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.

People dually eligible are often overwhelmed by the separate and confusing notices they receive from their Medicare managed care plan, such as a Dual Eligible Special Needs Plan (D-SNP), and their Medicaid Managed Care plan (MMC). This confusion is worsened when plan notices are not consumer tested, are not provided in the member’s preferred language, or fail to account for the health literacy needs of dually eligible members.

Communications and Marketing Materials Accessibility

Guiding Principle

Integrated models provide robust consumer protections.

Supporting Principle

Members receive clear, timely, and accessible communications.

Federal Requirement

All Medicare Advantage plans must adhere to the communication and marketing requirements provided in 42 CFR Part 422 Subpart V and 42 CFR 438.10. Many states require D-SNP plans to meet additional requirements to ensure materials are accessible and appropriate for the dually eligible populations they serve.

SMAC Recommendations

To meet the health literacy and accessibility needs of dually eligible enrollees, states should require D-SNPs to consumer test all marketing and communication materials before distribution. States should also impose additional requirements to ensure plan written materials are accessible, culturally and linguistically appropriate, and include nondiscrimination information.1

Template Language

Massachusetts

Massachusetts requires D-SNPs to ensure access to covered services by maintaining policies that guarantee reasonable accommodations for enrollees and potential enrollees:

  • D-SNP Contractors will ensure enrollees are provided with reasonable accommodations to guarantee effective communication, including auxiliary aids and services, which shall be made available upon request of the potential enrollee or enrollee at no cost and that enrollees can make standing requests for reasonable accommodations. Reasonable accommodations will depend on the particular needs of the individual and include:
    • Providing large print (at least eighteen (18)-point font) or Braille of all written materials to individuals with visual impairments, as requested;
    • Ensuring effective communication to and from enrollees in accordance with their communication preferences, including through email, telephone, text, and other electronic means;
    • Ensuring effective communication to and from individuals who are Deaf or hard of hearing, or who have disabilities impacting their speech or communication needs, by using these individuals’ preferred modes of communication access through email, text, telephone, and other electronic means, and through services and technologies such as TTY, Video Relay Services (VRS), computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays, qualified interpreters (including ASL interpreters), and other auxiliary aids and services;
    • Providing interpreters or translators for enrollees whose primary language is not English.2

California

California requires plans to provide enrollees with nondiscrimination notices:

  • D-SNP Contractor must post (1) a state-approved nondiscrimination notice, and (2) language taglines in a conspicuously visible font size in English, the threshold languages, and at least the top 15 non English languages in the state, and any other languages, as determined by the state, explaining the availability of free language assistance services, including written translation and oral interpretation, and information on how to request Auxiliary Aids and services, including materials in alternative formats. The nondiscrimination notice and taglines shall include D-SNP Contractor’s toll-free and TTY/TDD telephone number for obtaining these services, and shall be posted in the Member Services Guide/Evidence of Coverage, and in all Member information, informational notices, and materials critical to obtaining services targeted to Members, potential members, applicants, and members of the public.3

California requires plans to include information about how to file a grievance with the CA Department of Health Care Services (DHCS) Office of Civil Rights and the HHS Office of Civil Rights in plan nondiscrimination notices:

  • All Managed Care Plan nondiscrimination notices must include information about how to file a discrimination grievance directly with the State’s Office of Civil Rights, in addition to information about how to file a discrimination grievance with the plan and HHS Office of Civil Rights (i.e., file a grievance with HHS Office of Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex). Managed Care Plans are required to make the nondiscrimination notice available, upon request or as otherwise required by law, in the threshold and concentration languages, or in an ADA-compliant, accessible format.4

Additional SMAC language

The D-SNP Contractor shall gather and incorporate feedback from members serving on the Enrollee Advisory Committee and outside experts (e.g., providers, consumer advocates, trade associations, enrollees and caregivers) to produce consumer materials that meet the health literacy and accessibility needs of the dual eligible population.5 Additionally, all written materials and enrollee communications shall be in plain language and at the 7th grade reading level, using the Flesch scale analysis readability score.6

Language and Accessibility

Guiding Principle

Integrated models provide robust consumer protections.

Supporting Principle

Members receive clear, timely, and accessible communications.

Federal Requirement

All Medicare Advantage plans must adhere to the language and accessibility requirements outlined in 42 CFR 422.2267 including and not limited to translating required materials to any non-English language that is the primary language of at least 5 percent of the individuals in the plan service area. In addition, plans must make these translated materials available in any non-English language or accessible format on a standing basis once the plan receives a request or upon learning of enrollees’ language and/or accessibility needs. Plans must also adhere to language and format requirements outlined in 42 CFR 438.10(d) including making oral interpretation in all languages and American Sign Language available to individuals and members at no expense.7 Fully integrated dual eligible (FIDE) SNPs, highly integrated dual eligible (HIDE) SNPs, or applicable integrated plan (AIP) must also meet any additional language requirements outlined in the SMAC.8

SMAC Recommendations

States should require plans to provide written information to members describing how to request language or disability accommodations and how to file a grievance with the plan, the state, and the Health and Human Services (HHS) Office of Civil Rights. States with stronger language access rules than the federal minimum should require plans to adhere to both the federal and state requirements.

Template Language

California

California requires plans to adhere to language thresholds beyond federal minimums.

  • Managed Care Plans are required to provide translated written member information, using a qualified translator according to the State’s requirements for qualified translators, to the following language groups within their service areas, as determined by the State:
    • A population group of eligible beneficiaries residing in the Managed Care Plan’s (MCP) service area who indicate their primary language as a language other than English, and that meet a numeric threshold of 3,000 or five-percent (5%) of the eligible beneficiary population, whichever is lower (Threshold Standard Language); and
    • A population group of eligible beneficiaries residing in the MCP’s service area who indicate their primary language as a language other than English and who meet the concentration standards of 1,000 in a single ZIP code or 1,500 in two contiguous ZIP codes (Concentration Standard Language).9

Integrated Materials Review

Guiding Principle

Integrated models provide robust consumer protections.

Supporting Principle

Integrated models simplify procedures, so members experience a single system inclusive of the most comprehensive protections provided by both Medicare and Medicaid.

Federal Requirements

Medicare Advantage plans must submit communication and marketing materials outlined in 42 CFR 422.2261 for approval to CMS before distributing to enrollees. Per 42 CFR 422.107(e), states can use SMACs to require D-SNPs that operate with exclusively aligned enrollment (EAE) to establish (and operate within) contracts with CMS that only include D-SNPs within a state (“D-SNP-only contracts”), and integrate certain materials and notices for D-SNP enrollees.10 Additionally, State Medicaid Agencies that require contracted D-SNPs with EAE to operate within state-specific, D-SNP only contracts with CMS, are granted access to the CMS Health Plan Management System (HPMS) to review plan submitted materials.11 States can thus exercise greater oversight when they require plans to operate with EAE and a D-SNP only contract as this allows them to jointly review D-SNP integrated communication and marketing materials alongside CMS.

SMAC Recommendations

To ensure that plan marketing and communications materials adhere to state standards, states should require plans to submit all, or certain types, of marketing and communication materials for review and/or approval prior to distribution.

Template Language

Minnesota

Minnesota requires D-SNPs to submit “Enrollee Materials” to the state for approval prior to distribution and requires consultation with tribal governments when marketing materials target American Indian populations:

  • If the marketing materials target American Indian Beneficiaries, the State shall consult with tribal governments within a reasonable period of time before approval. The State must approve all information for enrollees that requires approval prior to use of the materials. The Managed Care Organization must submit its enrollee materials in a final format before approval from the State can be given. The State agrees to inform the Managed Care Organization of its approval or denial of documents within thirty (30) days of receipt of these documents.12

Massachusetts

Massachusetts requires D-SNPs submit for approval all “Outreach and Enrollees Materials” including materials in non-English languages prior to distribution:

  • The D-SNP Contractor shall submit to the State all forms of outreach and enrollee materials, including non-English outreach materials along with an English translation, an attestation from a certified translation agency, and a signature of the Managed Care Organization Director, for review and approval before use or distribution. The State must also approve any changes or updates to outreach materials before use or distribution.13

Integrated Materials and Processes

Guiding Principle

Integrated models provide robust consumer protections.

Supporting Principle

Integrated models simplify procedures so members experience a single system inclusive of the most comprehensive protections provided by both Medicare and Medicaid.

Federal Requirements

As noted in the discussion above in reference to 42 CFR 422.107(e), CMS affords states the flexibility to require D-SNPs with exclusively aligned enrollment (EAE) to integrate materials including and not limited to the summary of benefits; formulary; and combined Provider and Pharmacy Directory.14 Additionally, applicable integrated D-SNPs are required to use an integrated appeals and grievance process.15

SMAC Recommendations

To simplify the description of benefits, states should require D-SNPs with EAE to provide enrollees with a single set of fully integrated materials that describe both the Medicare and Medicaid benefits covered by the D-SNP (and its affiliated Medicaid plan, when applicable). For D-SNPs without EAE, states should require plans to provide descriptions of Medicare and Medicaid benefits in a more unified format. For example, states could require non-EAE D-SNPs to present Medicare and Medicaid appeals and grievances descriptions together in the member handbook, plan letters to enrollees, and in other communications as appropriate. To ensure dually eligible members are fully informed about the benefits they are entitled to, states should require D-SNPs to include information about Medicaid State Plan benefits in communications and marketing materials.

Template Language

Wisconsin

In addition to requiring D-SNPs with EAE to integrate enrollee information, Wisconsin requires D-SNPs to include Medicaid State Plan benefit information in the summary of benefits:

  • The MA Plan agrees to employ policies and procedures approved by CMS and the State to coordinate and integrate enrollee communication materials, including enrollment communications, grievance and appeals, and quality assurance.
  • The MA Plan will identify in the MA Plan’s Summary of Benefits those benefits the member may be eligible for under the State Plan that are not covered services under the Member’s MA Plan.16

California

California requires select D-SNPs to provide integrated materials and a single customer service number:

  • D-SNP Contractor is responsible for providing integrated Member materials to Members. Required integrated Member materials will include: 1) Annual Notice of Change (ANOC); 2) Member Handbook; 3) Summary of Benefits; 4) Member Identification (ID) Card; 5) Provider/Pharmacy directory; and 6) List of Covered Drugs (Formulary).
  • D-SNP Contractor must have a single Member services/customer service phone number for Members to contact D-SNP Contractor regarding their Medicare or State plan benefits. D-SNP Contractor must use the single Member services phone number in all integrated Member materials. D-SNP Contractor must have a single Application Programming Interface (API) for Members to access both Medicare and Medicaid information.17

Cost-sharing Protections Disclosures

Guiding Principle

Integrated models provide robust consumer protections.

Supporting Principle

Members are protected from cost-sharing that exceeds what they would pay in Medicaid or Medicare fee-for- service for the same service.

Federal Requirement

Per 42 CFR 422.107(c\(4), SMACs are required to include the cost-sharing protections covered under )the D-SNP.18

SMAC Recommendations

To ensure dually eligible enrollees are fully informed about cost-sharing protections, states should require D-SNPs to include information about financial liability protections in communication and marketing materials.19

Template Language

Wisconsin

Wisconsin requires D-SNPs to communicate enrollee financial liability protections:

  • The MA Plan shall communicate fully integrated Medicare-Medicaid coverage to all members, providers, MA Plan staff, and other stakeholders, including guarantee of complete member protection from financial liability – meaning all deductibles, premiums, coinsurance, copayments, and cost sharing of any kind, with exception for member post-eligibility treatment of income payment, if applicable.20

Minnesota

Minnesota requires D-SNPs to communicate enrollee cost sharing responsibilities in the plan handbook document and in other materials:

  • The Managed Care Organization (MCO) shall explain the cost-sharing policy in the MCO’s handbook and other materials for Enrollees. The MCO shall not offer waiver of cost-sharing as an inducement to enroll in the D-SNP plan unless CMS has approved waiver of payment of cost-sharing by the MCO as an additional benefit in the MCO’s Medicare bid process, and such waiver cannot be described in any of the MCO’s Marketing Material.21

Endnotes

  1. Nondiscrimination notices inform the public on the entity’s compliance with Federal Civil Rights laws and provide information about how individuals can file complaints or grievances when they have experienced discriminatory practices. See the Centers for Medicare and Medicaid Service (CMS) and Health and Human Services (HHS) nondiscrimination notices. See also, the California Department of Health Care Services (DHCS) nondiscrimination notice template for managed care plans that reference Federal Civil Rights and state laws. ↩︎
  2. Massachusetts Executive Office of Health and Human Services (EOHHS), “2023 One Care Model Contract,” §2.10.8.2, at 207-208. (Accessed March 19, 2025). ↩︎
  3. California Department of Health Care Services (DHCS), “Boilerplate 2025 SMAC Exclusively Aligned Enrollment D-SNP,” Exhibit E, Attachment 2 at 21, (July 8, 2024) (Accessed March 6, 2025); See also CA DHCS, “All Plan Letter 21-004(Revised),” at 2, (May3, 2022) (Accessed March 6, 2025). ↩︎
  4. CA DHCS, “All Plan Letter 21-004 (Revised),” at 2, (May 3, 2022) (Accessed March 6, 2025). ↩︎
  5. Language adapted from CA DHCS, “2024 Medi-Cal Managed Care Plan (MCP) Transition,” at 13 (November 2, 2023) (Access March 7, 2025); see also Lida Momeni, et al., “Integrating Dual Eligible Special Needs Plan Materials to Promote Enrollee Understanding of and Access to Benefits,” Integrated Care Resource Center at 5, (February 2024) (Accessed May 7, 2025). ↩︎
  6. Language adapted from Minnesota Department of Human Services (DHS),”Model Template for 2025 Contracts with MCOs for Seniors,” §3.10.5 at 49, (January 1, 2025) (Accessed March 6, 2025). ↩︎
  7. See also Section 1557 of the Affordable Care Act (ACA) (section 1557), 42 U.S.C. 18116 and Title VI of the Civil Rights Act of 1964 (title VI), 42 U.S.C. 2000d et seq., Section 504 of the Rehabilitation Act of 1973 (section 504), 29 U.S.C. 794. ↩︎
  8. 42 CFR 422.2267(a)(4) ↩︎
  9. Id. at 4. ↩︎
  10. For more information on D-SNP-only contracts and integrated materials, see Integrated Care Resource Center, “D-SNP-Only Contracts: Benefits and Key Steps for States,” (March 19, 2024) (Accessed March 6, 2025). ↩︎
  11. Ryan Stringer, et al., “Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans (D-SNPs): Optional Language Applicable to Certain D-SNPs,” Integrated Care Resource Center at 11, (January 2025) (Accessed March 6, 2025). ↩︎
  12. Minnesota DHS, supra note 5, §3.12.9 and 3.13 at 52. ↩︎
  13. Massachusetts EOHHS, supra note 1, §2.10 at 93. ↩︎
  14. 87 FR 27704 ↩︎
  15. 42 CFR 422.107(c)(9); see also Ryan Stringer and Alena Tourtellotte, “Integrated Appeal and Grievance Processes for Integrated D-SNPs with “Exclusively Aligned Enrollment,” Integrated Care Resource Center (July 2022) (Accessed March 6, 2025). ↩︎
  16. Wisconsin Department of Health Services (DHS), “State of Wisconsin Department of Health Services (DHS) and (MCO) for Dual Eligible Special Needs Medicare Advantage Health Plan,” §5 at 6-7 (2025), (Accessed March 6, 2025). ↩︎
  17. California DHCS, supra note 2, Exhibit A, Attachment 1 at 5-7. ↩︎
  18. See CMS, “Medicare Managed Care Manual,” Ch.16b, §20.2.2 at 18 (Re-issued 02-28-2014), (Accessed March 06, 2025). ↩︎
  19. This language should also be cross referenced in the SMAC provisions outlining care coordination requirements. ↩︎
  20. Wisconsin DHS, supra note 13, §5.3 at 7. ↩︎
  21. Minnesota DHS, supra note 5, §4.9.2 at 79. ↩︎

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