Table of Contents
This toolkit provides policy makers, 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. 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.
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 the coming months. The template language in this toolkit has been adapted from existing state SMACs.
Eligibility and Enrollment
People dually eligible often experience significant confusion during the D-SNP enrollment process, especially regarding the eligibility criteria for enrolling in a D-SNP, whether they may be subject to default enrollment, and what protections are available if they lose D-SNP eligibility. Clear and accessible contract language is key for individuals to understand their rights and options, and for plans to understand their obligations.
Default Enrollment: Choice
Guiding Principle
Integrated models safeguard consumer choice and enable informed and unbiased decision-making.
Supporting Principle
People dually eligible are guaranteed the right to choose their coverage.
Federal Requirement
The Centers for Medicare and Medicaid Services (CMS) permits default or automatic enrollment into a D-SNP when a Medicaid enrollee becomes newly eligible for Medicare either through age or disability, and the individual is already enrolled in a Medicaid Managed Care Organization (MMCO) operated by the same sponsor as the D-SNP.1
SMAC Recommendations
States should allow people dually eligible the opportunity to actively choose their coverage. Advocates should consider asking states to refrain from default enrollment. If default enrollment is allowed, plans should be required to provide a clear and streamlined opt-out mechanism without lock-in periods. SMACs should make clear that enrollees retain the right to choose how they receive their Medicare benefits, even when default enrollment is permitted. States should use their SMACs to collect information about default enrollment—who is default enrolled, how many individuals opt out, and how many complaints were filed— to better understand the implications of default enrollment.
Template Language
Ohio
Despite implementing default enrollment, the Ohio SMAC incorporates language around consumer choice.
- An eligible individual’s decision to enroll in the Medicare Advantage Organization (MAO) for Medicare benefits shall be choice-based. While default enrollment may be used to promote enrollment and alignment, individuals retain the right to opt out, consistent with federal regulations.2
Arizona
While default enrollment is allowed, Arizona incorporates language about improving alignment efforts and respecting member choice.
- The [state medicaid agency] and MAO will continue to work with stakeholders to establish practices which improve alignment for Full Benefit Dual Eligible Members. The beneficiary’s choice of MAO shall be fully respected, and consequently, misalignment may occur.3
Additional SMAC language
- The D-SNP Contractor shall clearly communicate the voluntary nature of plan enrollment and describe alternative care delivery options to enrollees in beneficiary facing enrollment materials, including but not limited to, enrollment notices and marketing materials.
- Upon request, the D-SNP Contractor shall provide [the state medicaid agency] with data related to default enrollment within timeframes and specifications defined by the Agency. This shall include, at a minimum:
- The number and percentage of individuals who opted out before enrollment became effective;
- The number and percentage of individuals who disenrolled within the first six months of plan enrollment, including to what extent disenrollment was attributed to the plan not meeting their needs (as self-reported through grievances, exit interviews, or other beneficiary feedback mechanisms);
- Disaggregated demographic data (e.g., age, zip code, race/ethnicity, sexual orientation and gender identity, primary language, and disability status);
- The number and nature of complaints or grievances related to the default enrollment process.
- [the state medicaid agency] reserves the right to request additional data or reporting to evaluate the equity, transparency, and beneficiary experience associated with default enrollment.4
Default Enrollment: Notice
Guiding Principle
Integrated models safeguard consumer choice and enable informed and unbiased decision-making.
Supporting Principle
People dually eligible receive clear, accurate materials that enable informed enrollment decisions.
Federal Requirement
Per 42 CFR 422.66(c)(2)(iv), if default enrollment is allowed, states must require plans to issue written notification to dual eligible populations impacted no fewer than 60 calendar days prior to the plan effective date.
SMAC Recommendations
In addition to the 60-day notice, D-SNPs should be required to issue an additional 30-day notice that is consumer tested, meets Medicare’s five percent (5%) threshold for language translation as outlined in 42 CFR Part 422 Subpart V and any additional language and accessibility standards required by the state.
Template Language
California
- California requires an additional 30-day notice for dual eligible individuals impacted by default enrollment. This notice informs individuals of their right to opt out before the enrollment becomes effective and provides key details, including how to decline enrollment, where to seek assistance in making an informed decision, and the contact information for the State Health Insurance Assistance Program (SHIP) and Ombuds program.5
Eligibility Criteria for D-SNP Enrollment
Guiding Principle
Integrated models safeguard consumer choice and enable informed and unbiased decision-making.
Supporting Principle
People dually eligible receive clear, accurate materials that enable informed enrollment decisions.
Federal Requirement
States must list D-SNP eligibility criteria in their SMAC.6 While federal law broadly describes D-SNP eligibility to apply to dual eligible individuals, states have the authority to further restrict eligibility to certain groups of dual eligible populations.
SMAC Recommendations
SMACs should clearly explain who is eligible for D-SNP enrollment so that individuals, their caregiver(s) and/or representatives understand their options. For example, states can deny D-SNP eligibility to partial- benefit dual eligible individuals and individuals who are in Medicaid with a spend down or share of cost (medically needy eligibility). States should also include antidiscrimination language within their description of D-SNP eligibility.
Template Language
Arizona
Arizona’s SMAC explicitly limits D-SNP enrollment to full benefit dual eligibles.
- The Contractor shall enroll an eligible Full Benefit Dual Eligible Member only in accordance with the eligibility, terms, service area counties and plan benefit packages (PBPs) listed for each of the respective integrated managed care contract, and populations as designated by specific contracts, contract terms, or as otherwise further specified.7
Washington
Washington’s SMAC provides antidiscrimination language.
- Unless a Dual Eligible is otherwise excluded under federal Medicare Advantage plan rules, the Contractor will accept all Full Dual Eligible individuals who meet the state-defined enrollment criteria without regard to physical or mental condition, health status or need for or receipt of health care services, claims experience, medical history, genetic information, disability, marital status, age, sex, national origin, race, color, or religion, and will not use any policy or practice that has the effect of such discrimination.8
Additional SMAC language
The Contractor shall enroll only those dually eligible members who meet the enrollment criteria as defined by [the state medicaid agency]. The Contractor shall enroll only full benefit dually eligible individuals. Individuals who qualify for only Medicare Savings Program (i.e., partial duals) and who do not have full Medicaid benefits, shall not be eligible for enrollment unless explicitly permitted by the State. The Contractor is required to specify populations eligible for enrollment in their beneficiary facing enrollment materials.
Enrollment and Consumer Assistance
Guiding Principle
Integrated models safeguard consumer choice and enable informed and unbiased decision-making.
Supporting Principle
People dually eligible have access to unbiased enrollment assistance.
Federal Requirement
Per 42 CFR 422.562(a)(5), D-SNPs are required to assist enrollees in accessing Medicaid benefits and resolving grievances. 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.9
SMAC Recommendations
States should require plans to support enrollees in resolving issues related to enrollment. SMACs should also specify a clearly defined role for Ombuds programs to ensure enrollees have access to objective information, and independent consumer assistance, so that they and or their caregiver(s) can make informed enrollment decisions. Plan enrollment notices should include the helpline numbers to the Ombuds programs, and other independent experts, for dual eligible individuals who seek options counseling.
Template Language
Ohio
The Ohio SMAC provides clearly defined roles for the State Ombuds program,10 and the language should be broadened to encompass additional independent Ombuds programs:
- Ombuds Programs provide core services to members, including outreach, member empowerment through education, complaint investigation, person-centered complaint resolution, and the collection and reporting of casework data and thematic complaint analysis to CMS on a quarterly basis.
Additional SMAC language
- D-SNP contractors must prominently feature the helpline numbers for Ombuds programs, State Health Insurance Assistance program (SHIP), and the Aging and Disability Resource Center(s) (ADRC) in all member enrollment materials.
Supplemental Benefits
D-SNP supplemental benefits often duplicate Medicaid benefits already available to dually eligible enrollees. In many cases, overlapping services provide limited utility and can be difficult for the members to navigate. In addition, information about eligibility and how to access supplemental benefits is often unclear, and transparency issues persist when data about who actually receives the benefits is not collected or reported.
Supplemental Benefit Offerings
Guiding Principle
Integrated models improve access to care and member experience across the diverse dual eligible population.
Supporting Principle
Integrated plans encompass services beyond those typically covered by Medicare and Medicaid.
Federal Requirement
D-SNP supplemental benefits consist of mandatory and optional supplemental benefits that must meet CMS requirements including the requirement that the benefits are not covered by Medicare Parts A, B or D.11
SMAC Recommendations
To avoid payment duplication, states can require plans to submit Medicare bid information.12 States should also require D-SNPs to explicitly avoid benefit duplication, fill in gaps in services, and expand existing benefits.
Template Language
Pennsylvania
Pennsylvania requires D-SNP supplemental benefits to fill gaps in coverage:
- The D-SNP will offer at least one mandatory Supplemental Medicare Benefit that is designed to fill a gap in Medicaid services for which full duals are eligible. These may include, but are not limited to, gaps in hearing or vision services. D-SNPs may not impose any cost sharing to the Supplemental Medicare Benefits offered.13
New Jersey
New Jersey requires D-SNPs to avoid duplication with supplemental benefits:
- Supplemental benefits offered as a component of the Contractor’s FIDE SNP product shall conform to the specifications in Chapter 4 of the Medicare Managed Care Manual (in section 30 et seq.), and 42 CFR 100, SSA 1852(a)(3)(D), and shall not be duplicative of services covered by Medicare or Medicaid as part of the base FIDE SNP benefits package.14
Additional SMAC language
- The D-SNP contractor shall offer supplemental benefits that expand access to services beyond those offered in the Medicaid state plan and/or Medicaid waivers, including and not limited to non-medical transportation, Home and Community Based Services (HCBS), caregiver supports, dental services, and behavioral health services.15
Flex Cards/Debit Cards
Guiding Principle
Integrated models improve access to care and member experience across the diverse dual eligible population.
Supporting Principle
Integrated plans encompass services beyond those typically covered by Medicare and Medicaid.
Federal Requirement
CMS recently clarified that Medicare Advantage (MA) supplemental benefits using debit cards should be excluded from the calculation of income when determining eligibility for public benefit programs.16
SMAC Recommendations
States can require D-SNPs to work directly with enrollees on supplemental benefits access, and assign a point-person to assist members with accessing supplemental benefits that overlap with existing Medicare and Medicaid benefits. SMACs should provide clear guidance and require plans to offer enrollment counseling supports to ensure that supplemental benefits in the form of debit or “flexible” spending cards do not negatively impact enrollees.
Template Language
Pennsylvania
Pennsylvania requires plans to inform enrollees and provide assistance with access to supplemental benefits:
- The D-SNP shall assess the member’s needs for services that are covered by the D-SNP as supplemental benefits such as dental and/or transportation services. Further, the D-SNP shall educate members on how to access supplemental benefits.17
Additional SMAC language
- The Contractor shall assign a plan representative such as a Care Manager to support enrollees when supplemental benefits overlap with Medicaid benefits including and not limited to dental care, durable medical equipment, and non-medical transportation.18 If supplemental benefits in the form of debit cards are offered, the contractor shall provide counseling support to ensure that these benefits meet the needs of enrollees and do not negatively impact eligibility for public benefits.19
Supplemental Benefit Utilization
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
By January 2026, D-SNP plans will be required to notify enrollees with a mid-year notice if enrollees have not used most of their supplemental benefits by June of that year.20
SMAC Recommendations
Many SMACs already establish additional requirements for supplemental benefits, such as requiring plans to report benefits utilization and clearly define eligibility criteria. States should ensure D-SNPs provide supplemental benefits equitably and transparently.
Template Language
Ohio
Ohio requires plans to report data on supplemental benefits utilization:
- All data on any services provided to members that are not reflected as claims or encounters will be reported to the state via [include specific reporting system]. This includes but is not limited to care coordination, non-emergency transportation, Medicare supplemental benefits, and other value- added or additional services.21
Washington
Washington requires plans to delineate which supplemental benefits are available to specific dual eligible populations:
- Upon receiving written approval from the State, the Contractor may operate separate Plan Benefit Packages (PBP) for full dual eligible Members and partial dual eligible Members. The Contractor’s PBPs and eligible Members are detailed in [insert smac section].22
Additional SMAC language
- The D-SNP Contractor shall report quarterly disaggregated demographic data (e.g., age, zip code, race/ethnicity, sexual orientation and gender identity, etc.) for all enrollees who utilize supplemental benefits. The Contractor shall include all eligibility requirements for supplemental benefits in a public-facing website.
Marketing and Communications
People dually eligible are often overwhelmed by the separate and confusing notices they receive from their Medicare managed care plan, such as a Dual Eligible Special Needs Plan (D-SNP), and their Medicaid Managed Care plan (MMC). This confusion is worsened when plan notices are not consumer tested, are not provided in the member’s preferred language, or fail to account for the health literacy needs of dually eligible members.
Communications and Marketing Materials Accessibility
Guiding Principle
Integrated models provide robust consumer protections.
Supporting Principle
Members receive clear, timely, and accessible communications.
Federal Requirement
All Medicare Advantage plans must adhere to the communication and marketing requirements provided in 42 CFR Part 422 Subpart V and 42 CFR 438.10. Many states require D-SNP plans to meet additional requirements to ensure materials are accessible and appropriate for the dually eligible populations they serve.
SMAC Recommendations
To meet the health literacy and accessibility needs of dually eligible enrollees, states should require D-SNPs to consumer test all marketing and communication materials before distribution. States should also impose additional requirements to ensure plan written materials are accessible, culturally and linguistically appropriate, and include nondiscrimination information.23
Template Language
Massachusetts
Massachusetts requires D-SNPs to ensure access to covered services by maintaining policies that guarantee reasonable accommodations for enrollees and potential enrollees:
- D-SNP Contractors will ensure enrollees are provided with reasonable accommodations to guarantee effective communication, including auxiliary aids and services, which shall be made available upon request of the potential enrollee or enrollee at no cost and that enrollees can make standing requests for reasonable accommodations. Reasonable accommodations will depend on the particular needs of the individual and include:
- Providing large print (at least eighteen (18)-point font) or Braille of all written materials to individuals with visual impairments, as requested;
- Ensuring effective communication to and from enrollees in accordance with their communication preferences, including through email, telephone, text, and other electronic means;
- Ensuring effective communication to and from individuals who are Deaf or hard of hearing, or who have disabilities impacting their speech or communication needs, by using these individuals’ preferred modes of communication access through email, text, telephone, and other electronic means, and through services and technologies such as TTY, Video Relay Services (VRS), computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays, qualified interpreters (including ASL interpreters), and other auxiliary aids and services;
- Providing interpreters or translators for enrollees whose primary language is not English.24
California
California requires plans to provide enrollees with nondiscrimination notices:
- D-SNP Contractor must post (1) a state-approved nondiscrimination notice, and (2) language taglines in a conspicuously visible font size in English, the threshold languages, and at least the top 15 non English languages in the state, and any other languages, as determined by the state, explaining the availability of free language assistance services, including written translation and oral interpretation, and information on how to request Auxiliary Aids and services, including materials in alternative formats. The nondiscrimination notice and taglines shall include D-SNP Contractor’s toll-free and TTY/TDD telephone number for obtaining these services, and shall be posted in the Member Services Guide/Evidence of Coverage, and in all Member information, informational notices, and materials critical to obtaining services targeted to Members, potential members, applicants, and members of the public.25
California requires plans to include information about how to file a grievance with the CA Department of Health Care Services (DHCS) Office of Civil Rights and the HHS Office of Civil Rights in plan nondiscrimination notices:
- All Managed Care Plan nondiscrimination notices must include information about how to file a discrimination grievance directly with the State’s Office of Civil Rights, in addition to information about how to file a discrimination grievance with the plan and HHS Office of Civil Rights (i.e., file a grievance with HHS Office of Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex). Managed Care Plans are required to make the nondiscrimination notice available, upon request or as otherwise required by law, in the threshold and concentration languages, or in an ADA-compliant, accessible format.26
Additional SMAC language
The D-SNP Contractor shall gather and incorporate feedback from members serving on the Enrollee Advisory Committee and outside experts (e.g., providers, consumer advocates, trade associations, enrollees and caregivers) to produce consumer materials that meet the health literacy and accessibility needs of the dual eligible population.27 Additionally, all written materials and enrollee communications shall be in plain language and at the 7th grade reading level, using the Flesch scale analysis readability score.28
Language and Accessibility
Guiding Principle
Integrated models provide robust consumer protections.
Supporting Principle
Members receive clear, timely, and accessible communications.
Federal Requirement
All Medicare Advantage plans must adhere to the language and accessibility requirements outlined in 42 CFR 422.2267 including and not limited to translating required materials to any non-English language that is the primary language of at least 5 percent of the individuals in the plan service area. In addition, plans must make these translated materials available in any non-English language or accessible format on a standing basis once the plan receives a request or upon learning of enrollees’ language and/or accessibility needs. Plans must also adhere to language and format requirements outlined in 42 CFR 438.10(d) including making oral interpretation in all languages and American Sign Language available to individuals and members at no expense.29: Fully integrated dual eligible (FIDE) SNPs, highly integrated dual eligible (HIDE) SNPs, or applicable integrated plan (AIP) must also meet any additional language requirements outlined in the SMAC.30
SMAC Recommendations
States should require plans to provide written information to members describing how to request language or disability accommodations and how to file a grievance with the plan, the state, and the Health and Human Services (HHS) Office of Civil Rights. States with stronger language access rules than the federal minimum should require plans to adhere to both the federal and state requirements.
Template Language
California
California requires plans to adhere to language thresholds beyond federal minimums.
- Managed Care Plans are required to provide translated written member information, using a qualified translator according to the State’s requirements for qualified translators, to the following language groups within their service areas, as determined by the State:
- A population group of eligible beneficiaries residing in the Managed Care Plan’s (MCP) service area who indicate their primary language as a language other than English, and that meet a numeric threshold of 3,000 or five-percent (5%) of the eligible beneficiary population, whichever is lower (Threshold Standard Language); and
- A population group of eligible beneficiaries residing in the MCP’s service area who indicate their primary language as a language other than English and who meet the concentration standards of 1,000 in a single ZIP code or 1,500 in two contiguous ZIP codes (Concentration Standard Language).31
Integrated Materials Review
Guiding Principle
Integrated models provide robust consumer protections.
Supporting Principle
Integrated models simplify procedures, so members experience a single system inclusive of the most comprehensive protections provided by both Medicare and Medicaid.
Federal Requirements
Medicare Advantage plans must submit communication and marketing materials outlined in 42 CFR 422.2261 for approval to CMS before distributing to enrollees. Per 42 CFR 422.107(e), states can use SMACs to require D-SNPs that operate with exclusively aligned enrollment (EAE) to establish (and operate within) contracts with CMS that only include D-SNPs within a state (“D-SNP-only contracts”), and integrate certain materials and notices for D-SNP enrollees.32 Additionally, State Medicaid Agencies that require contracted D-SNPs with EAE to operate within state-specific, D-SNP only contracts with CMS, are granted access to the CMS Health Plan Management System (HPMS) to review plan submitted materials.33 States can thus exercise greater oversight when they require plans to operate with EAE and a D-SNP only contract as this allows them to jointly review D-SNP integrated communication and marketing materials alongside CMS.
SMAC Recommendations
To ensure that plan marketing and communications materials adhere to state standards, states should require plans to submit all, or certain types, of marketing and communication materials for review and/or approval prior to distribution.
Template Language
Minnesota
Minnesota requires D-SNPs to submit “Enrollee Materials” to the state for approval prior to distribution and requires consultation with tribal governments when marketing materials target American Indian populations:
- If the marketing materials target American Indian Beneficiaries, the State shall consult with tribal governments within a reasonable period of time before approval. The State must approve all information for enrollees that requires approval prior to use of the materials. The Managed Care Organization must submit its enrollee materials in a final format before approval from the State can be given. The State agrees to inform the Managed Care Organization of its approval or denial of documents within thirty (30) days of receipt of these documents.34
Massachusetts
Massachusetts requires D-SNPs submit for approval all “Outreach and Enrollees Materials” including materials in non-English languages prior to distribution:
- The D-SNP Contractor shall submit to the State all forms of outreach and enrollee materials, including non-English outreach materials along with an English translation, an attestation from a certified translation agency, and a signature of the Managed Care Organization Director, for review and approval before use or distribution. The State must also approve any changes or updates to outreach materials before use or distribution.35
Integrated Materials and Processes
Guiding Principle
Integrated models provide robust consumer protections.
Supporting Principle
Integrated models simplify procedures so members experience a single system inclusive of the most comprehensive protections provided by both Medicare and Medicaid.
Federal Requirements
As noted in the discussion above in reference to 42 CFR 422.107(e), CMS affords states the flexibility to require D-SNPs with exclusively aligned enrollment (EAE) to integrate materials including and not limited to the summary of benefits; formulary; and combined Provider and Pharmacy Directory.36 Additionally, applicable integrated D-SNPs are required to use an integrated appeals and grievance process.37
SMAC Recommendations
To simplify the description of benefits, states should require D-SNPs with EAE to provide enrollees with a single set of fully integrated materials that describe both the Medicare and Medicaid benefits covered by the D-SNP (and its affiliated Medicaid plan, when applicable). For D-SNPs without EAE, states should require plans to provide descriptions of Medicare and Medicaid benefits in a more unified format. For example, states could require non-EAE D-SNPs to present Medicare and Medicaid appeals and grievances descriptions together in the member handbook, plan letters to enrollees, and in other communications as appropriate. To ensure dually eligible members are fully informed about the benefits they are entitled to, states should require D-SNPs to include information about Medicaid State Plan benefits in communications and marketing materials.
Template Language
Wisconsin
In addition to requiring D-SNPs with EAE to integrate enrollee information, Wisconsin requires D-SNPs to include Medicaid State Plan benefit information in the summary of benefits:
- The MA Plan agrees to employ policies and procedures approved by CMS and the State to coordinate and integrate enrollee communication materials, including enrollment communications, grievance and appeals, and quality assurance.
- The MA Plan will identify in the MA Plan’s Summary of Benefits those benefits the member may be eligible for under the State Plan that are not covered services under the Member’s MA Plan.38
California
California requires select D-SNPs to provide integrated materials and a single customer service number:
- D-SNP Contractor is responsible for providing integrated Member materials to Members. Required integrated Member materials will include: 1) Annual Notice of Change (ANOC); 2) Member Handbook; 3) Summary of Benefits; 4) Member Identification (ID) Card; 5) Provider/Pharmacy directory; and 6) List of Covered Drugs (Formulary).
- D-SNP Contractor must have a single Member services/customer service phone number for Members to contact D-SNP Contractor regarding their Medicare or State plan benefits. D-SNP Contractor must use the single Member services phone number in all integrated Member materials. D-SNP Contractor must have a single Application Programming Interface (API) for Members to access both Medicare and Medicaid information.39
Cost-sharing Protections Disclosures
Guiding Principle
Integrated models provide robust consumer protections.
Supporting Principle
Members are protected from cost-sharing that exceeds what they would pay in Medicaid or Medicare fee-for- service for the same service.
Federal Requirement
Per 42 CFR 422.107(c\(4), SMACs are required to include the cost-sharing protections covered under )the D-SNP.40
SMAC Recommendations
To ensure dually eligible enrollees are fully informed about cost-sharing protections, states should require D-SNPs to include information about financial liability protections in communication and marketing materials.41
Template Language
Wisconsin
Wisconsin requires D-SNPs to communicate enrollee financial liability protections:
- The MA Plan shall communicate fully integrated Medicare-Medicaid coverage to all members, providers, MA Plan staff, and other stakeholders, including guarantee of complete member protection from financial liability – meaning all deductibles, premiums, coinsurance, copayments, and cost sharing of any kind, with exception for member post-eligibility treatment of income payment, if applicable.42
Minnesota
Minnesota requires D-SNPs to communicate enrollee cost sharing responsibilities in the plan handbook document and in other materials:
- The Managed Care Organization (MCO) shall explain the cost-sharing policy in the MCO’s handbook and other materials for Enrollees. The MCO shall not offer waiver of cost-sharing as an inducement to enroll in the D-SNP plan unless CMS has approved waiver of payment of cost-sharing by the MCO as an additional benefit in the MCO’s Medicare bid process, and such waiver cannot be described in any of the MCO’s Marketing Material.43
Endnotes
1: See CMS, “Default Enrollment Policy and Data on Approved Medicare Advantage Plans,” (October 23, 2023) (Accessed February 12, 2025).
2: Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 41, (Accessed January 27, 2025). Not available online.
3: Arizona Health Care Cost Containment System (AHCCCS),”Medicare D-SNP Agreements: UnitedHealthcare Community Plan,” §2.1.13 at 6. (Accessed February 24, 2025)
4: This language was adapted from the Arizona SMAC, see id. §2.1.12, at 6.
5: CA Department of Health Care Services (DHCS), “CalAIM Managed Long Term Services and Supports (MLTSS) and Duals Integration Workgroup,” p. 18 (Accessed February 11, 2025); see also DHCS, “Medi-Medi Plan (EAE D-SNP) Default Enrollment Pilot” (Accessed February 24, 2025).
6: For more information, see CMS, “Medicare Managed Care Manual Chapter 16-B: Special Needs Plans,” § 20.2.2 at 18, (Rev. 131; Issued: 11-22-24), (Accessed January 17, 2025).
7: Arizona AHCCCS, supra note 7, § 4 at 29.
8: Washington State Health Care Authority, “Amended and Restated State Medicaid Agency Contract,” Revised May 2022 (Accessed January 17, 2025).
9: CMS, supra note 10 § 20.2.10 at 38.
10: Ohio Department of Medicaid, supra note 6, at 53.
11: 42 CFR 422.100(c)(2)(ii); 42 CFR 422.102
12: To learn more about how states can utilize Medicare bid information, see Ryan Stringer et al., “Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans (D-SNPs): Optional Language Applicable to All D-SNPs,” Integrated Care Resource Center (January 2024) p. 13, (Accessed February 12, 2025).
13: Pennsylvania Department of Human Services (DHS), “Medicare Improvements for Patients and Providers Act Contract,” (2025), p. 14-15, (Accessed February 13, 2025).
14: New Jersey Department of Human Services (DHS), “New Jersey FIDE SNP Model MIPPA Contract,” § 10.4.1.7. at 19 (January 2022), (Accessed February 24, 2025).
15: For more language around expanded benefits, see Massachusetts, Executive Office of Health and Human Services (HHS), “MassHealth Section 1115 Demonstration Amendment Request,” (October 11, 2024), (Accessed February 28, 2025).
16: See Center for Medicare Advocacy, “CMS Clarifies Treatment of Medicare Advantage “Flex Cards” For Public Benefit Purposes,” (January 9, 2025) (Accessed February 24, 2025).
17: Pennsylvania DHS, supra note 17.
18: This language should also be cross-referenced in the SMAC provisions outlining the responsibilities of a care manager.
19: To read more about how supplemental benefits such as flex cards can affect a person’s HUD benefits, see Frequently Asked Questions (FAQ): HUD-assisted Housing and Medicare Advantage Supplemental Benefits | HUD USER. Accessed January 22,2025.
20: 89 FR 30448
21: Ohio Department of Medicaid, supra note 6.
22: Washington State Health Care Authority, supra note 12 at 32.
23: Nondiscrimination notices inform the public on the entity’s compliance with Federal Civil Rights laws and provide information about how individuals can file complaints or grievances when they have experienced discriminatory practices. See the Centers for Medicare and Medicaid Service (CMS) and Health and Human Services (HHS) nondiscrimination notices. See also, the California Department of Health Care Services (DHCS) nondiscrimination notice template for managed care plans that reference Federal Civil Rights and state laws.
24: Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” §2.10.8.2, at 207-208. (Accessed March 19, 2025).
25: California Department of Health Care Services (DHCS), “Boilerplate 2025 SMAC Exclusively Aligned Enrollment D-SNP,” Exhibit E, Attachment 2 at 21, (July 8, 2024) (Accessed March 6, 2025); See also CA DHCS, “All Plan Letter 21-004(Revised),” at 2, (May3, 2022) (Accessed March 6, 2025).
26: CA DHCS, “All Plan Letter 21-004 (Revised),” at 2, (May 3, 2022) (Accessed March 6, 2025).
27: Language adapted from CA DHCS, “2024 Medi-Cal Managed Care Plan (MCP) Transition,” at 13 (November 2, 2023) (Access March 7, 2025); see also Lida Momeni, et al., “Integrating Dual Eligible Special Needs Plan Materials to Promote Enrollee Understanding of and Access to Benefits,” Integrated Care Resource Center at 5, (February 2024) (Accessed May 7, 2025).
28: Language adapted from Minnesota Department of Human Services (DHS),”Model Template for 2025 Contracts with MCOs for Seniors,” §3.10.5 at 49, (January 1, 2025) (Accessed March 6, 2025).
29: See also Section 1557 of the Affordable Care Act (ACA) (section 1557), 42 U.S.C. 18116 and Title VI of the Civil Rights Act of 1964 (title VI), 42 U.S.C. 2000d et seq., Section 504 of the Rehabilitation Act of 1973 (section 504), 29 U.S.C. 794.
30: 42 CFR 422.2267(a)(4)
31: Id. at 4.
32: For more information on D-SNP-only contracts and integrated materials, see Integrated Care Resource Center, “D-SNP-Only Contracts: Benefits and Key Steps for States,” (March 19, 2024) (Accessed March 6, 2025).
33: Ryan Stringer, et al., “Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans (D-SNPs): Optional Language Applicable to Certain D-SNPs,” Integrated Care Resource Center at 11, (January 2025) (Accessed March 6, 2025).
34: Minnesota DHS, supra note 5, §3.12.9 and 3.13 at 52.
35: Massachusetts EOHHS, supra note 1, §2.10 at 93.
36: 87 FR 27704
37: 42 CFR 422.107(c)(9); see also Ryan Stringer and Alena Tourtellotte, “Integrated Appeal and Grievance Processes for Integrated D-SNPs with “Exclusively Aligned Enrollment,” Integrated Care Resource Center (July 2022) (Accessed March 6, 2025).
38: Wisconsin Department of Health Services (DHS), “State of Wisconsin Department of Health Services (DHS) and (MCO) for Dual Eligible Special Needs Medicare Advantage Health Plan,” §5 at 6-7 (2025), (Accessed March 6, 2025).
39: California DHCS, supra note 2, Exhibit A, Attachment 1 at 5-7.
40: See CMS, “Medicare Managed Care Manual,” Ch.16b, §20.2.2 at 18 (Re-issued 02-28-2014), (Accessed March 06, 2025).
41: This language should also be cross referenced in the SMAC provisions outlining care coordination requirements.
42: Wisconsin DHS, supra note 13, §5.3 at 7.
43: Minnesota DHS, supra note 5, §4.9.2 at 79.
