Dual Eligible Special Needs Plans (D-SNPs)

Leveraging Dual Eligible Special Needs Plan (D-SNP) Models of Care to Enhance Enrollee Care Coordination

04/20/2023

This webinar will discuss strategies states can use to improve care coordination for D-SNP enrollees. It provides an overview of federal D-SNP care coordination and Model of Care (MOC) requirements, describes state options for incorporating care coordination requirements into state Medicaid agency contracts (SMACs) with D-SNPs, and/or requiring D-SNPs to incorporate state-specific information into MOCs, and discusses key considerations for states when implementing state-specific care coordination requirements.

Unified Appeal and Grievance Processes for States with Applicable Integrated Plans (AIPs)

CMS requires D-SNPs that qualify as AIPs—meaning they operate with exclusively aligned enrollment and cover certain Medicaid benefits through the D-SNP or the D-SNP’s affiliated Medicaid managed care plan—to use unified appeal and grievance processes. These integrated processes are designed to resolve misalignments between Medicare and Medicaid plan-level processes and streamline experiences for plans.

Reprioritization of PACE, Medicare Parts C and D Program, and Risk Adjustment Data Validation (RACV) Audit Activities

In response to the spread of COVID-19, the Centers for Medicare & Medicaid Services (CMS) has suspended non-emergency federal and state survey agency surveys. Consistent with that action, CMS is reprioritizing scheduled program audits for Medicare Advantage organizations, Part D sponsors, Medicare-Medicaid Plans, and PACE oganizations. Oversight will continue but will shift to prioritize the investigation and resolution of instances of noncompliance where the health and/or safety of beneficiaries is at risk and complaints allenging infection control concerns.

Additional Guidance on CY 2021 Medicare-Medicaid Integration Requirements for Dual Eligible Special Needs Plans (D-SNPs)

This HPMS memo provides additional guidance and clarification on four topics related to new integration standards for Dual Eligible Special Needs Plans: (1) distinctions between fully integrated D-SNPs (FIDE SNPs) and highly integrated (HIDE SNPs); (2) permissibility of carve-outs of behavioral health services and long term services and supports (LTSS) for FIDE SNPs and HIDE SNPs; (3) alignment of D-SNP and companion Medicaid plan service areas; and (4) compliance with integration requirements for D-SNPs that only enroll partial-benefit dually eligible individuals.

Appeals and Grievances: Comparisons of Existing and New Integrated Processes for Individuals Enrolled in Applicable Integrated Plans

Beginning in 2021, Dual Eligible Special Needs Plans (D-SNPs) with exclusively aligned enrollment must begin using integrated appeals and grievance processes. The flowcharts in this resource are designed to help states, health plans, and other stakeholders understand the differences between existing Medicare and Medicaid appeal and grievance processes and the new integrated appeal and grievance processes established at 42 CFR Part 422 Subpart M for fully and highly integrated D-SNPs with exclusively aligned enrollment.