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Duals Special Needs Plans—What Advocates Need to Know

February 27, 2024

Since 2020, enrollment in Dual Eligible Special Needs Plans (D-SNPs) has doubled. Today, over five million individuals eligible for both Medicare and Medicaid are enrolled in these Medicare Advantage plans, and enrollment is expected to continue rising. An increasing number of states are focusing on D-SNPs as a primary vehicle for integrating care and improving coordination of services for their dual eligible populations. Yet many advocates know little about what D-SNPs are, what makes them unique, and how they operate.

In this webinar, we provide an overview of our updated issue brief covering basic information about D-SNPs, their structure, and how they are regulated. We also identify specific areas where advocates can engage with their states to ensure that D-SNPs work effectively to coordinate care and benefits for dual eligibles, including strategies for centering equity from the outset in the design of D-SNPs.

This webinar is for:
State-based advocates working with older adults and people with disabilities enrolled in Medicare and Medicaid.

Presenters:
Rachel Gershon, Senior Attorney
Tiffany Huyenh-Cho, Director of California Medicare & Medicaid Advocacy

Transcript

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Hannah Diamond: Hello, everyone. Welcome for today’s presentation, Dual Eligible Special Needs Plans – What Advocates Need to Know. My name is Hannah Diamond. I’m a policy advocate in our health team here at Justice in Aging, and I’m joined by two of my colleagues, Rachel Gershon, who’s a senior attorney, and Tiffany Huyenh-Cho, who’s the director of our California Medicare and Medicaid Advocacy. A little bit about Justice in Aging, 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.

We’ve been doing this work since 1972, and we focused our efforts primarily on fighting for people who have been marginalized and excluded from justice, such as women, people of color, LGBTQ+ individuals, and people with limited English proficiency. Okay, a few housekeeping notes before we begin. There are quite a few attendees who are on today’s call. Again, welcome to you all. Everyone is on mute, but we do encourage your participation throughout this webinar by asking questions via the Q&A function, and I will be analyzing those questions throughout the course of the webinar and uplifting high-level themes during the Q&A component.

You can also use the Q&A component to ask for technical assistance. These materials, we always get the question, “Are these materials going to be available after the webinar?” and the answer is yes. All registrants will receive access to these materials. You can also find this recording on our resource library or our Vimeo page, but all registrants will be sent a recording and the PowerPoint presentation, and we are also going to be posting a link of the accompanying Issue Brief. Additionally, to enable closed captioning, you can do so by selecting CC from the Zoom control panel.

Justice in Aging is a wealth of information. We produce many educational materials, and we encourage you all, if you are not already a member of our network, to sign up, and you can do so. Here is the information on this slide. We are also launching an educational campaign, focused on integration, specifically to provide educational materials to advocates at the national and state levels to improve integration through D-SNPs. So, there is going to be a listserv.

We’re going to post the link in the chat, and we’re also going to include a link at the end of these slides to access the listserv. This listserv is for people who are advocates, consumer advocates on behalf of people dually eligible for Medicare and Medicaid. This listserv does not, at this time, focus on individuals who are receiving these services or individuals who are working within the state and federal government. So, if you are a consumer advocate, please sign up for this listserv to find out more about our educational materials focused on integration. Additionally, I just want to go over our Commitment to Advancing Equity.

To achieve Justice in Aging, we must advance equity for low-income older adults and economic security, healthcare, housing, and elder justice initiatives. To achieve Justice in Aging, we must address the enduring harms and inequities caused by systemic racism and other forms of discrimination, and to achieve Justice in Aging, we must recruit support and retain a diverse staff and board. And with that, I’m going to hand it over to Tiffany to start our presentation.

Tiffany Huyenh-Cho: All right. Thanks, Hannah, and thank you all for joining us. Today, we’ll provide a high-level overview of Dual Eligible Special Needs Plans, what they are, who can join, and how people are enrolled. We will explain the different types of Dual Eligible Special Needs Plans available, as well as the extent to which these plans coordinate with Medicaid. We will discuss recently proposed regulations and advocacy opportunities individual advocates can take with their state.

It’s a big agenda, and we hope you’ll come away with understanding what these plans are, what they can do, and how they can be better. Next slide, please. Dual Eligible Special Needs Plans are commonly referred to by the acronym D- SNPs. These plans are a type of Medicare advantage and are specifically designed for people who are dually eligible for Medicare and Medicaid. Dually eligible individuals are simultaneously enrolled in both Medicare and Medicaid, and access healthcare from both sources.

This group is sometimes referred to as dual eligibles or duals. D-SNPs are intended to address the barriers that the dually eligible population faces, as a result of having two separate health insurance sources. Medicare and Medicaid were not designed to work together originally, and this group often reports 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.

D-SNPs are responsible for the provision of Medicare’s Part A and Part B, as well as the Part D, prescription drug coverage. D-SNPs have provider networks and generally, members of D-SNPs must first get prior approval by the plan before certain medical services are provided. These plans also have some unique features that are not found in other types of Medicare Advantage Plans. First, D- SNPs can only enroll people dually eligible for Medicare and Medicaid because D-SNPs are specifically for this group. A person who only has Medicare cannot enroll, and in order to operate, all D-SNPs must have a contract with the State Medicaid Agency in their state.

These contracts are called SMACs, and are very important. And lastly, all D-SNPs are required to coordinate, at some level, Medicaid services on behalf of their members. Next slide, please. D-SNP enrollment is growing at a rapid pace, with over five million people enrolled nationwide. If you work with low-income older adults, you need to know about D-SNPs.

These plans were first introduced in 2006, and became permanent options in 2018. Notably, enrollment in D-SNPs have doubled since 2018. D-SNPs operate in almost every state, as well as D. C. and Puerto Rico. There are only five states today who do not have D-SNPs, and those states are Alaska, Illinois, New Hampshire, North Dakota, and Vermont. Compared to their Medicare-only counterparts, dually eligible individuals are more likely to have a chronic illness, they are more likely to be admitted to a hospital, and they are more likely to be a person of color.

More than half of all dual eligibles are people of color, compared with 20% of those who are Medicare-only, and about one quarter of dually eligible individuals report having five or more chronic conditions. So, D-SNPs serve a diverse population and many of whom who have high needs. Next slide, please. So, who regulates D-SNPs? D-SNPs are regulated by both the federal and state government. D-SNPs are a Medicare product, but because they serve people with Medicaid, states also have a say. The Center for Medicare and Medicaid Services, or CMS, sets the ground rules that all D-SNPs must abide by, but states can use those State Medicaid Agency Contracts to set additional requirements above and beyond CMS’s rules.

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, states can choose to further limit enrollment to a smaller subset by putting in provisions in their SMACs. They can limit enrollment to only dually eligible individuals who require a nursing facility level of care, as an example. In our updated D-SNP Brief, which will be released after this webinar, you can find links to a few particular SMAC contracts to give you an idea of all that SMACs can do. SMACs have a significant impact.

They are the vehicle for ensuring that D-SNPs serve their members effectively, and states can use these SMACs to create strong protections and a better experience for dually eligible individuals. Next slide, please. So next, we’ll dive into how people enroll into D-SNPs. Next slide. People can enroll into D-SNPs in multiple ways.

Insurance agents and brokers can market D-SNPs, but there are limits to how insurance agents and brokers directly interact with individuals. People can also affirmatively choose to enroll during one of the Medicare enrollment periods. Individuals may also be enrolled in a D-SNP through a process called default enrollment. In default enrollment, a person is automatically enrolled into a D- SNP when they first become Medicare eligible. That could be either by turning age 65 or through receipt of social security disability.

But to use this process, the D-SNP must meet certain criteria on quality standards and have approval from the state and federal government. Default enrollment is not used by every plan or in every state. There are limits to who is enrolled via default enrollment, and the plan must send at least one notice prior to default enrollment, so individuals always have the right to decline and can choose another path. There is also room for advocacy in this space, and in states where default enrollment is being contemplated or already in place, advocates can request an additional notice be mailed before default enrollment takes place so that people have more time to understand what is happening. Advocates can also ask for stronger continuity of care protections so that newly enrolled individuals do not experience a disruption in care if their previous medical provider is not a network with their new D-SNP.

I also want to particularly highlight State Health Insurance Counseling Programs, SHIPs, or also called HICAPs in some states, are a great resource. SHIP services are free, and they provide counseling on Medicare benefits and plan options. Next slide, please. So, D-SNP enrollment is limited to people who are full benefit, dually eligible individuals. This means they have Medicare Part A and B, and simultaneously enrolled in Medicaid.

Full benefit, dually eligible individuals are entitled to the full range of Medicare and Medicaid, including Medicaid’s covered long-term services and supports, such as home and community-based services. Partial duals are another group you may have heard about. These are people who have Medicare and a Medicare Savings Program, but they are not enrolled in Medicaid with full benefits. Medicare Savings Programs are a form of Medicaid, but they do not offer healthcare and simply provide financial assistance for Medicare cost- sharing. So federal rules do allow D-SNPs to enroll partial dual eligibles, but states can choose to limit that enrollment.

There is a question about the usefulness of enrolling partial dual eligibles into D- SNPs since they don’t have Medicaid services to coordinate. On the other hand, a D-SNP could be beneficial because this group could benefit from supplemental benefits that are offered by a D-SNP, such as vision or hearing. Benefits aren’t otherwise available under original Medicare, but overall, states have the authority to set criteria for a D-SNP enrollment. Next slide, please. D-SNPs can be confusing, and enrollment is no different.

Generally, a person is enrolled in a D-SNP for their Medicare benefits, and their Medicaid is delivered by a Medicaid plan or through fee-for-service. There are different enrollment scenarios for how dually eligible individuals receive their Medicare and Medicaid benefits. Under the Aligned Enrollment model, the D- SNP has an affiliated or matching Medicaid plan. Affiliated means the Medicaid managed care plan, the MMCO for short, has a specific and particular relationship with that D-SNP. Often, this simply means the insurance company that operates the D-SNP also has a Medicaid plan.

So, in Aligned Enrollment, a dually eligible individual is enrolled in the D-SNP, and the Medicaid plan affiliated with that D-SNP, but it’s not required to be in the affiliated Medicaid plan. Under Exclusively Aligned Enrollment, membership in the D-SNP is limited to individuals enrolled in the affiliated Medicaid plan. In this enrollment model, the dually eligible individual is required to enroll in the affiliated or matching Medicaid plan associated with their D-SNP. In Unaligned Enrollment, this means a person is enrolled in a D-SNP, and they could also be in an unaffiliated Medicaid plan, or the person might not be in Medicaid managed care altogether. Not all states have Medicaid managed care, but in these instances, the D-SNP and the Medicaid benefits are unaligned with each other.

And we are discussing these types of enrollment scenarios because in Aligned or Exclusively Aligned Enrollment, one company is responsible for substantially all members, Medicare and Medicaid benefits. That means they have a financial incentive to ensure their members are receiving quality healthcare and avoiding duplicative services or unnecessary hospital admissions and increasing costs. Communication is also increased because it’s easier to communicate and data share when both the Medicare and Medicaid services are administered by the same entity. States can also choose to dictate the level of alignment the D-SNP must have through the SMACs. It could be Aligned or Exclusively Aligned Enrollment, or none at all. Aligned or Exclusively Aligned Enrollment really come into play when you’re discussing integrating Medicare and Medicaid benefits, and Rachel will get to that in just a few slides.

Next slide, please. So people can also disenroll and leave the D-SNP if they want to, for any reason. You can disenroll during the open enrollment period that runs from January to March. Dually eligible individuals can also disenroll from a D-SNP every three months through an ongoing special enrollment period. There are also other special enrollment periods, where people can make changes, and you can learn more about those different special enrollment periods and the qualifying criteria from the link in the slide. And with that, I’ll pass it on to Rachel.

Rachel Gershon: Thank you so much, Tiffany. Next slide. So, we are now going to turn to describing D-SNPs according to their integration levels. And as Tiffany mentioned, navigating the healthcare system can be really hard, much harder if you have a chronic condition, low income, disability, or language access need. It can be harder still when managing two different systems, two different types of health coverage, like Medicare and Medicaid.

So, I’ll give some examples just to give a little bit of context about why we’re looking at integration. So, for example, let’s say you’re trying to access a service, like dental or mental health, your Medicaid may cover some of the service while your Medicare covers another part of that service. Medicare may have different provider networks, payment rules, and appeal processes than Medicaid. Your Medicaid may require a denial for Medicare First, because Medicaid is considered the payor of last resort, but your provider may not know how to get that Medicare denial. And like all individuals navigating the healthcare system, you may need care management and care coordination to navigate the specialty care that you may need.

To work on addressing those needs, CMS has identified different levels of integration for D-SNPs. Next slide. So, welcome. This is the slide with all of the acronyms, and this is the most acronyms we’ll show during the presentation. So these are different designations of D-SNPs according to the level of integration between the D-SNP plan and the Medicaid Managed Care Plan.

At the top, Fully Integrated D-SNPs or FIDE-SNPs, have the highest level of integration. That means a single entity has a contract with CMS to provide Medicare benefits, and a contract with the state to provide Medicaid benefits. They’ll also have that State Medicare Contract, the SMAC for the Medicare benefits as well. HIDE-SNPs are the next level down. The SNP may offer some Medicaid benefits, or have an affiliated Medicaid MCO that offers some Medicaid benefits.

Finally, the Coordination Only D-SNPs, also referred to as CO D-SNPs, have the least integration requirements to coordinate care in some circumstances. Next slide. As this pie chart shows, CO D-SNPs have 3.3 million enrollees. That’s more than half of total D-SNP enrollment. HIDE-SNPs come in at 2.1 million enrollees and FIDE-SNPs, the most integrated, have 400,000 enrollees.

Next slide. I’ll note that this data that we just showed is from CMS, and it’s available on a monthly basis. You can use it to find D-SNP enrollment by state, by plan, and by other factors. It’s in our Brief, under resources, and it’s called the SNP Comprehensive Data from CMS. It’s a great resource.

So, taking a closer look at FIDE-SNPs, a single entity contracted to provide Medicare and Medicaid services. FIDE-SNPs must integrate enrollee communication materials, grievances, and appeals. FIDE-SNPs get paid more than other D-SNPs. Starting in 2025, FIDE-SNPs must be exclusively aligned, meaning that the enrollment is limited to individuals enrolled in both the FIDE- SNPs, D-SNP, and their Medicaid Managed Care Organization. Starting in 2025, if the FIDE-SNP doesn’t already cover primary care, behavioral health, home health, and medical equipment and supplies, it must do so.

And I’m sorry, I think FIDE-SNPs already cover primary care, but in addition, in 2025, they must cover behavioral health, home health, and medical equipment, and supplies. And starting in 2025, FIDE-SNPs must cover Medicare’s cost- sharing, so that includes co-insurance and deductibles in your Medicare. Next slide. HIDE-SNPs will often cover most Medicaid services either through the same entity or through an affiliated Medicaid Managed Care Organization. HIDE-SNPs are permitted to have behavioral health or long-term services and supports excluded, but they can’t exclude both.

They have to either cover behavioral health, long-term services and supports, or both. The state itself may have carved behavioral health or long-term services and supports out of the Medicaid Managed Care Contract, which is one reason why you see HIDE-SNPs, instead of FIDE-SNPs in the state. HIDE-SNPs do not have to be exclusively aligned even after 2025, when FIDE-SNPs do. Next slide. So, CO D-SNPs, they have the lowest level of requirements in terms of integration.

They must provide care coordination, and they must notify Medicaid when a subset of their enrollees are hospitalized or admitted to a nursing facility. Next slide. So, there’s one more designation, one more acronym I’m going to cover. It’s called Applicable Integrated Plans, or AIPs, and it can apply to FIDE-SNPs, HIDE-SNPs, or CO D-SNPs. Applicable Integrated Plans, or AIPs, must implement integrated appeals, which I’ll talk about later.

In order to be an AIP, FIDE-SNPs and HIDE-SNPs must have exclusively aligned enrollment, meaning, that they will only accept enrollment from individuals also enrolled in a Medicaid Managed Care Organization. In order to be an Applicable Integrated Plan, CO D-SNPs must also have Exclusively Aligned Enrollment, and must offer additional benefits. If you look at our Brief, appendix B goes through each of these categories of FIDE-SNPs, HIDE-SNPs, and CO D-SNPs, along with whether they are an AIP or not an AIP and what they look like. Next slide. So, you may be watching this from a state that does not have Medicaid Managed Care or has limited Medicaid Managed Care, and that will affect the kind of D- SNPs available in your state, and the kind of integration level.

States vary in the terms of the levels of Medicaid Managed Care. Some states are working on helping individuals to navigate healthcare systems without Medicaid Managed Care, like through health homes. So managed care is not necessarily the only route through which states are looking at integrating care for dually eligible individuals. Next slide. So, it’s important to think through what integrated care might look like from an enrollee’s perspective. “Are they getting clear communication and help navigating services?”

“Are there available providers for them? Are there services? Are there services being approved? Is their integrated structures actually translating into better access to services, and are there consumer protections during times of transition to mitigate disruption and benefit access?” I’ll turn it over to Tiffany for D-SNP requirements.

Tiffany Huyenh-Cho: Great. Thanks, Rachel. So next, we’ll go into some of the minimum requirements that all D-SNPs must abide by. These are all the minimum requirements that CMS requires of D-SNPs. We’ll also discuss other protections D-SNPs can implement to specifically address the needs of their member population.

These are areas where D-SNPs are, or can be different from and do more than a regular Medicare Advantage Plan. Next slide, please. At a minimum, all D-SNPs, regardless of type, must meet certain requirements. First, all D-SNPs must have an improved Model of Care that is scored for quality. The Model of Care is a document that’s produced by the D-SNP, that describes how they will provide healthcare services and care management to the population that they serve.

D-SNPs are also required to at least generally coordinate Medicaid benefits. This means D-SNPs must offer assistance to its members with obtaining Medicaid services. It could be providing help with prior authorizations for Medicaid services, as well as assistance with grievances and appeals. All D-SNPs must screen members for social needs in the areas of housing, food insecurity, and transportation. And lastly, D-SNPs must have an enrollee advisory committee, that is reasonably representative of the plan’s membership.

And apologies, noticed a typo on the date. The slide should read January 2023, not 2025. So enrollee advisory committees are an important tool for both members and for plans. They represent opportunities for individuals to provide direct feedback to D-SNPs about their experience and any challenges that they are facing. D-SNPs, in turn, can use this feedback to modify internal practices and protocols, so they are more responsive to the experience of its members and their needs. Next slide, please.

Communications are also an area where D-SNPs can improve and simplify the experience of its members. Because all D-SNP members are dually eligible, they are receiving documents from both Medicare and Medicaid. Oftentimes, a mailing from a person’s Medicaid plan will not reference Medicare. This is problematic because it causes confusion about the role Medicare plays in this person’s care, and on the flip side, oftentimes, a D-SNP that does not have integrated communications may be sending out materials that do not reference a person’s Medicaid status. So D-SNPs can simplify the member experience by integrating member materials that it mails out.

If a D-SNP has aligned enrollment, there are opportunities for seamless communication about benefits. For example, one list of network providers or a single drug list, that includes both the Part D prescriptions and the over-counter medications that are covered by the Medicaid plan. The annual notice of change can be modified to describe what is changing on both the Medicare and Medicaid side as well for the new plan year. If done right, this is good. It is simpler and better for the dually eligible enrollee.

A single health plan number to address both Medicare and Medicaid questions is also a simple and impactful tool as well. Right now, there is no requirements for all D-SNPs to create integrated communications, but CMS is encouraging it and working with states and plans that have already started doing it or want to. And another advocacy point to highlight is that sometimes a state can have translation requirements for its Medicaid plans that is stronger than the federal standard for Medicare. This means the Medicaid plan is required by the state to translate its materials into more languages than the federal government requires. If that’s the case, we urge states to use their SMACs to require D-SNPs to translate its materials to the standard that is most beneficial to its members.

This way, a person enrolled in a D-SNP isn’t receiving materials on the D-SNP side in English, and then receiving Medicaid materials in their actually preferred language. Next slide, please. So all D-SNPs too, at a minimum, must provide some level of care coordination to help members navigate services. This includes the minimum requirement to coordinate Medicaid, and D-SNPs must also establish a care plan and create a individualized care team for each member and use health assessment tools to create the care plan and address unmet health and social needs. Because D-SNP server population with high needs, plans are expected to help arrange services on the member’s behalf if they need it.

Care coordination has greater potential too, in the Aligned Enrollment models, because information about inpatient stays, care transition, and service needs can be shared more efficiently and effectively when all benefits are administered by the same health plan entity, and, of course, all of this depends on reliable and accurate data sharing. Good data exchange is key to ensuring that all parties involved in a person’s care have up-to-date information on their condition and the medical services they are receiving or aren’t. There is a push for more integration in plans in order to increase the level of care coordination and seamless communication that is happening across D-SNPs, so it is important to pay attention to this space, because there is a lot of change that is happening in past months and in the future. Next slide, please. So D-SNPs can also offer supplemental benefits to its members.

These are extra benefits beyond what you can get from original Medicare Part A and B. These include services like dental and hearing aids, or even a grocery allowance for food. All of which, these are supplemental benefits that are not normally covered under traditional Medicare, so D-SNPs can fill in the gaps by offering these supplemental benefits. So while supplemental benefits are overall positive, advocacy is still needed. It’s not always clear to D-SNP members or to advocates how people can access these benefits.

It’s also not always clear, the eligibility criteria needed to qualify for these supplemental benefits. And additionally, supplemental benefits are often duplicative of services that are already covered by Medicaid, such as vision or dental. Some states include vision or dental in their Medicaid package. So in these instances, it can be confusing to determine if a person must use the supplemental benefit first or Medicaid. Advocacy can be done to ensure that individuals are given clear information about the scope of the supplemental benefits that their D-SNP offers and how to coordinate it with Medicaid so that they get the full scope, full benefit of each.

Next slide, please. Social determinants of health are non-medical needs that can impact a person’s overall health and well-being. Common examples are homelessness, or food insecurity. A person who does not have access to enough food or food of high quality may have poorer health. So the D-SNP has a responsibility to learn of these social determinants of health and determine how to address them.

It could be by offering a grocery food allowance as a supplemental benefit to address that food insecurity. D-SNPs can also address other needs too, by referring members to resources in their community, or collaborating with multiple parties to connect individuals to stable housing, for example. All to say, there isn’t just one strategy to address these social needs, but D-SNPs can play an important role in connecting individuals to resources in the community to offering supplemental benefits that can address a lot of needs and play a role in improving that person’s overall health and well-being. And with that, I’ll turn it over to Rachel.

Rachel Gershon: Thanks so much, Tiffany. So the next slide is about integrated appeals. So as I mentioned earlier in this presentation, D-SNPs with an AIP, Applicable Integrated Plan designation, must offer integrated appeals. What this means is that when there’s something that might be covered by Medicare or Medicaid, the plan in an integrated model reviews the request, looking at both the criteria of both Medicaid and Medicare, and then sends a notice reflecting that combined review. If the plan denies coverage, then the first level of appeal, which is always reconsideration by the plan, that would also be a combined review, looking at both Medicare and Medicaid criteria. For the member, this can really simplify the process.

Not only are they getting notices combined from the plan, but there’s only one set of procedures that they have to follow, and only one submission that they have to make, instead of making separate submissions for appealing a service, both on Medicare grounds and Medicaid coverage. But just to be clear, if there is still a denial, then further appeals do split, so after that reconsideration level, members do have to follow different routes for appeal, even in an integrated appeal scenario. Next slide. So looking forward, there is a proposed rule, that was proposed last fall. Comments were due in early January, and we’re looking at it being released soon, I think.

The rule could potentially implement some helpful policies, including reducing the choice overload that some folks face. We hear a lot about just dozens and dozens of plans in some areas, that people have to choose between. It may implement some policies that promote Aligned Enrollment through state D-SNP contracting through that SMAC. It introduces a new monthly special enrollment period for integrated plans. That’s a lot of big words, but basically, it means that for people who are dually enrolled in Medicare and Medicaid under this new rule, if it’s finalized as it was proposed, people could potentially disenroll from Medicare Advantage Plans on a monthly basis, rather than a quarterly basis, and they may have additional options to switch plans as well, though, there are some limitations around that offering.

There’s also some increased transparency around supplemental benefits, including a mid-year notice sent out to folks about which supplemental benefits they may be eligible for and may be missing out on. And then finally, there’s a potential for some Medicare plan finder improvements, which we’ve commented on a few times in the past, to make sure that for folks who are dually enrolled in Medicare and Medicaid, when they look up which Medicare Advantage Plans are available to them, including D-SNPs and other plans, they have the full amount of information they need to make those choices. Next slide. So now, I’m going to take some time and turn to some state advocacy opportunities in this space. Next slide.

I want to acknowledge, start by acknowledging that this can be a tough area for advocacy. These are two huge and hugely different systems in Medicare and Medicaid. We want to build an infrastructure for a better system so that folks who are dually enrolled can access their benefits when they need it, with minimum administrative burden on their part, and that means improving state capacity, building effective channels for individuals with lived experience to contribute to plan design early and often, rather than being told what the design is, addressing areas around communications, supplemental benefits, and transitions of care. For example, when you transition from one plan to another, whether your prior authorizations move over as well, so you don’t have to go through that process again, what happens if your network changes, those kind of transition issues, and accountability to hold plans to the high standard of making sure that people get coordinated, access to the care that they need. Next slide.

So where to start in this challenging environment? We recommend starting by learning your local and state D-SNP landscape, and we’ve listed some specific resources in the Brief, where you can find state-specific resources and to understand what’s going on in your state. You can engage with the state to leverage the power they have in contracting, really, thinking about those contracts with the D-SNPs, the SMACs is what we call them, and what states can put into those SMACs to make sure that plans are offering the best care for dually enrolled folks, and then also, accessing the state’s contract with Medicare Advantage, both while it’s being developed and when it’s finalized. Next slide. We’ve listed some resources.

Justice In Aging, as we mentioned before, has an Integrated Care Education Project, that will include a general audience, like today, and also some listserv and other offerings for different groups of advocates. We have our D-SNP Look- Alike Primer, talking about the issue where sometimes there are Medicare Advantage Plans that are not D-SNPs, so not covered under the rules that we talked about today, but they look like D-SNPs, so talk about how those are limited under new CMS rules. The Integrated Care Resource Center is a great place to look for additional materials, as well as the Kaiser Family Foundation, now known as KFF. I apologize, there’s a typo on that page. Kaiser Family Foundation changed their name to KFF.

I will mention that KFF is not affiliated with Kaiser Permanente, which does have Medicare Advantage Plans, but there are different organizations. And finally, I’ll turn my attention to the last bullet around Medicaid arrangements to coordinate Medicare and Medicaid. That is another option for looking at state- specific landscapes in terms of what is being offered state by state in D-SNPs. And with that, I will thank you for your attention, and turn it back over to Hannah.

Hannah Diamond: Thanks so much, Rachel and Tiffany. So we have gotten quite a few questions during the course of the webinar, and we encourage you all to keep asking. Maybe at a very high level, you could explain, either one of you, Tiffany or Rachel, the difference, again, between a Dual Eligible Special Needs Plan and a typical Medicare Advantage Plan.

Tiffany Huyenh-Cho: I can answer this one, and Rachel, feel free to add in anything that I missed. The Dual Eligible Special Needs Plans are a type of Medicare Advantage, but they are created specifically to serve that dual eligible population. Other Medicare Advantage Plans that are not D-SNPs are not designed that way. They do these other Medicare Advantage Plans that are not D-SNPs, do not have contracts with the State Medicaid Agency. They don’t have the same requirement to coordinate someone’s Medicaid benefits.

So there are additional requirements and features of a D-SNP that a regular Medicare Advantage Plan is not required to be beholden to. So on a high level, that’s the big differences, and then as you get down to each individual D-SNP itself and each state, there’s many more differences that can come up simply because of those state contracts, those State Medicaid Agency Contracts, that can require the D-SNP plans to do more on behalf of dual eligibles.

Rachel Gershon: Thanks so much, Tiffany. I will reiterate that D-SNPs are a type of Medicare Advantage Plan. In fact, they’re 40% of Medicare Advantage enrollment. So when you hear in the news of different challenges being experienced by enrollees to Medicare Advantage Plans, I think that’s absolutely things to look at for folks who are in D-SNPs, since they are under the umbrella of Medicare Advantage.

Hannah Diamond: Thanks, both. So there’s some questions about full and partial duals. If you could maybe define both for us, and regarding the full duals, does it matter kind of what Medicaid pathway you’re using to access these benefits? Maybe help us define, what is a full benefit dual, what is a partial dual, and who is making the decision at the state level regarding whether or not partial duals can enroll in a D-SNP?

Rachel Gershon: Absolutely, thank you. So when you think of a full dually enrolled individual, that’s someone who has full Medicaid, so the full slate scope of services that you typically see in a Medicaid enrollee. You can have full Medicaid, and also get a Medicare Savings Program, often QMB, to help pay for Medicare premiums, but if you have those full Medicaid scope of benefits, you’re considered a full benefit dual. Partial duals are folks who do not receive Medicaid services through their Medicaid benefit. They are only enrolled in a Medicare Savings Program.

There’s a lot of names for Medicare Savings Programs. You might’ve heard Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, or Qualified Individual. Sometimes you might hear acronyms like QMB, SLMB, or QI for those individuals. So folks who are partial duals, meaning, that they have Medicare benefits and their State Medicaid Agency helps pay, maybe for premiums, maybe for co-insurance and deductibles, but the Medicaid agency doesn’t offer traditional Medicaid benefits, those partial duals may may be able to enroll in a D-SNP. It depends on a state decision.

I haven’t seen the most recent statistics around how many states allow partial duals to enroll in D-SNPs, but the last time a organization looked at this, I think MACPAC, we have it in our Brief, the majority of states were still allowing partial dual folks to enroll in D-SNPs. As we’ve raised, there are some questions about whether D-SNPs are the best option for somebody who is a partial dual, just because they’re not receiving those Medicaid benefits, so they may not be the target audience for the coordination of payers, coordination of benefit functions of a D-SNP. But that’s kind of still an open question that we’re looking at, and trying to listen to enrollees in terms of what works for them.

Tiffany Huyenh-Cho: I’ll just add, Rachel summed it up well, SMACs, the State Medicaid Agency Contracts may have that information about whether or not they are allowing partial duals to enroll, but I mean, I think the best and most accurate place to get that answer is to reach out to the Medicaid agency or the D-SNP itself to determine if they will allow partial dual eligibles to enroll into the plan.

Hannah Diamond,…: Thanks, both. So it seems like there’s some questions from individuals themselves who, perhaps are receiving benefits through both programs or someone who’s assisting an individual to make these insurance decisions. So how does someone know if they’re enrolled in a D-SNP, and specifically, how do they know what kind of D-SNP, and then maybe who helps individuals or who’s available to help them in navigating this decision-making process?

Tiffany Huyenh-Cho: That’s a good question, and that is a very common question. That is one of the struggles that we hear nationwide, is that it’s difficult to determine what type of D-SNP that you are enrolled in, or that is available in your county or state. It’s not always readily apparent. Oftentimes, the evidence of coverage will say FIDE or HIDE, but on someone’s health plan ID card, it may not necessarily list or identify the type of D-SNP, so we do recognize that that is not something that is fully transparent. The D-SNP should be able to tell a person what level of integration that they have.

SHIP counselors are good resource for getting help with understanding what their options are, understanding what the different levels mean, and what they can provide, who are the contracted providers, as well. And then, as Rachel mentioned, there is some recent proposed rulemaking that was released late last year. Part of that rulemaking does ask for suggestions about, like the Medicare Plan Finder, and there were a lot of comments from us, including that the Medicare Plan Finder should be adjusted so that it is more transparent about what type of D-SNP is being offered. Is it a FIDE, is it a HIDE, or is it a Coordination-Only D-SNP? But right now, unfortunately, from what I’ve seen and understand, it isn’t fully transparent, but there’s definitely a lot of advocacy and push to make that information a lot clearer.

Rachel Gershon: Great answer. Summed it up well, Tiffany. I’ll add a couple of other things. I would definitely start with the route that Tiffany mentions, look at your plan documents, talk to your plan to try to figure it out. There’s also a supplement to the Medicare & You handbook.

It is not available online, but you can request it for your local area, which will list plans available in your area, which may give additional information. And then as a data person, I often go to CMS’s monthly. They put out a monthly Excel spreadsheet of all the D-SNPs, their names, their contract name, plan name, and how many enrollees by state, and whether they’re a FIDE, HIDE, CO. I say that with a caveat because I don’t know how well those names, though, the official contract and plan names may match up with what’s on your card, so that might be a little challenging to match up from a data perspective.

Hannah Diamond: Thanks, both. So we just answered the question kind of about on the individual level, how someone’s finding out more about the services and benefits that they’re receiving. What about advocates who are hoping to get more engaged in the D-SNP landscape in their state? Where do they find out information about their D-SNP landscape? How can they access their state SMAC? What are some steps that they can take to kind of start educating themselves?

Rachel Gershon: Thanks so much. For advocates, the two resources I mentioned are probably better at an advocate level than an individual level, though. So the Medicare & You might be helpful for individuals to find, but also advocates to just know what’s offered. The data resources will show you how many enrollees there are by state, by plan, and by type of plan, so that can be helpful as well. And in terms of accessing the SMAC, I think we are on a journey to figure out how transparent these SMACs are.

Some states have them available on their website. In our Brief, we do mention a resource. It’s called… It’s from the Integrated Care Resource Center, that has sample SMAC language, and those footnotes in that Brief actually link to a lot of online SMAC, so you can start there to see if there’s online, and some are not available online. And ICRC will say that right there. And that is a great opportunity and advocacy to make sure they do become public, because these are documents that affect a great number of people and documents that reflect policy decisions that states are responsible for.

Hannah Diamond: Thanks so much, Rachel, for underscoring kind of the importance of the SMACs there, and how advocates also can engage. Okay, I see a good question, just kind of fundamental differences between FIDE, HIDE, and Coordination-Only D- SNPs. If we could, at a very high level, talk about the varying levels of integration there.

Rachel Gershon: Absolutely. It can be confusing. I find myself having to go back to my notes, even to write the script for this webinar, even though I wrote the Brief, because it can be hard to wrap your head around. So FIDE-SNPs have the most integrated requirements. That means that one entity contracts with the state and contracts with CMS for both Medicaid and Medicare benefits.

The HIDE-SNP is a little less. So it can be one plan, just like FIDE-SNPs, that contracts for those Medicaid and Medicare benefits, or it could be a D-SNP and a Medicaid Managed Care Organization, which we also call MMCO, that are different plans, but they may be owned by the same parent company. So they’re related in an organizational way, but they don’t have to be the exact same entity. HIDE-SNPs also don’t have the same amount of coverage requirements. They do have to cover either LTSS, long-term services and supports, or behavioral health.

And then finally, Coordination-Only D-SNPs don’t have that requirement to have a related organization, cover the Medicaid, be in contracts with the State Medicaid Agency to cover Medicaid benefits, though, the Coordination-Only D- SNP can contract with that Medicaid agency for their D-SNP benefits. So that’s where the SMAC comes in. It gets complicated. And then CO D-SNPs do have some care coordination requirement, that you can imagine, if you are a CO D- SNP, that has an entirely different Medicaid plan that’s not even in the same company that offers Medicaid benefits. There may be some limitations and barriers to offering truly coordinated and truly navigate the benefits in there.

But as we mentioned, if you’re an Applicable Integrated Plan, like CO D-SNPs can be, there may be some additional benefits, including integrated appeals, that can be helpful for folks.

Hannah Diamond: Thank you. I see some questions throughout about supplemental benefits, and there’s a lot of data needs surrounding supplemental benefits, so I appreciate that people are asking about that. What should an individual consider when reviewing a plan supplemental benefits, especially as it relates to their Medicaid benefits?

Tiffany Huyenh-Cho: Well, I think a good first start is to understand what benefits that your Medicaid plan or Medicaid package in your state offers, and if it is duplicative of the supplemental benefits that the D-SNP may offer. We do see often that they are duplicative, so it does call into question whether or not a D-SNP that is offering vision is actually providing an extra benefit since that person is already getting access to vision care through their Medicaid benefits itself. Same thing with dental. And it is an individual decision, so I think that is the first step, is to really think about, “Does this plan really offer me more just because they have vision?,” since you’re already getting access to vision through Medicaid. Oftentimes, when a plan is offering a supplemental benefit that is duplicative of Medicaid, that person must use the Medicare supplemental benefit first, and that can also cause some problems if someone is getting a service from a supplemental benefit provider, that is not enrolled in Medicaid.

If you’re then veering into a space where you may need to use some of the Medicaid benefits, it would be important to use a provider that accepts both Medicare and Medicaid, so you’re not running into issues where you may get improperly billed for services, because the provider that you saw does not contract with Medicaid and won’t then bill them for any extra services, such as dental or vision, if that is what you’ve originally came to them for through your Medicare D-SNP.

Rachel Gershon: I will add on, if you are a dually enrolled person, you generally should not be being charged or improperly billed, and Justice In Aging does have resources around what we call the Improper Billing Toolkit around how to address those issues.

Hannah Diamond: Okay. Quickly, before we do a final closing, Rachel, you talked about integrated appeals. There was a request for you to review kind of what an integrated appeal is and kind of its importance.

Rachel Gershon: Of course. I will start with, if you’re not in an integrated appeal scenario, at the beginning, let’s say you need a certain benefit and you’re not sure if Medicare or Medicaid covers it, you may have to request it from both plans, and then if they deny it, you may have to follow different timelines, different methods of asking the plan to reconsider, and just a lot of paperwork. And we know that appeals are already confusing as they are, but doing two appeals at once can be really difficult. Under integrated appeals, it’s not a perfect solution, but it is moving in the right direction in terms of a plan is required to do the work of applying the Medicaid requirements and applying the Medicare requirements to your request, to see if either one will say yes, and then giving you a notice that has both Medicaid and Medicare decisions and the same notice. So you’re not taking two sheets of paper with different ways of describing things and trying to figure out what they mean together.

And then, you can appeal at the reconsideration level, and similarly, the plan has to offer an integrated decision, integrated communication around that decision. And again, not all D-SNPs have to do an integrated appeal. D-SNPs that are Applicable Integrated Plans do. In our Brief, we actually break down the numbers to show how many plans are Applicable Integrated Plans by integration level.

Hannah Diamond: Thank you so much, both Rachel and Tiffany for today’s presentation and for your wealth of knowledge and for sharing it with us. Advocates, thank you for joining us today, and be on the lookout for the accompanying Issue Brief, and also, we’re recording today’s presentation and the PowerPoint materials. We look forward to joining you all on Improving Integrated Care for People Dually Eligible. Have a great day, everyone.

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