Technical Assistance Tool

Glossary of Terms Related to Integrated Care for Dually Eligible Individuals

The Integrated Care Resource Center (ICRC) uses a variety of terms related to integrated care for dually eligible individuals in our written products and webinars. ICRC broadly uses the term “integrated care” to describe systems in which Medicare and Medicaid program administrative requirements, financing, benefits, and/or care delivery are aligned. In general, in “integrated care” systems, Medicare and Medicaid services are coordinated and may be covered through a single entity or coordinating entities, such as through health plans, medical systems, and/or providers.

Integrated Appeal and Grievance Processes for Integrated D-SNPs with “Exclusively Aligned Enrollment”

On April 16, 2019, CMS released a final rule that implements provisions of the 2018 Bipartisan Budget Act (BBA) requiring greater D-SNP integration, including integrated plan-level appeal and grievance processes for certain “applicable integrated plans.” This fact sheet is intended to help states with applicable integrated plans understand the new integrated appeal and grievance processes, the types of D-SNPs that are required to use them, and steps that states can take to help ensure effective implementation of the new processes in 2021.

Scripts for Medicare-Medicaid Plan (MMP) Enrollment Brokers Assisting Individuals with CARA Lock-In Indicators

The Comprehensive Addiction and Recovery Act of 2016 (CARA) included provisions that give Medicare Prescription Drug Plans and Medicare Advantage plans (including Medicare-Medicaid Plans (MMPs)) tools to address opioid overutilization.

Medicare-Medicaid Plan (MMP) Enrollment Restrictions Resulting from the Comprehensive Addiction and Recovery Act of 2016 (CARA)

This technical assistance tool describes the regulation that allows Medicare plans that provide prescription drug coverage (including MMPs) to use drug management programs to limit access to certain controlled substances determined to be “frequently abused drugs” for patients who are determined to be at-risk for prescription drug abuse due to the Comprehensive Addiction and Recovery Act of 2016 (CARA).

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Using Medicare Modernization Act (MMA) Files to Identify Dually Eligible Individuals

States need to be able to identify individuals who are (or will become) dually eligible for several reasons. Since 2005, states have exchanged files -- known as the Medicare Modernization Act (MMA) files -- with the Centers for Medicare & Medicaid Services (CMS) that identify current and prospective dually eligible individuals. This technical assistance tools explains how states can identify Medicaid enrollees who are currently dually eligible, as well as Medicaid enrollees who will become dually eligible in the next three months (known as “prospective” dually eligi

State Guide to Identifying Aligned Enrollees: How to Find Medicare Plan Enrollment for Dually Eligible Individuals in Medicaid Managed Care Plans

States can advance integrated care for dually eligible individuals by promoting aligned enrollment in Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) and Medicaid managed care plans owned by the same parent company (“affiliated” plans). Dually eligible individuals who receive Medicare and Medicaid coverage from affiliated plans can benefit from improved integration of benefits and care coordination.

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.

State Options and Considerations for Sharing Medicaid Enrollment and Service Use Information with D-SNPs

New federal rules released in April 2019 require that Dual Eligible Special Needs Plans (D-SNPs) must, at a minimum, coordinate the delivery of Medicare and Medicaid benefits. The final rule includes new regulatory language effective January 1, 2020 and provides examples of ways that D-SNPs should coordinate their members’ Medicare and Medicaid services.

Sample Language for State Medicaid Agency Contracts with Dual Eligible Special Needs Plans

To operate in a state, a Dual Eligible Special Needs Plan(D-SNP) must hold a contract with the state Medicaid agency. Those state Medicaid agency contracts (SMACs) must all have at least certain minimum elements, and states can also add additional requirements that aim to further coordination or integration of Medicare and Medicaid benefits for D-SNP enrollees.

The Complex Art of Making It Simple: Factors Affecting Enrollment in Integrated Care Demonstrations for Dually Eligible Beneficiaries

Dually eligible beneficiaries began enrolling in integrated Medicare-Medicaid plans (MMPs) under the Financial Alignment Initiative (FAI) in calendar year 2013. Under the FAI, the Centers for Medicare & Medicaid Services (CMS) and 10 participating states contracted with MMPs under capitated arrangements to coordinate Medicare and Medicaid benefits. Beneficiary participation has been lower than anticipated. Only about 29 percent of eligible individuals enrolled in MMPs in 2017.