participation, integrated models must establish and sustain consumer advisory groups that are supported with technical assistance, administrative and accessibility support, and consumer stipends. Contract language must specify that plans respond to member feedback and consider how to incorporate it into the design and delivery of plan offerings.
Template Language
Arizona[3]
The Arizona SMAC demonstrates common contract language to fulfill federal requirements.
- Medicare Advantage Organization (MAO) shall establish and conduct on a periodic basis, at least one Enrollee Advisory Committee (EAC) in accordance with the requirements of 42 CFR Section 422.107(f) and this Agreement.
- MAO’s EAC shall meet with the same frequency as its companion health plan Member Advocacy Council (as applicable) as per the requirements of 42 CFR 438.110.
- Membership of the MAO’s EAC shall be representative of and reflect the enrolled populations, the communities and the Geographic Service Areas (GSAs) served by MAO. A plan representative shall attend each meeting.
New York[4] and Massachusetts[5]
Both state contracts exceed federal requirements by defining specific accessibility standards to ensure meaningful enrollee participation, requiring plans to actively solicit and incorporate member suggestions, and mandating member feedback on designated topics.
- The Plan will be required to have at least one EAC open to all participants and family representatives, as well as to the participant Ombuds.[6] The EAC shall meet both (1) Medicaid managed care requirements for a Member Advisory Committee as described at 42 CFR 438.110; and (2) Medicare D-SNP requirements for an EAC as described at 42 CFR 422.107(f).[7]
- Composition: The EAC shall be comprised of enrollees, family members, and other enrollee caregivers. The composition of the EAC shall reflect the diversity of the plan’s member population, including individuals with various disabilities, with a membership that considers cultural, linguistic, racial, disability, sexual orientation, and gender identities, among others.[8]
- Meeting Frequency/Notice: The EAC must meet at least quarterly. The EAC meetings must be open to all participants and their family representatives; all participants and family representatives should receive notice of the EAC meetings.[9]
- Plan Requirements: The plan must establish a process for the EAC to provide input to the plan.[10] The Contractor shall conduct marketing and outreach to plan members (or their family members or caregivers, as applicable) to ensure enrollees are aware of the opportunity to apply to join or otherwise participate.[11] The plan must share any updates or proposed changes as well as information about the number and nature of grievances and appeals, information about quality assurance and improvement, information about enrollments and disenrollments, and more.[12] The plan shall also review and discuss participant ombuds reports in quarterly updates to the EAC and shall participate in all statewide stakeholder and oversight convenings as requested by the State and/or CMS.[13]
- Accessibility: The Contractor shall proactively ensure: reasonable accommodations and interpreter services, as well as other resources, are provided as may be needed to support full participation by enrollees, their family members, and caregivers in the EAC, and that the process and opportunity for joining the EAC is publicized.[14]
- Member Input: Duties of the EAC include, but are not limited to: providing regular feedback to the plan on issues of the plan management, enrollee care and services, and on other solicited input; identifying and advocating for preventive care practices to be utilized by the Contractor; being involved with the development and updating of cultural and linguistic policies and procedures, including those related to quality improvement, education, Contractor marketing materials and campaigns, and operational and cultural competency issues affecting groups who speak a primary language other than English; and providing input and advice on member experience survey results, ways to improve access to covered services, coordination and integration of services, and health equity for enrolled and specific underserved sub-populations and other appropriate data and assessments, among other topics.[15]
- In addition to EAC quarterly meetings, the plan must conduct at least two participant feedback sessions in its service area each year. These sessions provide participants with in-person and remote opportunities to provide positive feedback and raise problems and concerns. The plan must summarize each session and publicly post the meeting record promptly.[16]
Ohio[17]
As part of its EAC requirements, Ohio’s contract requires plans to document all recommendations made by the EAC and to report on the plan’s corresponding responses.
- The plan must report the following EAC information to the State Medicaid Agency: a list of attending members during the prior quarter for each council; meeting dates, agenda, and the minutes from each council meeting that occurred during the prior quarter; improvement recommendations developed by each council; the plan’s response to or implementation of the council’s improvement recommendations; and plan’s method for determining that the council’s membership reflects the diversity of the plan’s enrolled population.
One Care’s Implementation Council[18]
Lessons learned from One Care’s (Massachusetts’ integrated offering for people dually eligible under the age of 65) Implementation Council (IC) helped to inform federal requirements for EACs. The IC engages in systemic advocacy to monitor service quality, champion health equity in service delivery and design, promote transparency from plans and the state Medicaid agency, and hold plans accountable for person-centered care.
While EACs hold significant potential to gather insights that shape plan service delivery, their effectiveness may be constrained by plan oversight. In contrast, the IC assumes a distinct role that sets it apart from EACs, as it operates separately from plans. This separation ensures that the IC can offer conflict-free and impartial recommendations, unburdened by potential conflicts of interest.
To enable meaningful participation, the IC also receives extensive support and technical assistance from the UMass Chan Medical School, including full-time staff to provide technical support, administrative assistance, and accessibility support to enable meaningful involvement of IC members.
Lessons Learned from D-SNP EAC Strategic Conversations[19]
The Medicare-Medicaid Coordination Office (MMCO) at the Centers for Medicare and Medicaid Services (CMS) conducted strategic conversations with Medicare Advantage Organizations to identify best practices for supporting EACs. Key findings highlight the importance of strong recruitment and engagement practices to ensure committees reflect plan membership. Effective strategies include proactive, culturally and linguistically accessible outreach with trusted community partners, over-recruitment to offset attrition, direct follow-up with participants, and permissible stipends to recognize members’ expertise.
EAC meetings should reflect both geographic and linguistic diversity, offering hybrid, in-person, and virtual formats to promote accessibility. Members must have meaningful opportunities to shape agendas, and plans should report back on how member feedback is incorporated into plan operations. For organizations operating multiple EACs, periodic leadership convenings have proved useful to align best practices and support reporting EAC-specific outcomes to the State.
Ombuds Programs
Given the complexities of Medicare and Medicaid coverage criteria, the inherent power dynamics between plans and members, and factors like low literacy rates and language barriers impacting members’ social determinants of health, ombuds services are vital for dually eligible people to overcome barriers to care. Ombuds programs provide essential support to enrollees by helping them navigate individual care concerns and addressing systemic challenges related to plan offerings. They assist clients in resolving complaints and in navigating grievance and appeal processes.
Complaint data collected by ombuds programs is critical for identifying trends and informing care improvements at both the state and federal levels. Ombuds frequently meet with state Medicaid agency staff to address systemic issues, and as noted in the Enrollee Advisory Committee (EAC) SMAC template toolkit section, often participate in member advisory boards. They also play a vital role in member education and outreach, explaining enrollee rights and protections, and connecting members to services that support their needs and community-integration goals.
Guiding Principle
Integrated models provide robust consumer protections.
Supporting Principle
Members have access to independent support, separate from plans, to navigate challenges associated with their care through fully funded ombuds services.
Federal Requirements
The Financial Alignment Initiative (FAI), an integrated model testing demonstration, supported states in developing integrated care models aimed at improving care, enhancing coordination, and reducing costs for individuals dually eligible for Medicare and Medicaid.
As part of this demonstration, states could leverage existing Long-Term Care ombuds infrastructure, build new programs, or contract with existing non-profits, including legal services, to provide ombuds support, helping enrollees to resolve individual care concerns, conduct member outreach and education, and address systemic issues related to plan offerings.[20]
Currently, federal requirements do not mandate that integrated models extend ombuds support to D-SNP enrollees. Accordingly, this toolkit highlights FAI contract language, despite these models sunsetting in December 2025 (or earlier).
Notably, the ombuds programs included in the FAI demonstrations built upon the existing state Long-Term Care (LTC) Ombudsman Programs, which are authorized under the Older Americans Act and operate in every state.
These programs are designed to protect the health, safety, welfare, and rights of residents in long-term care facilities, including nursing homes and assisted living facilities. They are responsible for identifying, investigating, and resolving resident complaints; providing education and information about residents’ rights and available benefits; ensuring residents have access to ombuds support; representing residents’ interests to secure remedies that safeguard their health and well-being; and conducting systemic advocacy to improve the quality of care and services in long-term care settings.[21]
SMAC Recommendation
SMAC contains explicit language to ensure members have access to ombuds services that empower members about their rights and work with plans to resolve care disruptions and barriers to care, including assisting with appeals and grievances, as well as resolving systemic challenges impacting members.
Template Language
Ohio[22]
Ohio’s contract specifies member access to ombuds support.
- The State Long-Term Care Ombuds Program provides core ombuds services to members, including outreach, member empowerment through education, complaint investigation, and person-centered complaint resolution. Ombuds representatives will be accessible to the member and enrollee advisory council and other member advisory boards and will participate in all statewide stakeholder and oversight activities.
Massachusetts[23]
Massachusetts’ contract specifies the role of an independent ombuds program, contracted by the state Medicaid agency, to provide support to plan enrollees. It also establishes specific requirements for plans to work with the ombuds to resolve both individual and systemic enrollee concerns.
- Ombuds Definition: A neutral entity that has been contracted by the State Medicaid Agency to assist Enrollees and any other Medicaid members (including their families, caregivers, representatives, and/or advocates) with information, issues, or concerns related to D-SNP or other Medicaid health plans, benefits, or services. Ombuds staff fulfill both individual and systemic advocacy roles.
- The Contractor shall support Enrollee access to, and work with, the Ombuds to address Enrollee requests for information, issues, or concerns related to the plan, including:
- Educating Enrollees about the availability of Ombuds services.
- Communicating and cooperating with Ombuds staff as needed for them to investigate and resolve Enrollee requests for information, issues, or concerns related to the plan, including by: Designating a staff person as the Contractor’s Ombuds liaison; Providing Ombuds staff with access to records needed to investigate and resolve Enrollee Grievances (with the enrollee’s approval); and Ensuring ongoing communication and cooperation of plan staff with ombuds staff in working to investigate and resolve enrollee grievances, including updates on progress made towards resolution, until such time as the grievances have been resolved.
- The Contractor shall also include ombuds reports, as available, in quarterly updates to the Enrollee Advisory Committee.
Additional SMAC Language
The D-SNP will contract with an external entity, independent of the plan and with demonstrated expertise in serving the plan’s member population, to operate and provide Ombuds services to enrollees. The Ombuds will provide enrollees with an array of services, including, but not limited to: education, benefits counseling, support with appeals and grievances, and, when requested by the enrollee, direct representation in such processes.
Massachusetts’ My Ombudsman Program
My Ombudsman is the ombuds program for One Care enrollees (the state’s integrated offering for people dually eligible for Medicare and Medicaid under age 65) and Medicaid recipients in Massachusetts. My Ombudsman educates One Care members about their rights, negotiates with plans to resolve care disruptions, and informs plan improvement activities based on My Ombudsman intake and complaint data.
Importantly, My Ombudsman is operated by the Disability Policy Consortium (DPC), a disability rights organization with a majority disabled workforce. In addition to their lived experience with disability, My Ombudsman staff receive extensive training on delivering culturally and linguistically competent services.
The background of DPC staff enables strong rapport building with One Care members, minimizes biases contributing to health disparities, and promotes innovation in member-specific services and outreach. The fact that My Ombudsman is operated by a nonprofit organization, distinct from the plans themselves, ensures that members receive unbiased counseling and assistance aligned with their best interests rather than the priorities of plans.
A current limitation of the program, according to Massachusetts’ advocates, is that although My Ombudsman can educate and inform members about their rights, it cannot legally represent members in appeals and grievances. While the program’s staff refers members to external entities such as legal aid providers, advocates note that these entities often have limited capacity and cannot always provide needed support.
Endnotes
The Medicare Managed Care Manual Chapter 16-B: Special Needs Plan Section 20.2.9-2 reiterates regulatory requirements while offering some additional editorial language. See CMS, Medicare Managed Care Manual Sections 20.2.9-20.2.9.1, November 2024. ↑
Arizona Health Care Cost Containment System (AHCCCS), ”MEDICARE ADVANTAGE ORGANIZATION AGREEMENT BETWEEN AHCCCS AND Bridgeway Health Solutions of Arizona, In,” pp. 19-20, 41. ↑
Language is adapted from New York Department of Health, FIDA-IDD Model Contract, pp. 105-7. ↑
Language is adapted from Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 34-36. ↑
Language is adapted from New York Department of Health, FIDA-IDD Model Contract, pp. 105-7. ↑
Language is adapted from Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 34-36. ↑
Ibid. ↑
Language is adapted from New York Department of Health, FIDA-IDD Model Contract, pp. 105-7. ↑
Ibid. ↑
Language is adapted from Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 34-36. ↑
Language is adapted from New York Department of Health, FIDA-IDD Model Contract, pp. 105-7. ↑
Language is adapted from New York Department of Health, FIDA-IDD Model Contract, pp. 105-7; Language is adapted from Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 34-36. ↑
Language is adapted from Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 34-36. ↑
Ibid. ↑
Language is adapted from New York Department of Health, FIDA-IDD Model Contract, pp. 105-7. ↑
Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” p. 53. Not available online. ↑
Mass.gov, One Care Implementation Council. ↑
Based on suggestions from MMCO, Lessons Learned from Dual Eligible Special Needs Plans Enrollee Advisory Committee Strategic Conversation, June 2024. ↑
ICRC, State Approaches to Developing and Operating Ombudsman Programs for Demonstrations under the Financial Alignment Initiative, March 2021. ↑
45 C.F.R. § 1324.13; See also ACL, “Long-Term Care Ombudsman Program.” ↑
Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” p. 53. Not available online. ↑
Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 22, 36, 118-9. ↑
