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Printing Test – Justice in Aging

Printing Test – Justice in Aging

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Table of Contents

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.

This is Part III of the toolkit, which provides a robust discussion on Care Coordination. Part 1 of this toolkit covers Eligibility and Enrollment as well as Supplemental Benefits, while Part II of this toolkit focuses on Marketing and Communications. 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.

This publication highlights best practices drawn from D-SNP model contracts, Financial Alignment model contracts, and state long-term care requirements, aligning most closely with the federal standards for Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs).[1] 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.

Table of Contents

Federal Requirements

Care coordination for dually eligible individuals is shaped by several overarching federal requirements, including Model of Care requirements, the Home and Community-Based Settings Rule, and the Medicaid Access Rule. Because these requirements have broad applicability across the SMAC recommendations contained in this toolkit, a dedicated section has been created to highlight their significance and impact.

Model Of Care

D-SNPs must implement an evidence-based model of care (MOC) tailored to the characteristics and needs of the population they serve.[2] D-SNPs are required to submit their MOCs to the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) for evaluation and approval.

The MOC outlines how the plan will coordinate an enrollee’s Medicare and Medicaid benefits. Notably, state Medicaid agencies can require D-SNPs to submit their MOCs to the state Medicaid agency prior to, or concurrent with, federal submission of the full D-SNP bid, providing states with an opportunity to tailor the MOC requirements to state-specific population needs and identify potential inconsistencies between the MOC and SMAC care coordination requirements.[3]

At a minimum, D-SNPs must meet the model of care requirements outlined in 42 CFR 422.101(f) and the Medicare Advantage Model of Care Submission Requirements, including, and not limited to, the following:[4]

  • Health Risk Assessments: The plan must assess each enrollee’s medical, functional, cognitive, psychosocial, mental health, and social determinants of health needs, including screening for housing stability, food security, and access to transportation. The results of this assessment are addressed in the Member’s individualized care plan;
  • Individualized Care Plan: The plan must develop a comprehensive person-centered care plan that outlines the enrollee’s goals and objectives, including measurable outcomes and the specific services and benefits to be provided;
  • Interdisciplinary Care Team: The plan must utilize an interdisciplinary care team with demonstrated expertise and training to manage the enrollee’s care;
  • Care Coordination: The plan must coordinate the delivery of care (including Medicaid benefits) and communication of health care activities with stakeholders, including providers both inside and outside the SNP’s network, to help ensure that enrollees’ health care needs, preferences for services, and information sharing across health care settings are met; and
  • Care Transition Protocols: The plan must describe, in their MOCs, how care transition protocols will maintain continuity of care for enrollees, as well as which personnel are responsible for coordinating care throughout the transition process. Specific elements of the MOC require D-SNPs to explain how the plan will coordinate with providers of any Medicaid-covered services during a care transition.

2026 Medicare Advantage and Part D Final Rule

The 2026 Medicare Advantage and Part D Final Rule added additional care coordination requirements for D-SNPs. The Rule requires specific types of D-SNPs to conduct a single, integrated health risk assessment for Medicare and Medicaid, rather than separate assessments for each program. The Rule also codifies timeframes for the development of members’ individualized care plans and prioritizes the involvement of the enrollee or the enrollee’s representative in their care planning process.[5]

Home and Community-Based Settings Rule: Person-Centered Service Planning Process and Service Plan[6]

For individuals receiving Medicaid home and community-based services (HCBS), the Medicaid Settings Rule establishes requirements for both the person-centered service planning process and the resulting person-centered service plan. The Rule advances efforts to ensure the individual receiving services is at the center of the planning process. The goal is to develop a plan that reflects the individual’s strengths, preferences, and needs, including those related to health, safety, and well-being, and outlines services and supports that are important to and for the person. The plan must also reflect the individual’s goals for community integration, including where and how they want to receive those services.

Ensuring Access to Medicaid Services: Person-Centered Service Plans[7]

The Access Rule strengthens existing person-centered planning requirements to more clearly affirm that the individual, or if applicable, the individual and the individual’s authorized representative, lead the person-centered planning process.

Person-Centered Care

Lack of coordination between Medicare and Medicaid often creates significant barriers for people dually eligible, preventing them from accessing the services they need to meet their health goals and care needs. Insufficient coordination results in individuals experiencing fragmented care and confusion navigating benefits, all of which can worsen health outcomes and result in unnecessary and costly expenditures.

This population also tends to have highly complex medical and social needs: 90% have at least one chronic condition, and 37% have three or more.[8] People dually eligible also experience higher rates of physical and behavioral health conditions, functional and cognitive needs,[9] and the majority survive on very limited incomes.[10] These intersecting challenges make it essential to have person-centered care delivered by a well-coordinated team.

Strong care coordination requirements in SMACs are essential. SMACs should contain explicit language to ensure the member knows their Care Manager, that care is driven by the member to the greatest extent possible, and that services reflect the member’s unique goals and preferences. SMACs should also clearly define the Care Manager’s responsibilities in supporting the member and ensuring their care plan is effectively implemented.

Guiding Principle

Supporting Principle

SMAC Recommendation: The Member Should Know Who Their Care Manager Is and How to Contact Them

Template Language

Massachusetts

The contract ensures enrollees know how to contact their Care Manager and that communication is accessible to the member.

New Jersey

The contract requires a plan to ensure that caregivers have the name and contact information for the member’s Care Manager.

  • The Contractor’s Care Managers shall use a person-centered approach regarding the member assessment and needs, taking into account not only covered services, but also formal and informal support services as applicable. Care Managers shall ensure all identified caregiver(s) have the MCO Care Manager’s name and contact information.[12]

SMAC Recommendation: Care Management Engagements Prioritize Member Autonomy and Choice

Template Language[13]

Massachusetts

The contract requires care coordination in a manner accessible and preferred by the member.

  • In-person care coordination/care management engagement occurs at least once per year:[14]
    • In-person visits must occur at least annually for enrollees receiving in-home services who agree to, and can participate in, a visit. The visit can be in the enrollee’s home or another location of their choice.
    • If in-person visits are not possible or preferred, care coordinators must maintain active, effective communication using the enrollee’s preferred method—such as phone, email, virtual meetings, or written correspondence. Communication supports, including assistive technologies, must be provided as needed. No enrollee shall receive a lower standard of care coordination based on communication preferences, abilities, or the need for accommodations.

SMAC Recommendation: Define Core Responsibilities for Care Managers in Care Planning and Coordination

SMACs should define minimum Care Manager responsibilities, including but not limited to: answering questions, navigating care challenges, and facilitating access to benefits and supports reflective of people’s needs, goals, and quality of life objectives. Among other requirements, Care Managers should help people maintain Medicaid eligibility, including assistance with renewals; complete appeals and grievances and gather supporting documents; advocate for their needs and goals; connect to critical Medicare, Medicaid, and community-based services and supports; address common care coordination challenges stemming from lack of integration between Medicare and Medicaid, including durable medical equipment, transportation and pharmacy coverage; and advance rebalancing efforts by working with members to determine community-based alternatives to institutionalized care.[15]

Template Language

Massachusetts, New Jersey, California, and Washington

The Care Manager plays a critical role in helping members access the care and benefits they need. Contract language should require Care Managers to communicate effectively with members and provide educational counseling to support informed decision-making.

The contractor shall incorporate the following responsibilities in the Care Manager role:

Template Language

Ohio, Massachusetts, New Jersey, California, and Washington

SMACs should specify the Care Manager’s responsibilities for developing, updating, and implementing the member’s individualized care plan while also emphasizing the Care Manager’s role in addressing the member’s psychosocial needs and upholding key consumer protections.[20] Care coordination bridges the beneficiary’s systems of care, including non-clinical support.[21]

The Care Manager shall be responsible for developing their individualized care plan (ICP).

    • Serves as the lead professional responsible for developing and updating the person-centered care plan and arranging services through both formal and informal supports.[22]
    • Provides approval of the ICP and any amendments, as appropriate. The member must be offered and provided, upon request, a copy of the ICP and any amendments to the ICP. The ICP must be made available in alternative formats and in the member’s preferred written or spoken language upon request.[23]

The Care Manager shall be responsible for updating the member’s ICP.

    • Maintain enrollee records to ensure that health plan services (medical, BH, LTSS, social) are recorded and that requests for services are appropriately documented, submitted, tracked, and adjudicated.[24]
    • Review and update the person-centered care plan with the member, share it with the interdisciplinary care team, and ensure it is re-evaluated at least annually or upon a significant change in the member’s condition.[25]

The Care Manager shall be responsible for the execution of the member’s ICP.

  • Support the enrollee, or if applicable, the enrollee and their authorized representative, in leading the person-centered planning process;[26]
    • Coordinate the member’s Medicaid and Medicare services.[27] Potential activities include scheduling appointments, arranging transportation, making referrals, securing necessary authorization(s) for services to ensure members’ timely access to the services identified in the ICP, exchanging information with providers, and actively engaging in discharge planning;[28]
    • Advocate for community-based alternatives to long-term care and assist enrollees in accessing culturally competent home and community-based services that align with their care goals; and[29]
    • Monitor the delivery of services and assess the member’s progress in achieving ICP goals and take action to close service gaps and update the ICP as needed.[30]

The Care Manager shall be responsible for supporting the psychosocial needs of the member.[31]

  • Social Determinants of Health (SDOH) shall be addressed by the Care Manager and other members of the Care Team. Activities include but are not limited to the following:
    • Assist member in maintaining public benefits, including, at a minimum, SNAP, Medicaid, Medicare Savings Programs, energy assistance such as Low-Income Home Energy Assistance (LIHEAP), affordable housing, and disability benefits;[32]
    • Connect members to relevant referrals and community resources that meet their social and transportation needs and preferences.[33]  

The Care Manager shall be responsible for consumer protections:

    • Assist enrollees in filing grievances related to their care, Medicare and Medicaid-related appeals, and navigating health plan escalation procedures and state processes for reporting critical incidents;[34]
    • Ensure ADA compliance of services provided and arrange for care in the enrollee’s preferred language; and[35]
    • Document and comply with Advance Directives about the enrollee’s wishes for future treatment and designate a healthcare proxy if the enrollee wants one.[36]

Conflict-Free, Long-Term Supports Coordination Position:[37]

Various states require plans to subcontract with entities with specialized expertise in coordinating long-term care benefits. This structural separation between the plan and Care Manager helps ensure that care decisions are driven by the member’s needs rather than the plan’s financial interests.

For example, Massachusetts One Care members can receive care coordination from a Long-Term Supports Coordinator (LTS-C) for their long-term care benefits. LTS-Cs are provided by community-based organizations separate from plans, with expertise in the independent living philosophy and recovery principles. LTS-Cs provide conflict-free support to educate and empower members about their community-based care options, advocate for their care needs, and connect members to tailored long-term services and community-based supports. This position is preserved in Massachusetts’ statute.

SMAC Recommendation: Care Manager Core Competencies Should Be Tailored to the Needs of People Dually Eligible

Plans should also ensure that Care Managers possess core competencies tailored to the needs of people dually eligible, including expertise in community integration, person-centered planning, culturally competent and trauma-informed care, Medicaid HCBS and Medicare home health benefits, health-related social needs, dignity of risk, and health equity. Additionally, Care Managers should have training and experience working with older adults and individuals with physical disabilities, cognitive, intellectual, and developmental disabilities, and behavioral health needs.[38]

Template Language

Ohio, Massachusetts, and California

SMACs define explicit Care Manager competencies, demonstrated through documented qualifications and ongoing training, to ensure staff have the skills and expertise to effectively serve the plan’s dual eligible population.

  • The Contractor shall establish written qualifications for Care Managers employed by the plan, including, at a minimum:[39]
    • Completion of person-centered planning and person-centered direction training;
    • Experience working with people with disabilities, behavioral health needs, and/or older adults;
    • Knowledge of cultural competency and the ability to provide informed advocacy; and
    • Ability to write an ICP and communicate effectively, both verbally and in writing, across complicated service and support systems.
  • The Contractor must provide onboarding and ongoing training for all care coordination staff on the following:[40]
    • Health equity and implicit bias; cultural and disability competency; person-centered care planning; trauma-informed care; motivational interviewing; fraud, waste, and abuse; communication; grievance and appeals processes and procedures; community resources; strategies for addressing any disease-specific processes; incident reporting requirements; Health Insurance Portability and Accountability (HIPPA) requirements; self-direction; independent living and recovery; Medicare services and coordination of dual services; general behavioral health; behavioral health crisis training; wellness principles; Americans with Disabilities Act (ADA)/Olmstead Requirements; and other topics as specified by the state.
  • The Contractor must ensure that care coordinators attend mandatory annual training on the following topics:[41]
    • Cultural competency/diversity training that reflects the diversity of the plan’s member population; medication management; level of care criteria; State HCBS Waiver; coordinating dual services; provider service specifications; process for requesting home and vehicle modifications and adaptive and assistive equipment; person-centered planning; self-direction; restraints, seclusion, and restrictive interventions; community resources; HIPPA; and customer service.
  • D-SNP care managers participating in the Interdisciplinary Care Team (ICT) must be trained by the plan to identify and understand the full spectrum of Medicare and Medicaid Long-Term Services and Supports (LTSS) programs, including home and community-based services and long-term institutional care. The ICT should include providers of any Medicaid services the member is receiving, including LTSS and Community Supports.[42]

Additional SMAC Language

  • Care Manager must obtain knowledge of health disparities and the Care Manager’s role in reducing disparities and improving health equity. Care Manager must also possess knowledge of intersectional identities and their compounding impact on health outcomes.

SMAC Recommendation: Staffing and Cultural Representation Requirements

Additional SMAC Language

The Contractor shall recruit, hire, and maintain a care coordination workforce, to the greatest extent possible, that is culturally and linguistically reflective of the enrollee population served under this Contract. To achieve this goal, the Contractor shall:

Overlapping and Carved-Out Benefits

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 Requirements

Per section 1902(a)(25) of the Social Security Act, states must ensure that Medicaid remains the payer of last resort, such that Medicare pays first whenever Medicare and Medicaid cover the same services. This applies whether the benefits are paid for on a fee-for-service or capitated basis. [43] Additionally, 42 CFR 422.107(c)(1), D-SNPs must coordinate the delivery of Medicaid benefits to enrollees who are eligible to receive these benefits. [44] Federal law also requires D-SNPs to assist enrollees with accessing Medicaid covered benefits including and not limited to assisting with resolving grievances and navigating the Medicaid appeals and grievances process. [45] According to 42 CFR §422.107(c)(3), the contract between the state and the D-SNP must document the Medicaid benefits covered by the plan or by a Medicaid managed care plan offered by the same parent organization for the contract year. [46]

SMAC Recommendation: Requirements for Coordinating Overlapping and Carved-Out Benefits

States should incorporate Care Coordination requirements directing D-SNPs to take explicit actions when coordinating overlapping and carved-out benefits (e.g., dental, behavioral health benefits, durable medical equipment, non-emergency medical transportation) to ensure timely access to care. States can and should require plans to create streamlined systems that facilitate effective communication and collaboration between care and utilization management teams to ensure enrollees have timely access to benefits and care management support services.

Template Language

Ohio

To avoid duplication of benefits and ensure effective service delivery, Ohio requires D-SNPs to implement systems that facilitate effective sharing of member data and require plans to ensure all members receive care coordination, regardless of whether other entities are involved in overseeing specific parts of their care. Additionally, Ohio delineates specific information-sharing responsibilities to the broad range of activities assigned to the D-SNP Care Coordinator role.

California

For certain D-SNPs, California requires plans to track enrollee supplemental benefits to ensure that plan benefits are exhausted before Medicaid coverage of any overlapping benefits. Additionally, California requires D-SNPs with Exclusively Aligned Enrollment (EAE) to report to the state the level of overlapping dental provider network information. Lastly, California requires D-SNP Care Coordinators to assist enrollees with accessing Medicaid benefits, appeals, and grievances.

  • If D-SNP Contractor offers Supplemental Benefits as referenced in this contract, member use of Supplemental Benefits and exhausts Supplemental Benefits prior to or concurrent with authorization of or referral for Medicaid benefits, including but not limited to Dental, Vision, Transportation, Community Supports, and Behavioral Health; [50]
  • D-SNP Contractor that offers Dental Supplemental Benefits must report to the state on the level of overlap for their Medicare dental network and the Medicaid dental network, as outlined in this contract; [51]
  • For benefits that are carved out, such as Medicaid Dental, D-SNP Contractor must also follow the regulations at 42 CFR section 422.562(a)(5) and 422.629(e) that require D-SNP Contractor to provide members reasonable assistance completing forms and taking other procedural steps to assist members with appeals and grievances. This includes offering to assist members with obtaining Medicaid-covered services and navigating Medicaid appeals and grievances in connection with the member’s own Medicaid coverage, regardless of whether such coverage is in Medicaid fee-for-service or a separate Medicaid Dental Managed Care Plan. If the member accepts the assistance, the D-SNP Contractor should assist the member as needed, such as by 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. [52]

Additional Template Language

The D-SNP Contractor will take the following actions to ensure members use plan benefits before using overlapping Medicaid benefits:

Care Transitions

The confusion resulting from the lack of coordination between Medicare and Medicaid is most acute when individuals transition from one healthcare setting to another. Poorly planned and administered care transitions cause undue stress for dually eligible individuals and their caregivers, and can result in costly hospital readmissions and poor health outcomes. [54] D-SNPs should include robust care transition requirements to ensure enrollees are supported and protected during the most challenging moments in their health care continuum.

Care Transitions: Roles and Training Requirements

Guiding Principle

Supporting Principle

Federal Requirements

SMAC Recommendation: Ensure Care Managers Support Care Transitions

Template Language

Massachusetts

Massachusetts requires D-SNP plans to prioritize care transition models that center enrollees at home and create systems where the Care Coordinator and other members of the ICT share information timely and are available to provide on-site support to enrollees in care transition activities.

As part of the Care Coordination role, Massachusetts requires plans to delineate specific clinical responsibilities that include:

  • Work with the ICT to ensure safe transitions for enrollees moving between health care settings;
  • Ensure post-hospitalization services are discussed with enrollees and put into place (for both medical and behavioral health conditions);
  • Assist enrollees in connecting with recovery supports necessary to prevent hospitalization or re-hospitalization;
  • Follow-up within twenty-four (24) hours of an enrollee’s admission to an acute inpatient hospital, and coordinate with the enrollee and hospital staff to facilitate hospital discharges; and
  • Provide Care Coordination/Care Management to enrollees residing in a skilled nursing facility or nursing facility that has a positive PASRR level II screening. [58]

Ohio

Ohio requires plans to provide detailed descriptions of Care Management staff, including an organizational chart, the number of staff per role, qualifications, and their physical location. The state also mandates plans to report on training topics, frequency of training, and how staff training is tracked.[59]

  • The Managed Care Organization (MCO) care coordination staff must include a range of disciplines with complementary skills and knowledge to deliver a comprehensive, integrated care coordination program fully capable of addressing members’ physical, behavioral, LTSS, and psychosocial needs. [60]
  • The plan’s care coordination program submission must include: an organizational chart and the number of staff by role, qualifications, and physical location; training topics and frequency of initial and ongoing training. [61]

Additional Template Language

  • The member’s Primary Care Manager shall be responsible for coordinating the member’s care across all settings, including but not limited to acute care, post-acute care, outpatient, and long-term care services, to ensure continuity of care and support effective care transitions. [62]

Care Transitions: Discharge Planning Requirements

Guiding Principle

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

Supporting Principle

Members have access to quality, person-centered care coordination.

Federal Requirements

SMAC Recommendation: Share Enrollee-Specific Data, Incorporate Care Team, Prioritize HCBS

Template Language

Washington

Washington requires plans to develop a system that facilitates coordination of services, including LTSS and community-based services, during discharge and transition planning.

Massachusetts

Massachusetts requires plans to develop a system for effective person-centered discharge planning that prioritizes the individual in the home.

  • The Contractor shall develop, implement, and maintain written protocols for facilitating timely and effective Care Transitions between settings, including with all network hospitals and nursing facilities. Such protocols shall include elements such as, but not limited to, the following:
    • Event notification written protocols that ensure key providers and individuals involved in an enrollee’s care are notified of admission, transfer, discharge, and other important care events;
    • Prioritizing return to an appropriate home or community-based setting rather than a facility setting whenever possible, including proactive planning to identify and mitigate barriers to effectively supporting an enrollee to return to and remain in their home, and make best efforts to ensure a smooth transition to the next service or to the community;
    • Policies and procedures to ensure inclusion of enrollees and enrollees’ family members/guardians and caregivers, as applicable, in discharge planning and follow-up, and to ensure appropriate education of enrollees, family members, guardians, and caregivers on post-discharge care instructions;
    • Culturally and linguistically competent post-discharge education regarding symptoms that may indicate additional health problems or a deteriorating condition; [65]

Additional SMAC Language

The D-SNP Contractor is responsible for effectuating discharge planning that centers enrollees’ medical, behavioral health, and social needs, including, but not limited to, the following:

Care Manager as Part of an Interdisciplinary Care Team

The Care Manager functions as part of a robust interdisciplinary team to support the member in achieving their care goals. Clearly defined team composition, roles, and Care-Manager-to-member ratios are essential to ensure coordination, communication, and collaboration in meeting members’ needs.

Guiding Principle

Supporting Principle

SMAC Recommendation: Contracts Should Require Collaboration Amongst the Member’s Care Team

To ensure timely benefits approval and care management activities, states should require D-SNPs to collaborate with care and utilization management teams.

Template Language

California and Massachusetts

The SMAC specifies the required members of the interdisciplinary care team responsible for developing and implementing the member’s individualized care plan.

The ICT must be person-centered and developed around the member’s specific preferences and needs, including language and culture, and ensure integration of the member’s medical and LTSS care. The member has the primary decision-making role in identifying their needs, preferences, and strengths and has a shared decision-making role in determining the services and supports that are most effective and helpful for their care.[67]

The ICT must be led by professionally knowledgeable and credentialed personnel, and at a minimum, be comprised of the following core individuals.[68]

  • The member and/or their authorized representative, if the member consents to the participation of the authorized representative;
  • Family and/or caregiver, if approved by the member;
  • Care Manager – See specified responsibilities noted above.
  • Primary Care Physician – A physician or non-physician medical practitioner under the supervision of a physician, who is responsible for supervising, coordinating, and providing initial and primary care to patients, initiating referrals, and maintaining the continuity of patient care;
  • Specialist, including behavioral Health provider and Long-Term Support Coordinator (LTS-C), as indicated.[69]

The ICT must include the aforementioned individuals to the extent possible. At the discretion of the member, the ICT may also include other individuals or providers actively involved in their care, including a hospital discharge planner, nurse, social worker, nursing facility representative, and other providers as appropriate.[70]

  • ICT Responsibilities:
    • ICT to support enrollee, to the extent possible, in leading the care plan development process to develop an ICP that reflects their treatment goals (medical, functional, behavioral, and social);[71]
    • ICT to measure progress and success in meeting ICT goals and the goals of each ICT member in supporting treatment goals;[72]
    • With the assistance of the Care Coordinator and/or LTS-C as appropriate, promote independent functioning of the enrollee and provide services in the most appropriate, least restrictive environment using Independent Living Principles and recovery principles;[73]
    • Conduct ICT meetings periodically, including at the member’s request. The ICT must take the member’s individual needs (e.g., communication, cognitive, and other barriers) into account when communicating with the member; and[74]
    • Maintain a call line or other mechanism for member inquiries and input, and a process for referring to other agencies, as appropriate.[75]

Additional SMAC Language

SMAC Recommendation: Care Manager Ratios Should Enable Person-Centered Care

States should require D-SNPs to ensure Care Manager ratios enable individualized attention responsive to the unique needs of each member. These ratios account for the medical and psychosocial needs of members as well as their geographic location relative to the Care Manager.

Template Language[76]

Ohio

SMAC contains Care Manager-to-member ratios adjusted based on members’ risk levels and corresponding visit schedules.

  • The Plan must use individual-level risk stratification as one factor when determining the level of care coordination that is appropriate for each member;
  • The Plan must assign a risk tier to each member. The Plan must develop a risk stratification framework as part of its care coordination program that is comprised of four tiers (i.e., from lowest to highest: low monitoring risk [Tier 1], medium risk [Tier 2], high risk [Tier 3], and intensive risk [Tier 4]. The Plan’s risk framework must include the criteria and thresholds for each tier to determine member assignments;[77] and
  • The Plan must stratify members according to the risk tiers described below and comply with the following ratios for its care coordination program, including Plan care coordinators and waiver service coordinators.

Care Manager to Member Ratios by Risk Tier

Care Manager Contact Schedule by Risk Tier.[78]

Printing Test - Justice in Aging

  1. Justice in Aging, Dual Eligible Special Needs Plans (D-SNPs): What Advocates Need to Know; 42 C.F.R. § 422.2. ↑

  2. 42 C.F.R. 422.101(f)(1-3). 42 U.S.C. § 1395w-28(f)(5)(A) and (7) (§ 1895(f)(5)(A) and (7) of the Social Security Act); see also CMS webpage “Model of Care” NCQA webpage “What is a Model of Care?.” See also Breslin, Ellen and Dennis Heaphy. A Call for Equity: Re-Committing to an Independent Living Recovery-Centered Model of Care, February 2024. Notably, most MOCs are not available to the public. ↑

  3. See ICRC, Tips to Improve Medicare-Medicaid Integration Using D-SNPs: Integrating Medicaid Managed Long-Term Services and Supports into D-SNP Models of Care, June 2019. ↑

  4. 42 C.F.R. 422.101(f)(1-3); CMS, Medicare Advantage Model of Care Submission Requirements, June 2025. ↑

  5. 42 C.F.R § 422.101(f) ↑

  6. 42 C.F.R. § 441.725 ↑

  7. 42 C.F.R. § 441.301(c) ↑

  8. KFF, A Profile of Medicare-Medicaid Enrollees (Dual Eligibles), January 2023. ↑

  9. ATI, A Profile of Medicare-Medicaid Dual Beneficiaries, June 2022. ↑

  10. KFF, A Profile of Medicare-Medicaid Enrollees (Dual Eligibles), January 2023. ↑

  11. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” § 2.6.1.1.2 at p. 99. ↑

  12. New Jersey Department of Human Services (DHS), “New Jersey FIDE SNP Model MIPPA Contract,” Article 9 § 9.6.3 at p. 37 (January 2022). ↑

  13. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” § 2.6.1.2 at pp. 99-100. ↑

  14. Language adapted from the Massachusetts Three-Way Contract. Ibid. ↑

  15. Rebalancing refers to efforts to “achieve a more equitable balance between the share of spending and use of services and supports delivered in home and community-based settings relative to institutional care.” See CMS, Long-Term Services and Supports Rebalancing Toolkit, p. 1 (November 2020). ↑

  16. Language adapted from: Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” § 2.6.1.4 at p. 100. ↑

  17. Language adapted from: New Jersey Department of Human Services (DHS), “New Jersey FIDE SNP Model MIPPA Contract,” § 9.6.3 and 9.6.4 at pg. 24, 36, and 38-39 (January 2022); Washington Health Care Authority, Covered Health Care Services to Dual Eligible Beneficiaries, pg. 79 (January-December 2025); and ICRC, Sample Language for State Medicaid Agency Contracts with D-SNPs: Optional Language Applicable to all D-SNPs, p. 4 (January 2024). ↑

  18. CA DHCS, “Care Coordination Requirements for Managed Long-Term Services and Supports,” pg. 6 (July 2017). ↑

  19. New Jersey Department of Human Services (DHS), “New Jersey FIDE SNP Model MIPPA Contract,” Article 9 § 9.6.3 at p. 36 (January 2022). ↑

  20. Psychosocial refers to the combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness. See CMS, Psychosocial Severity Guide, October 2022. ↑

  21. This language is adapted from: Washington Health Care Authority, Covered Health Care Services to Dual Eligible Beneficiaries, pg. 79 (January-December 2025). ↑

  22. Language adapted from: Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, pp. 167-9. Not available online; and New Jersey Department of Human Services (DHS), “New Jersey FIDE SNP Model MIPPA Contract,” Article 9 § 9.6.3 at p. 36 (January 2022). ↑

  23. CA DHCS, “Care Coordination Requirements for Managed Long-Term Services and Supports,” p. 7 (July 2017). ↑

  24. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” § 2.6.1.4 at p. 100. ↑

  25. Language adapted from: Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 178. Not available online and CA DHCS, “Care Coordination Requirements for Managed Long-Term Services and Supports,” p. 8 (July 2017). ↑

  26. Language adapted from: Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 178. Not available online and additional language from Justice in Aging . ↑

  27. Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 156. Not available online. ↑

  28. Ibid., pp. 168-70. See subsequent sections for discussion on carved out benefits, discharge planning, and care transitions. ↑

  29. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” § 2.6.1.4 at pp. 104-7. ↑

  30. Language adapted from Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, pp. 178-8. Not available online. ↑

  31. D-SNPs must assess the enrollee’s physical, psychosocial, and functional needs. CMS requires D-SNPs to ask questions about housing stability, food security, and access to transportation. See C.F.R. § 422.101(f)(1)(i). ↑

  32. Justice in Aging additional language. ↑

  33. CA DHCS, “Care Coordination Requirements for Managed Long-Term Services and Supports,” p. 6 (July 2017). ↑

  34. Language adapted from: Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 100-109 and Justice in Aging added language. ↑

  35. Language adapted from Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” pp. 100-109. ↑

  36. Ibid. ↑

  37. Ohio requires Plans to contract with the AAAs as the primary waiver service coordination entity for members age 60 and older who are enrolled in the state’s HCBS waiver. ↑

  38. Dignity of risk refers to the right of the individual to make informed choices and their experiences and care, even when they may have negative consequences. ↑

  39. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” § 2.6.1.4 at p. 103-4. ↑

  40. Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, pp. 161-2. Not available online. ↑

  41. Language adapted from Ibid., p. 162. ↑

  42. DHCS, CalAim Dual Eligible Special Needs Plans Policy Guide, June 2022. ↑

  43. See CMS, “Frequently Asked Questions on Coordinating Medicaid Benefits and Dual Eligible Special Needs Plans Supplemental Benefits,” pp. 2-3 (May 21, 2021) (Accessed June 6, 2025). ↑

  44. See Ryan Stringer et al., “Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans (D-SNPs): Required Language Applicable to All Types of D-SNPs,” Integrated Care Resource Center (January 2025) p. 3, (Accessed June 5, 2025). ↑

  45. 90 FR 15792; see also 42 CFR 422.562(a)(5). ↑

  46. Stringer et al., supra note 43 at 4. ↑

  47. Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 159, (Accessed June 09, 2025). Not available online. ↑

  48. Id. ↑

  49. Id. at 166. ↑

  50. California Department of Health Care Services (DHCS), “Boilerplate 2025 SMAC Exclusively Aligned Enrollment D-SNP,” Exhibit A, Attachment 1 at 2, (July 8, 2024) (Accessed June 9, 2025). ↑

  51. Id. at 12. ↑

  52. Id. at 16. ↑

  53. This language is adapted from CMS, “Frequently Asked Questions on Coordinating Medicaid Benefits and Dual Eligible Special Needs Plans Supplemental Benefits,” (May 21, 2021) (Accessed June 6, 2025). ↑

  54. See CMS, “Community-based Care Transitions Program,” (Accessed June 3, 2025); See also HealthStream, “The Economic & Emotional Cost of Hospital Readmissions,” Blog (April 21, 2025) (Accessed June 3, 2025). ↑

  55. CMS, supra note 3. ↑

  56. For additional sample language, see Ryan Stringer et al., “Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans (D-SNPs): Required Language Applicable to All Types of D-SNPs,” Integrated Care Resource Center (January 2025) p. 11, (Accessed June 12, 2025). ↑

  57. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” §2.6.3, at 110-111. (Accessed June 4, 2025). ↑

  58. Id. at §2.6.1.5. ↑

  59. Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 160-161, (Accessed June 04, 2025). Not available online. For more information on care manager training requirements, see also Justice in Aging, “Dual Eligible Special Needs Plans (D-SNP) State Medicaid Agency Contract Toolkit,” § Care Coordination (May 2025). ↑

  60. Id. at 160. ↑

  61. Ibid at pg. 160. ↑

  62. Notably, Washington recently made changes to ensure that dual eligible recipients of the Home Health benefit will receive a single care coordination across settings. See Health Affairs, How Washington State Used Dual Eligible Beneficiary Survey Results to Understand Enrollment Decisions, June 2025. ↑

  63. Stringer et al., supra note 2, at 3. ↑

  64. Washington State Health Care Authority, “Amended and Restated State Medicaid Agency Contract,” §1.5.1.4.3, Revised May 2022 (Accessed July 25, 2025). ↑

  65. Massachusetts Executive Office of Health and Human Services (EOHHS), supra note 2, §2.6.3.1.7. ↑

  66. Language adapted from CA DHCS, “DUALs Plan Letter 16-003,” at 2, (July 25, 2016) (Accessed June 5, 2025). ↑

  67. CA DHCS, “Care Coordination Requirements for Managed Long-Term Services and Supports,” p. 9 (July 2017). ↑

  68. Ibid. ↑

  69. Language adapted from CA DHCS, “Care Coordination Requirements for Managed Long-Term Services and Supports,” p. 9 (July 2017). ↑

  70. Language adapted from CA DHCS. Ibid. ↑

  71. Language adapted from Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” § 2.6.2.6.3 at p. 109. ↑

  72. Ibid. ↑

  73. Ibid. ↑

  74. CA DHCS, “Care Coordination Requirements for Managed Long-Term Services and Supports,” pp.8- 9 (July 2017). ↑

  75. Ibid., p. 8. ↑

  76. Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 164. Not available online. ↑

  77. Ibid. See pp. 164-5 for risk criteria and threshold minimum considerations. ↑

  78. Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 179. Not available online. ↑





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