Samantha Morales: Hello everyone, and welcome to today’s webinar presentation entitled State Medicaid Agency Contract (SMAC) Template Toolkit: What Consumer Protections Advocates Need To Know. I’m Samantha Morales, Senior Policy Advocate on the Health Team at Justice in Aging. And today I’m joined by my colleague, Hannah Diamond, Senior Policy Advocate on the Health Team.
Next slide, please. Before we begin, I would like to go over a few webinar logistics. Again, welcome to all participants. You are all on mute, but we welcome your participation in today’s presentation through the Q&A function in the Zoom control panel. Also available in the Zoom control panel is the CC button, which enables closed captioning. We will be watching the participant questions as they come in throughout the webinar, and we will uplift high level themes during the Q&A segment at the end of today’s presentation. Any questions unanswered in today’s webinar will be addressed via email following the conclusion of the presentation.
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We would also appreciate your participation in our post-webinar survey that will pop up on your screen following the close of the webinar. We are also providing American sign language interpretation on this webinar. The ASL interpreter will stay on video throughout the training to provide this service. You do have the option to pin the interpreter’s video box to maximize your view of the interpreter. To do this, click their video window, then select the PIN icon. Next slide, please.
A little bit about Justice in Aging. As many of you may know, we are a national organization that uses the power of law to fight senior poverty by securing access to affordable healthcare, economic security, and the courts for older adults with limited resources. Since our founding in 1972, our efforts have focused on fighting for people who have been historically marginalized and excluded from justice, such as women, people of color, LGBTQ+ individuals, and people with limited English proficiency.
Next slide, please. Justice in Aging is committed to advancing equity for low-income older adults in economic security, healthcare, housing, and elder justice initiatives. We strive to address the enduring harms and inequities caused by systemic racism and other forms of discrimination that uniquely impact low-income older adults in marginalized communities. Next slide, please.
Thank you. So Justice in Aging produces a wealth of information like the webinar you’re viewing today, along with fact sheets, issue briefs, alerts, and other material to keep you up to date with important developments. If you’re not already a member of our network, we encourage you to join by going to our website and signing up or simply emailing info@justiceinaging.org. Thank you for sticking with me through this background information, and now let’s review the agenda for today’s presentation.
So we will do a very high level overview of dual eligible special needs plans or D-SNPs. And for a more in-depth discussion on D-SNPs with the full alphabet soup, we encourage you to view the recording of our August 2025 webinar on D-SNPs, What Advocates Need to Know. For the training today, we will provide an overview of the State Medicaid agency contracts or SMACs and uplift advocacy opportunities.
We will spend the majority of our time delving into the SMAC template toolkit, specifically our latest publication focused on consumer protections. Lastly, we will end our discussion by uplifting important reminders and key takeaways. Next slide, please. And now we’re going to delve into top lines for advocates. Next slide, please.
So here we have some key points to frame the discussion. So nearly 50% of people that are dually eligible for Medicare and Medicaid in the nation receive their care from a D-SNP or a dual eligible special needs plan. Because of this, it is important that advocates understand these plans to help individuals make informed decisions, as well as to hold plans accountable to regulatory requirements and to shape policies at the state and federal levels. And we’re going to point out how you as advocates can really uplift some of these consumer protections throughout this presentation.
Secondly, people dually eligible for Medicare and Medicaid navigate two health insurance programs, and this means navigating different medical criteria under both. Medicare covers the majority of care for dually eligible individuals, but this group also utilizes Medicaid services. Medicaid is an important source of other types of care not typically covered by Medicare.
Things like in home personal care services, transportation, dental, long-term care in a nursing facility, just to name a few. Lastly, D-SNPs can streamline care and benefits, but enrollment is always a personal decision. It is influenced by a person’s individual needs and preferences. If your preferred provider, for example, is not in a D-SNP, it may not be wise to join that plan because you could lose your provider. So it’s important that people are informed about the benefits of D-SNPs as well as the limitations that come with joining that kind of Medicare Advantage plan. Next slide, please.
So what are D-SNPs? So as many of you know, D-SNPs are a type of Medicare Advantage plan specifically designed for people who are dually eligible for Medicare and Medicaid. D-SNPs are intended to address the barriers that the dually eligible population faces as a result of having two separate health insurance payers. Medicare and Medicaid, as you all know, were not designed to work together, and dually eligible populations often report confusion and barriers to getting needed care. D-SNPs were intended to address these problems. Like other Medicare Advantage plans, D-SNPs are a form of managed healthcare.
Unlike other Medicare Advantage plans, there are some core features that make these types of plans fundamentally different. I would like to uplift the core elements that make D-SNPs different than other Medicare Advantage plans. So number one, enrollment is limited to dually eligible individuals or a subset. And now the state, again, has a lot of power here to limit this further.
So for example, the state can limit enrollment in a D-SNP to dually eligible individuals who have full Medicaid benefits, also known as full duals. Secondly, again, the State Medicaid agency contract or SMAC. Unlike other Medicare Advantage plans, D-SNPs are required to have a SMAC. This is where the state can really leverage its power with D-SNPs and incorporate more consumer protections. Lastly, federal requirements for some coordination with Medicaid services.
This, again, makes D-SNPs unique and unlike other Medicare Advantage plans that do not have this requirement. When we speak of coordination with Medicaid services, it is important again to understand the spectrum of coordination that exists in the D-SNP landscape. Next slide, please. Thank you.
So in terms of who regulates D-SNPs, both the Centers for Medicare and Medicaid Services, CMS, and the State Medicaid Agencies where these plans operate regulates D-SNPs. An important point to uplift is the State Medicaid Agency Contract, again, the SMAC, as this is the vehicle states can use to impose additional requirements and consumer protections that go beyond the minimum to ensure the needs of dually eligible individuals are met.
The contracts or SMACs are used to set the criteria for enrollment, plan materials, and the level of care coordination between Medicare and Medicaid that the D-SNP will have. While all D-SNP enrollees must have Medicare and Medicaid, as I’ve mentioned before, states can choose to further limit enrollment to a smaller subset of the population by putting this in the provisions in their SMAC, so they can limit enrollment to only dually eligible individuals who require a nursing facility level of care as an example.
So to drive home the point, SMACs have a significant impact. They’re incredibly important. On our website, we have several resources available to assist advocates around the topic of D-SNPs, including the SMAC toolkit linked in this slide. In this webinar, we will be delving into the SMAC Template Toolkit and Uplift Consumer Protection Language. Next slide, please.
So now we’re going to discuss the impact of HR1 on people dually eligible. While HR1 or the One Big Beautiful Bill Act, as some people are referring to it, does not directly make changes to D-SNPs, it contains nearly a trillion dollars in cuts to Medicaid that are going to shift the burden of cost from the federal government to the states. The law also contains significant changes that will impact the Medicaid expansion population.
These are adults under the age of 65 who are not enrolled in Medicare. So some of this includes, for example, work requirements, additional eligibility determinations and cost sharing requirements. And we believe even though people dually eligible are not in the Medicaid expansion population, people dually eligible could be impacted by these changes. So for example, there’s a lot of confusion about what is in the law. There’s a lot of misinformation. And also because this law is so burdensome to implement for states, it could cause system strain, which will impact other populations.
So additionally, people dually eligible may use a caregiver or rely on a caregiver that is in the Medicaid expansion population. So if there are negative consequences for them, it could negatively impact people dually eligible. The law also contains extensive administrative requirements that states will have to implement. So this will reduce the state’s capacity overall to focus on duals integration and oversee D-SNP performance.
So because states have to balance their budgets, there are concerns about states reducing or cutting optional benefits, so specifically home and community-based services, vision, dental, and hearing benefits could be on the chopping block. So now I’m going to pass it over to Hannah, who will provide an overview of the State Medicaid Agency Contracts or SMACS.
Hannah Diamond: Thanks so much, Sam. So what are State Medicaid Agency Contracts or SMACs? You’re hearing us refer to them as the acronym SMACS. These are contracts between the D-SNPs, so the plan and the state Medicaid agency in which the plan operates. CMS, the Centers for Medicare and Medicaid Services, require SMACs to contain baseline requirements. That said, states can go above and beyond the federal floor established by CMS to include stronger consumer protections.
So in addition to the consumer protections that we’re going to talk about today, SMACS contains some really great basic information about plan offering. So it’s a good place to go to find out what the plan provides and who the plan provides these services to. So for example, the SMAC will outline whether or not the plan will enroll full and/or partial duals. So SMACs, if they are publicly available, are a good place to go to learn about D-SNP requirements and offerings.
So where can you find SMACS? Unfortunately, not all SMACs are publicly available. If they are available, they will be online. And actually, we just updated a resource yesterday, our DSNP FAQ resource, where within the appendix of that resource, we have consolidated all of the publicly available SMACs that we are aware of. So I would encourage you to go there to see if your state SMAC is publicly available.
If your state does not post their SMAC, this is a great place to start. And actually, on the next slide, I’m going to cover engagement opportunities. So where do you begin your integration advocacy journey? We have some suggestions for you here. First, I would suggest contacting your state Medicaid agency and finding out who is responsible for developing and overseeing your state’s SMACs. This will help you better understand who you’re targeting at the state level. If your SMAC is not publicly available, this is the place to start.
Request a copy of your SMAC and ask when it will be released and use the framing of transparency. You want to see your SMAC so that you can hold your state and the plans accountable for what they have promised to deliver, and then you also want to see the SMAC so that you can make improvements. So that leads to our next recommendation here, which if your state publishes their SMAC, that’s great. We encourage you to review it and then submit feedback to your Medicaid agency. So we encourage you to consider uplifting the content within our SMAC toolkit, which you’re going to hear about in a minute from Sam and what we’re presenting in today’s webinar.
Now, this SMAC toolkit is pretty comprehensive. It has multiple sections which you’re going to learn about out, think of it as a menu in which you can pick and choose to uplift the content that is most appropriate for your state’s integration environment.
And then additionally, if your state holds public listening sessions, we would really encourage you to participate in those sessions. Show up, elevate the member experience, elevate the advocate experience, excuse me, and encourage your networks to share their perspectives. This is a great opportunity with proven demonstrated impact of success, which we’re going to share with you.
So when to engage. SMACs are required to be updated on an annual basis. CMS, the Centers for Medicare and Medicaid Services requires Medicare Advantage organizations to upload their SMACs by July of every year. This allows the federal government to monitor the contracts for basic compliance with federal requirements.
So working backwards, in order to meet this July deadline, it means that states are beginning the drafting process and modification process of their SMACs much earlier. So therefore, we suggest that as advocates, you all are engaging with your state Medicaid agency in the fall prior to that June deadline. This will allow time for the state to incorporate advocates’ suggestions as they update their SMAC and then negotiate with plans.
And here is an example of the power of advocacy that we want to uplift, and I hope our Ohio friends are on this call. In Ohio, advocates participated in a series of public listening sessions conducted by their state Medicaid agency to inform their state’s transition of a duals demonstration to a [inaudible 00:16:52] D-SNP. And we recently learned that advocate feedback was accepted by the state and is reflected in this year’s model SMAC.
So advocates were able to successfully embed stronger consumer protections into their D-SNP offerings via this advocacy lever, so via participating in public listening sessions and via the SMAC. So just to summarize this section and what you’ve heard so far, D-SNPs are serving more and more people dually eligible, and the SMACs are a powerful policy lever in which to shape integration at the state level. And we have proven examples of success when advocates participate.
We see stronger consumer protections in these offerings. And with that, I’m going to pass it back to my colleague, Sam.
Samantha Morales: Thanks so much, Hannah. So in this next section, we will take a deep dive in the Justice in Aging SMAC Template Toolkit. So before we can begin discussing the SMAC Template Toolkit, we really have to scaffold concepts and build on the conversation with the Guiding Principles document. We released this document in September of 2024, the Guiding Principles Document provides a core set of values and goals that call for robust consumer protections, health equity, person-centered care, and more oversight and accountability and integration models.
So advocates can use the Guiding Principles Document to guide their advocacy around D-SNPs and SMACs. And you can see that it is linked on this slide. So once you receive the materials post this webinar, you will have access as well. Next slide, please. Thank you. So building off of the Guiding Principles Document, we published a toolkit which incorporates SMAC template language with an emphasis on strong consumer protections.
And here I provide an overview of the structure and the purpose of the toolkit. So in terms of the purpose, the toolkit is intended to help advocates as they push for stronger consumer protections in D-SNPs in their states. The toolkit incorporates the Justice in Aging guiding principles to guide advocates and provide user-friendly language that could be incorporated into SMACS to ensure robust consumer protections.
In terms of structure, the toolkit encompasses five sections with template language covering the topics listed here in this slide. So enrollment eligibility, supplemental benefits, marketing and communications, care coordination, and our two very recently released publications on consumer protections, including member rights and member engagement and support, which we will be focusing on in the last part of this presentation. Next slide, please.
So we’re uplifting D-SNPs as an opportunity to think about them as a mitigation strategy in relation to HR1. The reason D-SNPs provide this opportunity has to do with the SMACs. We have a powerful policy lever via the SMACs at the state level. That said, because before I can get into some of these examples, it’s really important for us to state that D-SNPs cannot fill the void that is caused by the HR1 Medicaid cuts.
It’s really important that in our collective advocacy, you consider uplifting D-SNPs as a policy lever, as a mitigation tool, and that you’re also forming coalitions to protect existing Medicaid benefits and expand Medicaid offerings to address gaps in coverage as there really is no replacement for investment in home and community-based services and Medicaid overall.
So here we have some ideas to highlight. As we discussed about plan supplemental benefits, D-SNPs can offer benefits that go above and beyond those offered by Medicare and Medicaid.
This is important to uplift as you’re considering mitigation strategies, and also via the SMAC, you can get detailed and robust care coordination requirements that can help to ensure that an individual doesn’t lose their Medicaid benefits or prevents it to the best extent possible, which is especially important given the changes in HR1. The last point is especially important, as deeming periods can really provide enrollees with the opportunity to address their Medicaid status before they lose D-SNP coverage altogether. As Hannah will get into later, advocates can really push to get deeming period protections with their state Medicaid agencies. Next slide, please.
So as many of you know, a major issue with D-SNP enrollment is the confusion due to complex enrollment processes and eligibility criteria that is not always clear. This is especially true if people are automatically enrolled in D-SNPs via the default enrollment process. CMS allows default enrollment in specific situations, so not all plans are allowed to automatically enroll people. To address the confusion around eligibility and enrollment, we raise some recommendations in the SMAC template toolkit for advocates to consider. So we list a few of those recommendations here in this slide.
So number one, at the end of the day, states should allow dually eligible people the opportunity to actively choose their coverage. SMAC should be clear about the voluntary nature of enrollment in D-SNPs. Number two, if default enrollment is allowed, plans should be required to provide a clear and streamlined opt-out mechanism without lock-in periods.
These opt-out mechanisms should be clearly outlined in the SMAC. Number three, to ensure people impacted by default enrollment are fully informed and can make informed decisions about their care timely, an additional 30-day consumer tested notice that meets language and accessibility standards should be issued to these folks.
So as we will see in the next slide, some states are already doing this. Lastly, to ensure dually eligible people have access to unbiased and objective information to make informed decisions, SMAC should define the role of OMBUDS programs. Next slide, please.
Here, we wanted to provide examples of states that incorporate strong protections in their SMACs. For example, Ohio incorporates language around consumer choice despite implementing default enrollment. California requires an additional 30-day notice for individuals impacted by default enrollment. For template language, we uplifted language that emphasizes the voluntary nature of D-SNP enrollment and the importance of providing access to the independent consumer advocacy groups that can provide enrollees with unbiased assistance around their Medicare coverage.
Next slide, please. As many of you know, through your work with clients, D-SNPs often duplicate benefits that dually eligible people already have access to through their Medicaid program. So to address this issue that can make it challenging for people to access the Medicaid benefits they are already eligible for, states can require D-SNPs to explicitly avoid duplicating Medicaid benefits, and instead mandate the plan’s fill in gaps in services or expand existing benefits.
Pennsylvania and New Jersey are two states that already incorporate anti-duplication language in reference to D-SNP supplemental benefits in their SMACs. From the template language, you can see how SMACS can really serve as a tool to mitigate the HR1 federal cuts. By incorporating this type of template language where states can require D-SNPs to expand existing benefits covered under Medicaid, such as HCBS, dental services, services provided under Medicaid waivers, et cetera, states can really reduce the harms of HR1. Next slide, please.
Medicare enrollees are often inundated with plan marketing materials and notices. For dually eligible individuals who may be enrolled in a D-SNP and then in a separate Medicaid managed care plan, the issue is much more magnified because they are likely getting double the notices and plan materials. The SMAC recommendations that we uplift here is to emphasize the importance for states to require D-SNPs to streamline plan materials as much as possible, even for those plans that are not required to provide integrated materials because they do not meet the criteria as operating with exclusively aligned enrollment.
Now, exclusively aligned enrollment occurs when a state limits DSNP enrollment to full benefit dually eligible individuals who receive their Medicaid benefits from the D-SNP or an affiliated Medicaid managed care plan offered by the same parent organization as the D-SNP. Plans with exclusively aligned enrollment are federally required to provide integrated materials, including an integrated appeals and grievance process at the plan level for all Medicare and Medicaid benefits.
States can, of course, go above and beyond these federal minimums. Next slide, please.
Here we uplift the state of Wisconsin and their requirements that D-SNPs with exclusively aligned enrollment not only integrate enrollee information, which they’re required to do, but that they also require plans to include the Medicaid state plan benefit information in the summary of benefits. This is important because enrollees will be able to see the benefits they should have access to via their Medicaid coverage. The template language that we provide at the bottom of this slide comes directly from the Wisconsin SMAC. And now I’m going to pass it back to Hannah who’s going to delve into care coordination.
Hannah Diamond: Thank you, Sam. So as Sam mentioned, I’m going to talk about care coordination. Care coordination is really the meat and potatoes of D-SNPs. The entire point of these plans is to better integrate Medicare and Medicaid offerings, and robust coordination requirements are a primary vehicle of achieving the same. So within this section, we’re featuring four care coordination SMAC suggestions, but our toolkit for this section is quite comprehensive, so we encourage you to go to our entire toolkit, but especially this portion to see additional recommendations.
So D-SNPs are required to screen for what’s called health-related social needs or social determinants of health. And although they screen for these needs, they often fail to actually address the holistic needs of an individual, so they fail to connect an individual to community resources and other resources that they need to address their needs. So our SMAC recommendation here is to clearly define responsibilities for care managers to address the social determinants of health needs of members, so their psychosocial needs.
So we’re featuring recommendations here from multiple states that require care managers to assist the member in “maintaining public benefits, including at a minimum, SNAP, Medicaid, Medicare savings programs, energy assistance such as LIHEAP, affordable housing and disability benefits.” And we also have template language here that requires connection and relevant referrals to meet the social and transportation needs and preferences of the member.
So by being explicit within the SMAC and holding plans accountable to the SMAC’s requirements, we can better ensure that members do not lose access to critical benefits, which is especially important within the environment of HR1, where we’re concerned about the law’s implications on Medicaid, excuse me, and SNAP access. And by being explicit, when we’re calling out particular resource needs like transportation, for example, which is a common concern for people dually eligible, care manager requirements can be a tool to increase access to these services.
So people dually eligible experience access challenges stemming from overlapping coverage criteria between Medicare and Medicaid. A common example that we see is challenges accessing durable medical equipment. Duals also experience significant challenges when a benefit is carved out from a D-SNP’s offering. For example, when long-term care benefits or behavioral health benefits are carved out.
So to address this concern, care coordination requirements should directly require plans to take explicit action to coordinate overlapping and carved-out benefits. Here, we’re uplifting an example from California. California requires plans to track D-SNP supplemental offerings, so you heard about supplemental offerings earlier from Sam, in order to ensure that all benefits are exhausted prior to Medicaid coverage of any overlapping benefits.
This ensures that supplemental benefits are in fact additive as opposed to duplicative of the members’ existing benefits, their Medicare and Medicaid benefits, and it also preserves state Medicaid dollars, which is especially important within the context, again, of HR1 and budget constraints.
Another critical area that we’re focusing on when it comes to care coordination and care manager requirements is to focus on care transition. So for example, when an individual is transitioning from the hospital, back to the community, this is a time when without explicit care manager requirements that the member is at particular risk of increased institutionalization or repeat hospitalization.
So therefore, it’s critical that the SMAC prioritizes a member’s access to home and community-based services during their discharge planning processes. So here we feature an example from Washington State, which requires prioritization of community-based services in the discharge and transition planning processes. Their SMAC requires transition protocols to focus on enabling access to home and community-based services in order to prevent unnecessary institutionalization.
Another example that I want to uplift that’s not on the slide, but something that’s very important and backed in research is the importance of medication management and reconciliation during this time of care transitions.
So basically, we want to ensure and utilize care coordination requirements to ensure that members don’t have conflicting medications, that they can access their medications, and that they understand how and when to take their medications. When we see robust medication management and reconciliation requirements in place in the SMAC, it’s been shown to greatly reduce institutionalization and subsequent hospitalizations post-discharge. So this is an important area for care coordination requirements within the SMAC to outline.
An additional care coordination requirement that we are uplifting is the importance of care manager to member ratios that enable person-centered care. So when these ratios are too high, it limits the staff’s capacity to be able to provide individualized attention to the member, which prevents a timely response in terms of access to services. So again, the recommendation is to require care manager ratios that enable person-centered care.
And our recommendation here is featuring Ohio SMAC. Ohio SMAC requires explicit care manager to member ratios with differing ratios based on the member’s risk level. So now I’m going to transition us from care coordination requirements to member engagement and support suggestions. So the suggestions here on this slide highlight opportunities to meaningfully engage members in advisory committees.
Too often, people with lived experience are not incorporated into the design and the delivery of integrated offerings. And despite these plans, having member engagement requirements through what’s called an enrollee advisory committee, ensuring that these bodies remain representative of the member populations and also offer a meaningful platform for feedback that the plan actually incorporates, continues to be a challenge for many plans.
So we have two resources that we uplift within our toolkit that I’d like to alert you to. The first is really to take a look at Massachusetts One Care, One Care is one of their integrated offerings, their implementation council. This council provides the foundation for federal requirements for enrollee advisory committees. What’s unique about the implementation council is that unlike an enrollee advisory committee, it operates separately from plans, which addresses some of the power dynamics and conflict of interest concerns that exist potentially within an enrollee advisory committee that comes from the plan.
Additionally, the council receives state funded support from the UMass Chan Medical School. This support provides technical assistance and accommodation assistance to better enable meaningful participation from the implementation council members themselves.
Additionally, CMS, again, the Centers for Medicare and Medicaid Services, has put together a resource, which we’ve linked on this slide, where they’ve identified best practices for member engagement in enrollee advisory committees. So some examples of these best practices include engaging proactively and engaging in a culturally competent and linguistically competent outreach to members, conducting recruitment to offset attrition, offering permissible stipends to recognize members’ expertise and to compensate them for their participation in these advisory councils, and then also offering these meetings in various formats, including hybrid, in person and virtual formats in order to make engagement more accessible.
And then finally here, you heard Sam talk about earlier the importance of ombudsman programs, and I’m using Ombuds as a gender-neutral term for Ombudsman. Ombudsmen are critical in offering support to members in resolving complaints, in navigating complicated grievance and appeals processes, and also in addressing systemic challenges faced by members. So within the SMAC, it is recommended to advocate for language that ensures that all members have access to Ombud services to ensure that members can receive assistance with addressing their personal barriers to care and that they’re aware of their rights, and that also the Ombudsman can work on addressing systemic challenges faced by all members. And here we’re featuring an example from Massachusetts.
Massachusetts SMAC requires the role of an independent Ombuds program contracted by the state Medicaid agency to support plan enrollees, and the contract also explicitly requires plans to work with the Ombuds to resolve individual and systemic enrollee concerns.
So for our final section of the toolkit, we’re going to be talking about two suggestions to uplift and protect member rights. Here, we uplift the concern that because many people dually eligible lose their Medicaid coverage due to procedural or administrative reasons, not because they are no longer eligible for care, we’re concerned about them, A, losing their coverage, but also B, within the context of HR1, there are additional pressures that might cause them to lose coverage.
So here we’re providing a suggestion to help people maintain their enrollment within a D-SNP. So SMACS can utilize something called Deeming protections. Deeming protections enable temporary sustained enrollment in a D-SNP, in a plan, in the event of Medicaid loss for a period of one to six months. So deeming protections recognize that the loss of Medicaid coverage amongst members is often temporary. So by providing these protections, it prevents disruption for both the member and also the plan.
So here we’re uplifting SMAC examples from Virginia, from Indiana and Pennsylvania, all of which require their D-SNPs to provide the maximum deeming period protection of six months. So here’s the language, which I think is really straightforward. When a member loses Medicaid eligibility and the contractor determines the individual is likely to regain Medicaid eligibility within six months of the termination date, the contractor must retain the member for the full six months.
And finally here, we’re talking about separate Medicare and Medicaid appeals processes. When there are separate appeals processes, it’s very confusing for members and it can often delay access to care. So it’s actually a federal requirement for certain types of D-SNPs to use integrated appeals and grievances processes, so at that initial determination level and then at the first level of appeal.
In these circumstances, plans may only recover for Medicaid service costs after a final decision has been made. We recommend via the SMAC that protections go further than the federal minimums and require plans to integrate appeals processes at all levels, not just the initial decision and the initial appeal level.
Plans should also be required to continue benefits throughout the entire appeals process. And in the event that the determination does not go in the enrollee’s favor, the enrollee should not be liable for services received when the appeal is pending.
And New York is the example that we’re uplifting here. They had an integrated appeals and grievance process in their duals demonstration, so their duals demonstration provides lessons learned that can be mimicked by other states to have a fully integrated appeals process. And with that, I’m going to hand it back to Sam to do important reminders and key takeaways.
Samantha Morales: Thanks so much, Hannah. So in this last section of the webinar, we would like to review, again, important reminders and key takeaways. Next slide, please. So here we would like to uplift some important reminders that we mentioned throughout the presentation that we want to make sure to emphasize.
So first, it is important for dually eligible individuals to remember that they have the freedom of choice to decide how to receive their Medicare benefits. No one can take that away from them. Second, and connected to the first point, D-SNP enrollment is completely voluntary. Even if dually eligible individuals are automatically enrolled in a D-SNP via the default enrollment process, they will be allowed to opt out. Lastly, it is essential for dually eligible individuals to get access to independent and unbiased counseling to ensure they can understand their options and make informed decisions about how they would like to receive their care.
Here, I would like to recognize the important work that the state Ombuds programs, the state health insurance assistance programs, the SHIPS, the Aging and Disability Resource Centers, the ADRCs, and all of the independent experts who work to ensure that dually eligible people are getting reliable information about their Medicare options. Next slide, please.
So here we have the crux of the issue. We want you to take away these key points. First, SMACs are a powerful tool for shaping D-SNP policy and strengthening consumer protections. Second, because SMACs are so critical, advocates should actively engage with their state Medicaid agencies in the development and in the revision of their state SMACs. The Justice in Aging SMAC toolkits are linked on the slide. These provide strong consumer protection language, as Hannah has gone over, that can be incorporated into existing state SMACs. Next slide, please. And here we provided you with a link or multiple links to the Justice in Aging Resources focused on D-SNPs, SMACS, and Duals integration. Next slide, please.
Additionally, we provided links to the Integrated Care Resource Center, the ICRC materials that provide a wealth of information on D-SNPs, Duals integration, and SMACS. And again, you will receive the slides and webinar recording after the webinar. Next slide, please.
And with that, thank you for your participation and engagement. We have quite a few questions. We have some time to go over your questions. Hannah and I will do our best to choose high level themes. So there is a question, Hannah, that came up that I thought really connects to your section on care coordination. And the question is, do dually eligible participants have caseworkers or coordinators to work with through their insurance plan?
Hannah Diamond: Yes. The answer is yes, but I will say that many people who are enrolled in these plans are not aware that they have access to care managers and that they’re assigned one. So there are explicit federal requirements for SMACs and also an additional document called Model of Care that kind of overviews how these plans are going to provide services to people dually eligible. One of those requirements is that they have a person-centered plan, and that plan is developed in partnership with the member and implemented by an interdisciplinary care team.
And the care manager is a part of that care team. So each individual should have access to a care manager. Again, these plans via the SMAC, the SMAC contains the requirements for the care manager. And the fact that a member might not know who their care manager is, we actually have recommendations within our SMAC toolkit of requirements for plans to do proactive outreach, outreach on a timely basis to ensure that members know who their care manager is.
So the answer is yes. And this is an area that we’re trying to address lack of knowledge on behalf of the member via the SMAC. So that’s a great question.
Samantha Morales: Another question that is also really important given the content of what we just delved into is, do you have any recommendations for how SMACs can require plans to be clear about Medicare savings programs restrictions?
And this person writes that there’s a plan in their state that is MSP-restricted, but the restrictions aren’t visible in Planfinder and the plan’s own documents are poorly worded. And it seems like the plan doesn’t really understand their restriction and erroneously enrolls people who don’t have the correct Medicare savings program and then disenrolls them after the six-month grace period.
And so any recommendations on that. I can take a stab and then Hannah, feel free to add more to this. So this is definitely a concern because unfortunately eligibility criteria for D-SNPs, as we mentioned during this presentation, can be very confusing for these reasons that this participant listed here in this question.
One of the things that advocates can push for in terms of consumer protections is making sure that state Medicaid agencies are requiring D-SNPs to incorporate clear eligibility criteria in their D-SNPs, in their SMACs, excuse me. So in those contracts, it should be clear what populations of duals are eligible to enroll in the plan, in the D-SNP plan. So if it’s a full dual that’s eligible, only full duals, meaning folks who are dually eligible individuals enrolled in full Medicaid benefits, or if the plan is also accepting partial duals. These are the folks that have, for example, a Medicare savings program, but they’re not enrolled in full Medicaid benefits.
So partial duals have a Medicare savings program, but not full Medicaid benefits, so not access to all of the Medicaid, for example, the medical, the long-term care, they only have the MSP. So it’s important to get those types of eligibility pieces in the SMAC so that it’s easier for advocates and consumers to navigate.
Hannah, did I miss anything on that?
Hannah Diamond: I would just, to address the confusing notices that are coming from plans, and forgive me if you said this, Sam, but you can require, and we have this within our SMAC toolkit, the SMACs can require that plans submit their notices to the state Medicaid agency and for advocates to review prior to release to members. And so that’s a really important way, A, to ensure that the materials are correct, and B, to ensure that the language as written is having its intended impact.
So when I say stakeholders, that could be advocates, but that could also be a great role for the enrollee advisory committees, for example, which are comprised of members. Their review of materials before released to the full plan could help ensure that those materials are accessible and are relaying appropriate information. So would encourage you to look at our communications-specific toolkit for more recommendations to improve how information is being provided to members.
Samantha Morales: So here’s another question that also touches on just the independent consumer advocacy groups that we reference in different parts of our presentation in terms of providing assistance to dually eligible individuals with their Medicare options. So this question from a California advocate, for example, asks, “Couldn’t the area agencies on aging be a good resource for an advisory council since they already have one? Maybe the Older Americans Act would need to be revised.”
Hannah Diamond: I would say that as sources of unbiased information for people dually eligible, there are agencies on aging are great. SILs are wonderful. SHIPs are incredible. And so I would really encourage you, especially when making a decision about whether or not to enroll in a D-SNP in the first place, unbiased counseling is extremely important when navigating that process.
And in terms of uplifting best practices, yes, I think leveraging lessons learned from existing enrollee advisory committees in other spaces, like the suggestions we outlined from CMS that they’ve consolidated, but also looking at various councils that have been successful. So we uplift the importance of the implementation council in Massachusetts One Care plan. Within that integrated offering, there are lots of ideas for best practices to pull from and utilize. So yes, if you have a great example in your state that’s working, we encourage you to take those recommendations and offer them to your Medicaid agency via your SMAC advocacy.
Samantha Morales: There’s another question specific to transportation benefits, for example, and this gets to, are plans going to exclude transportation in their D-SNPs? And I can take a stab at this, and Hannah, please add more information. So in the presentation when we’re covering these supplemental benefits and really D-SNPs as an opportunity for states to mitigate HR1 cuts, we reference transportation benefits. We also reference dental benefits, for example, HCBS services, but really D-SNPs are not necessarily going to exclude transportation in their coverage.
The point of the discussion is that advocates working with their state Medicaid agencies can really push the state to require D-SNPs that are operating in the state to incorporate transportation benefits that go above and beyond what the state Medicaid benefits are being offered to dually enrolled individuals. So really it’s about seeing the D-SNP and seeing the SMAC as an opportunity to incorporate and expand if there are existing transportation benefits, not duplicate those benefits, but really expand and add more so that dually eligible individuals are protected, especially with the looming Medicaid cuts.
Hannah, anything you wanted to add there?
Hannah Diamond: I would just add at a very high level, there’s nothing within HR1 that requires the services that we’ve mentioned, these optional Medicaid benefits, so transportation, home and community-based services, provider reimbursement rates, enhanced eligibility pathways. There is nothing within the law that requires those benefits to be cut. And so that’s why it’s really important that those who are listening in on this call are participating in advocacy opportunities with their state Medicaid agency, with their state legislature, with their federal lawmakers, all to uplift the importance of home and community-based services, to uplift the importance of integrated offerings, to uplift the importance of the unique needs of people dually eligible in their state. Again, there’s nothing that requires the state to make those cuts. It would be a choice on behalf of the state.
Samantha Morales: And there is a question on HR1, Hannah. Does HR1 prohibit notices in languages other than English?
Hannah Diamond: No, it does not. I will say that sometimes we see the Medicaid requirements in terms of language access to be more robust than the federal Medicare requirements. So that’s something that you want to be advocating for at the state level, is the most robust language access protections that are available. And again, within our SMAC toolkit, within the communication section, we have language that you can pull from to ensure that that is the most comprehensive offering possible. But no, there’s nothing within HR1 that requires notices to just be provided in English.
Samantha Morales: And then lastly, we have time for one more question. There is a question from a person who is a dually eligible recipient on an HCBS waiver, and the concern is that their income may make them ineligible for Medicaid. And the question is, there’s no way that this person will be able to afford, for example, their care on their income. Any advocacy tips for a person in this situation?
Hannah Diamond: I can take a stab at this. So your state may have what’s called spend down, so you can spend down your excess income in order to qualify for a Medicaid pathway. I think that this person… I would like to take it a little bit more macro. This person raises a really good point about the fact that the income and asset restrictions that are associated with long-term care and Medicaid eligibility are very, very low. And so this is an opportunity if we’re working not only to protect what we have, but also to expand access, increasing those thresholds is a really important way to increase access to critical care.
So that’s what I would say. I would focus on trying to expand eligibility and also seeing what paths your state offers in order to provide access for those who might be slightly over income.
Samantha Morales: Thank you so much, Hannah. And thank you again to all of you for joining us today. As a reminder, any questions that went unanswered today will be followed up on via email, and feel free to reach out to us. Our contact information is here on the slide with any additional questions that come up later. Don’t forget to complete the post-webinar survey. Your feedback is much appreciated and is important for us to improve our services and have a great rest of your day. Thank you so much.
Hannah Diamond: Thank you.
