According to the CMS fact sheet released April 29, 2022, there are about 4.1 million dually eligible beneficiaries receiving Medicare services through Medicare Advantage (MA) dual eligible special needs plans (D-SNPs). Based on the final rule for MA and Part D marketing and communications (CMS-4192-F), there are several key changes that D-SNPs need to prepare for in Contract Year (CY) 2023.
- Enrollee input on D-SNP Operations. CMS is finalizing the requirement for all D-SNPs to establish and maintain one or more enrollee advisory committees for each state in which the D-SNP is offered. D-SNPs must consult with advisory committees on various issues, including ways to improve health equity for underserved populations.
- Social Determinants of Health and SNP Health Risk Assessments (HRAs). CMS is finalizing a requirement for all SNP HRAs to include at least one question from a list of screening instruments specified by CMS on each of the following three domains: (1) housing stability (2) food security (3) access to transportation. This will improve identification of risk factors that may inhibit enrollees from accessing care and achieving optimal health outcomes and independence. For enrollee care plans, the SNPs will be able to take these risk factors into account.
- Simplified Appeals and Grievance Processes. Enrollees in D-SNPs go through a Medicare-Medicaid appeals process and do not have to file with both Medicare and Medicaid to avoid duplicate filings. To improve this process, CMS is requiring the unified appeals and grievance processes apply to D-SNPs to simply the process and extend the protection of continuation of benefits pending appeal to additional dually eligible beneficiaries.
- Star Ratings and Performance of the Local D-SNP. CMS is developing a pathway to allow certain states with integrated care programs to require that MA plans establish a contract that includes one or more D-SNPs. This will allow for Star Ratings for that contract to reflect the D-SNPs’ local performance. This will assist CMS in easily identifying disparities between D-SNPs and other MA plans and better drive quality improvement for dually eligible enrollees.
- Simplify D-SNP Enrollee Materials. CMS has integrated many enrollee materials for demonstration programs and with a small number of D-SNPs to help people better understand coverage and reduce confusion. The final rule provides a mechanism for states to require the D-SNPs in D-SNP-only contracts to use integrated materials to make it easier to understand all of the Medicare and Medicaid benefits available through D-SNPs.
- Maximum Out-of-Pocket (MOOP) Policy for Dually Eligible Beneficiaries. The MOOP limit in an MA plan is calculated based on the accrual of all Medicare cost-sharing in the plan benefit. The Medicare cost-sharing includes whether it was paid by the enrollee, Medicaid, or other secondary insurance, or remains unpaid. CMS projects that this change will save state Medicaid agencies $2 billion over ten years while increasing payment to providers serving D-SNP enrollees by $8 billion over ten years.
- Technical and Definitional Updates for FIDE SNPs and HIDE SNPs. Final rule key changes include:
- For plan year 2025 and subsequent years, all FIDE SNPs must have exclusively aligned enrollment (i.e., limit enrollment to individuals in the affiliated Medicaid MCO) and cover Medicaid home health, durable medical equipment, and behavioral health services through a capitated contract with the state Medicaid agency
- Each HIDE SNP’s capitated contract with the state shall apply to the entire service area for the D-SNP for plan year 2025 and subsequent years
- The final rule codifies specific limited benefit care-outs for FIDE SNPs and HIDE SNPs.
Contact ATTAC Consulting Group to learn how our D-SNP experts can assist your organization to prepare for the upcoming changes.