Table of Contents

This toolkit provides policy makers, including State Medicaid Agency staff, and advocates, with principles and corresponding template language to develop State Medicaid Agency Contracts (SMACs) that are responsive to the needs of the dually eligible populations they serve. Stakeholders are encouraged to use this tool to advance their priorities by tailoring the components that are most appropriate for their state’s integrated environments. For this tool, in instances where existing SMAC language is not publicly available or has not yet been written, Justice in Aging provides suggested template language to help advance key consumer protections and principles.

Drawing from Justice in Aging’s D-SNP Issue Brief, we center the experiences of dually eligible enrollees and highlight the challenges faced by this population in navigating their health insurance coverage. To guide the discussion, we reference the Justice in Aging Guiding Principles, a core set of values and goals that call for robust consumer protections, health equity, person-centered care, and more oversight and accountability in integration models. Justice in Aging will release subsequent sections of this toolkit in the coming months. The template language in this toolkit has been adapted from existing state SMACs.

Eligibility and Enrollment

People dually eligible often experience significant confusion during the D-SNP enrollment process, especially regarding the eligibility criteria for enrolling in a D-SNP, whether they may be subject to default enrollment, and what protections are available if they lose D-SNP eligibility. Clear and accessible contract language is key for individuals to understand their rights and options, and for plans to understand their obligations.

Default Enrollment: Choice

Guiding Principle

Integrated models safeguard consumer choice and enable informed and unbiased decision-making.

Supporting Principle

People dually eligible are guaranteed the right to choose their coverage.

Federal Requirement

The Centers for Medicare and Medicaid Services (CMS) permits default or automatic enrollment into a D-SNP when a Medicaid enrollee becomes newly eligible for Medicare either through age or disability, and the individual is already enrolled in a Medicaid Managed Care Organization (MMCO) operated by the same sponsor as the D-SNP.1

SMAC Recommendations

States should allow people dually eligible the opportunity to actively choose their coverage. Advocates should consider asking states to refrain from default enrollment. If default enrollment is allowed, plans should be required to provide a clear and streamlined opt-out mechanism without lock-in periods. SMACs should make clear that enrollees retain the right to choose how they receive their Medicare benefits, even when default enrollment is permitted. States should use their SMACs to collect information about default enrollment—who is default enrolled, how many individuals opt out, and how many complaints were filed— to better understand the implications of default enrollment.

Template Language

Ohio

Despite implementing default enrollment, the Ohio SMAC incorporates language around consumer choice.

  • An eligible individual’s decision to enroll in the Medicare Advantage Organization (MAO) for Medicare benefits shall be choice-based. While default enrollment may be used to promote enrollment and alignment, individuals retain the right to opt out, consistent with federal regulations.2
Arizona

While default enrollment is allowed, Arizona incorporates language about improving alignment efforts and respecting member choice.

  • The [state medicaid agency] and MAO will continue to work with stakeholders to establish practices which improve alignment for Full Benefit Dual Eligible Members. The beneficiary’s choice of MAO shall be fully respected, and consequently, misalignment may occur.3

Additional SMAC language

  • The D-SNP Contractor shall clearly communicate the voluntary nature of plan enrollment and describe alternative care delivery options to enrollees in beneficiary facing enrollment materials, including but not limited to, enrollment notices and marketing materials.
  • Upon request, the D-SNP Contractor shall provide [the state medicaid agency] with data related to default enrollment within timeframes and specifications defined by the Agency. This shall include, at a minimum:
    • The number and percentage of individuals who opted out before enrollment became effective;
    • The number and percentage of individuals who disenrolled within the first six months of plan enrollment, including to what extent disenrollment was attributed to the plan not meeting their needs (as self-reported through grievances, exit interviews, or other beneficiary feedback mechanisms);
    • Disaggregated demographic data (e.g., age, zip code, race/ethnicity, sexual orientation and gender identity, primary language, and disability status);
    • The number and nature of complaints or grievances related to the default enrollment process.
  • [the state medicaid agency] reserves the right to request additional data or reporting to evaluate the equity, transparency, and beneficiary experience associated with default enrollment.4

Default Enrollment: Notice

Guiding Principle

Integrated models safeguard consumer choice and enable informed and unbiased decision-making.

Supporting Principle

People dually eligible receive clear, accurate materials that enable informed enrollment decisions.

Federal Requirement

Per 42 CFR 422.66(c)(2)(iv), if default enrollment is allowed, states must require plans to issue written notification to dual eligible populations impacted no fewer than 60 calendar days prior to the plan effective date.

SMAC Recommendations

In addition to the 60-day notice, D-SNPs should be required to issue an additional 30-day notice that is consumer tested, meets Medicare’s five percent (5%) threshold for language translation as outlined in 42 CFR Part 422 Subpart V and any additional language and accessibility standards required by the state.

Template Language

California
  • California requires an additional 30-day notice for dual eligible individuals impacted by default enrollment. This notice informs individuals of their right to opt out before the enrollment becomes effective and provides key details, including how to decline enrollment, where to seek assistance in making an informed decision, and the contact information for the State Health Insurance Assistance Program (SHIP) and Ombuds program.5

Eligibility Criteria for D-SNP Enrollment

Guiding Principle

Integrated models safeguard consumer choice and enable informed and unbiased decision-making.

Supporting Principle

People dually eligible receive clear, accurate materials that enable informed enrollment decisions.

Federal Requirement

States must list D-SNP eligibility criteria in their SMAC.6 While federal law broadly describes D-SNP eligibility to apply to dual eligible individuals, states have the authority to further restrict eligibility to certain groups of dual eligible populations.

SMAC Recommendations

SMACs should clearly explain who is eligible for D-SNP enrollment so that individuals, their caregiver(s) and/or representatives understand their options. For example, states can deny D-SNP eligibility to partial- benefit dual eligible individuals and individuals who are in Medicaid with a spend down or share of cost (medically needy eligibility). States should also include antidiscrimination language within their description of D-SNP eligibility.

Template Language

Arizona

Arizona’s SMAC explicitly limits D-SNP enrollment to full benefit dual eligibles.

  • The Contractor shall enroll an eligible Full Benefit Dual Eligible Member only in accordance with the eligibility, terms, service area counties and plan benefit packages (PBPs) listed for each of the respective integrated managed care contract, and populations as designated by specific contracts, contract terms, or as otherwise further specified.7
Washington

Washington’s SMAC provides antidiscrimination language.

  • Unless a Dual Eligible is otherwise excluded under federal Medicare Advantage plan rules, the Contractor will accept all Full Dual Eligible individuals who meet the state-defined enrollment criteria without regard to physical or mental condition, health status or need for or receipt of health care services, claims experience, medical history, genetic information, disability, marital status, age, sex, national origin, race, color, or religion, and will not use any policy or practice that has the effect of such discrimination.8
Additional SMAC language

The Contractor shall enroll only those dually eligible members who meet the enrollment criteria as defined by [the state medicaid agency]. The Contractor shall enroll only full benefit dually eligible individuals. Individuals who qualify for only Medicare Savings Program (i.e., partial duals) and who do not have full Medicaid benefits, shall not be eligible for enrollment unless explicitly permitted by the State. The Contractor is required to specify populations eligible for enrollment in their beneficiary facing enrollment materials.

Enrollment and Consumer Assistance

Guiding Principle

Integrated models safeguard consumer choice and enable informed and unbiased decision-making.

Supporting Principle

People dually eligible have access to unbiased enrollment assistance.

Federal Requirement

Per 42 CFR 422.562(a)(5), D-SNPs are required to assist enrollees in accessing Medicaid benefits and resolving grievances. CMS allows plans to provide assistance in multiple ways including referring enrollees to outside experts such as Ombuds Programs, State Health Insurance Assistance Programs (SHIPs), and others.9

SMAC Recommendations

States should require plans to support enrollees in resolving issues related to enrollment. SMACs should also specify a clearly defined role for Ombuds programs to ensure enrollees have access to objective information, and independent consumer assistance, so that they and or their caregiver(s) can make informed enrollment decisions. Plan enrollment notices should include the helpline numbers to the Ombuds programs, and other independent experts, for dual eligible individuals who seek options counseling.

Template Language

Ohio

The Ohio SMAC provides clearly defined roles for the State Ombuds program,10 and the language should be broadened to encompass additional independent Ombuds programs:

  • Ombuds Programs provide core services to members, including outreach, member empowerment through education, complaint investigation, person-centered complaint resolution, and the collection and reporting of casework data and thematic complaint analysis to CMS on a quarterly basis.
Additional SMAC language
  • D-SNP contractors must prominently feature the helpline numbers for Ombuds programs, State Health Insurance Assistance program (SHIP), and the Aging and Disability Resource Center(s) (ADRC) in all member enrollment materials.

Supplemental Benefits

D-SNP supplemental benefits often duplicate Medicaid benefits already available to dually eligible enrollees. In many cases, overlapping services provide limited utility and can be difficult for the members to navigate. In addition, information about eligibility and how to access supplemental benefits is often unclear, and transparency issues persist when data about who actually receives the benefits is not collected or reported.

Supplemental Benefit Offerings

Guiding Principle

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

Supporting Principle

Integrated plans encompass services beyond those typically covered by Medicare and Medicaid.

Federal Requirement

D-SNP supplemental benefits consist of mandatory and optional supplemental benefits that must meet CMS requirements including the requirement that the benefits are not covered by Medicare Parts A, B or D.11

SMAC Recommendations

To avoid payment duplication, states can require plans to submit Medicare bid information.12 States should also require D-SNPs to explicitly avoid benefit duplication, fill in gaps in services, and expand existing benefits.

Template Language

Pennsylvania

Pennsylvania requires D-SNP supplemental benefits to fill gaps in coverage:

  • The D-SNP will offer at least one mandatory Supplemental Medicare Benefit that is designed to fill a gap in Medicaid services for which full duals are eligible. These may include, but are not limited to, gaps in hearing or vision services. D-SNPs may not impose any cost sharing to the Supplemental Medicare Benefits offered.13

New Jersey

New Jersey requires D-SNPs to avoid duplication with supplemental benefits:

  • Supplemental benefits offered as a component of the Contractor’s FIDE SNP product shall conform to the specifications in Chapter 4 of the Medicare Managed Care Manual (in section 30 et seq.), and 42 CFR 100, SSA 1852(a)(3)(D), and shall not be duplicative of services covered by Medicare or Medicaid as part of the base FIDE SNP benefits package.14
Additional SMAC language
  • The D-SNP contractor shall offer supplemental benefits that expand access to services beyond those offered in the Medicaid state plan and/or Medicaid waivers, including and not limited to non-medical transportation, Home and Community Based Services (HCBS), caregiver supports, dental services, and behavioral health services.15

Flex Cards/Debit Cards

Guiding Principle

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

Supporting Principle

Integrated plans encompass services beyond those typically covered by Medicare and Medicaid.

Federal Requirement

CMS recently clarified that Medicare Advantage (MA) supplemental benefits using debit cards should be excluded from the calculation of income when determining eligibility for public benefit programs.16

SMAC Recommendations

States can require D-SNPs to work directly with enrollees on supplemental benefits access, and assign a point-person to assist members with accessing supplemental benefits that overlap with existing Medicare and Medicaid benefits. SMACs should provide clear guidance and require plans to offer enrollment counseling supports to ensure that supplemental benefits in the form of debit or “flexible” spending cards do not negatively impact enrollees.

Template Language

Pennsylvania

Pennsylvania requires plans to inform enrollees and provide assistance with access to supplemental benefits:

  • The D-SNP shall assess the member’s needs for services that are covered by the D-SNP as supplemental benefits such as dental and/or transportation services. Further, the D-SNP shall educate members on how to access supplemental benefits.17
Additional SMAC language
  • The Contractor shall assign a plan representative such as a Care Manager to support enrollees when supplemental benefits overlap with Medicaid benefits including and not limited to dental care, durable medical equipment, and non-medical transportation.18 If supplemental benefits in the form of debit cards are offered, the contractor shall provide counseling support to ensure that these benefits meet the needs of enrollees and do not negatively impact eligibility for public benefits.19

Supplemental Benefit Utilization

Guiding Principle

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

Supporting Principle

Members can access their Medicare and Medicaid benefits without delay.

Federal Requirement

By January 2026, D-SNP plans will be required to notify enrollees with a mid-year notice if enrollees have not used most of their supplemental benefits by June of that year.20

SMAC Recommendations

Many SMACs already establish additional requirements for supplemental benefits, such as requiring plans to report benefits utilization and clearly define eligibility criteria. States should ensure D-SNPs provide supplemental benefits equitably and transparently.

Template Language

Ohio

Ohio requires plans to report data on supplemental benefits utilization:

  • All data on any services provided to members that are not reflected as claims or encounters will be reported to the state via [include specific reporting system]. This includes but is not limited to care coordination, non-emergency transportation, Medicare supplemental benefits, and other value- added or additional services.21

Washington

Washington requires plans to delineate which supplemental benefits are available to specific dual eligible populations:

  • Upon receiving written approval from the State, the Contractor may operate separate Plan Benefit Packages (PBP) for full dual eligible Members and partial dual eligible Members. The Contractor’s PBPs and eligible Members are detailed in [insert smac section].22
Additional SMAC language
  • The D-SNP Contractor shall report quarterly disaggregated demographic data (e.g., age, zip code, race/ethnicity, sexual orientation and gender identity, etc.) for all enrollees who utilize supplemental benefits. The Contractor shall include all eligibility requirements for supplemental benefits in a public-facing website.

Endnotes

  1. See CMS, “Default Enrollment Policy and Data on Approved Medicare Advantage Plans,” (October 23, 2023) (Accessed February 12, 2025). ↩︎
  2. Ohio Department of Medicaid, “Next Generation MyCare Ohio Provider Agreement for MyCare Ohio Plan,” Attachment A, p. 41, (Accessed January 27, 2025). Not available online. ↩︎
  3. Arizona Health Care Cost Containment System (AHCCCS),”Medicare D-SNP Agreements: UnitedHealthcare Community Plan,” §2.1.13 at 6. (Accessed February 24, 2025) ↩︎
  4. This language was adapted from the Arizona SMAC, see id. §2.1.12, at 6. ↩︎
  5. CA Department of Health Care Services (DHCS), “CalAIM Managed Long Term Services and Supports (MLTSS) and Duals Integration Workgroup,” p. 18 (Accessed February 11, 2025); see also DHCS, “Medi-Medi Plan (EAE D-SNP) Default Enrollment Pilot” (Accessed February 24, 2025). ↩︎
  6. For more information, see CMS, “Medicare Managed Care Manual Chapter 16-B: Special Needs Plans,” § 20.2.2 at 18, (Rev. 131; Issued: 11-22-24), (Accessed January 17, 2025). ↩︎
  7. Arizona AHCCCS, supra note 7, § 4 at 29. ↩︎
  8. Washington State Health Care Authority, “Amended and Restated State Medicaid Agency Contract,” Revised May 2022 (Accessed January 17, 2025). ↩︎
  9. CMS, supra note 10 § 20.2.10 at 38. ↩︎
  10. Ohio Department of Medicaid, supra note 6, at 53. ↩︎
  11. 42 CFR 422.100(c)(2)(ii); 42 CFR 422.102 ↩︎
  12. To learn more about how states can utilize Medicare bid information, see Ryan Stringer et al., “Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans (D-SNPs): Optional Language Applicable to All D-SNPs,” Integrated Care Resource Center (January 2024) p. 13, (Accessed February 12, 2025). ↩︎
  13. Pennsylvania Department of Human Services (DHS), “Medicare Improvements for Patients and Providers Act Contract,” (2025), p. 14-15, (Accessed February 13, 2025). ↩︎
  14. New Jersey Department of Human Services (DHS), “New Jersey FIDE SNP Model MIPPA Contract,” § 10.4.1.7. at 19 (January 2022), (Accessed February 24, 2025). ↩︎
  15. For more language around expanded benefits, see Massachusetts, Executive Office of Health and Human Services (HHS), “MassHealth Section 1115 Demonstration Amendment Request,” (October 11, 2024), (Accessed February 28, 2025). ↩︎
  16. See Center for Medicare Advocacy, “CMS Clarifies Treatment of Medicare Advantage “Flex Cards” For Public Benefit Purposes,” (January 9, 2025) (Accessed February 24, 2025). ↩︎
  17. Pennsylvania DHS, supra note 17. ↩︎
  18. This language should also be cross-referenced in the SMAC provisions outlining the responsibilities of a care manager. ↩︎
  19. To read more about how supplemental benefits such as flex cards can affect a person’s HUD benefits, see Frequently Asked Questions (FAQ): HUD-assisted Housing and Medicare Advantage Supplemental Benefits | HUD USER. Accessed January 22,2025. ↩︎
  20. 89 FR 30448 ↩︎
  21. Ohio Department of Medicaid, supra note 6. ↩︎
  22. Washington State Health Care Authority, supra note 12 at 32. ↩︎

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