As we noted, Centers for Medicare & Medicaid Services (CMS)  recently proposed its Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs rules (Proposed Rule) that would increase consumer protections and reduce health care disparities in Medicare Advantage (MA) and Part D.  In the Proposed Rule, CMS proposes major modifications to its regulations governing Dual Eligible Special Needs Plans (D-SNPs), which are MA products specifically for individuals who are dually eligible for Medicare and Medicaid. These changes are informed by the success of CMS’ Financial Alignment Demonstration and Medicare-Medicaid Plans (MMPs).  In fact, under the Proposed Rule, CMS is proposing that many key characteristics of MMPs be incorporated into D-SNPs.  CMS is also proposing to update the definitions of Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) and Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs) to incorporate successful characteristics of MMPs and to better clarify and differentiate these terms.

This post focuses on the several major provisions of the Proposed Rule impacting D-SNPs.  It discusses CMS’ proposals to clarify the definitions FIDE SNPs and HIDE SNPs.  It also specifically addresses CMS’ proposed requirements around enrollee participation in plan governance and updates to the health risk assessment (HRA) to obtain information on social risk factors, as well as its proposals to enhance integration of Medicare and Medicaid benefits through modifications to the framework for the required State Medicaid agency contracts.

Redefining Definitions for Fully Integrated and Highly Integrated D-SNPS

Under the proposed rule, CMS acknowledges that its current terminology is too complex for beneficiaries and seeks to make several modifications to the definitions of FIDE SNPs and HIDE SNPs to help differentiate the types of D-SNPs available to beneficiaries.

Fully Integrated Dual Eligible Special Needs Plans

FIDE SNPs provide dually eligible individuals access to Medicare and Medicaid benefits under a single organization that holds both an MA contract with CMS and a capitated Medicaid managed care contract with a State Medicaid agency.  To qualify as a FIDE SNP, the D-SNP must provide coverage of primary care, behavioral health, and long-term care services and supports (LTSS). Under CMS’ current definition, the MA contract does not need to limit enrollment to individuals who are enrolled in an affiliated Medicaid managed care organization (MCO).  In other words, an entity can be a FIDE SNP and can provide Medicare benefits to beneficiaries who are in Medicaid FFS or a competitor’s Medicaid MCO.  This undermines a plan’s ability to provide fully-integrated services.

CMS proposes to amend the definition of FIDE SNPs to require that, as of 2025 all FIDE SNPs must have “exclusively aligned enrollment,” which means only enrollees who are receiving Medicaid benefits from an affiliated Medicaid MCO may enroll in the FIDE SNP.  MMPs currently have exclusively aligned enrollment, and this is necessary to facilitate many of the other proposed changes under the rule, such as integrated beneficiary communication materials and a truly unified grievance and appeals process.  It would also clarify the overall accountability for enrollees’ health outcomes and coordination of care delivery.

CMS has also proposed a revision that will specify that FIDE SNPs are to cover Medicare cost-sharing, in the form of coinsurance, copayments, or deductibles for Medicare Parts A and B Benefits, for both Qualified Medicare Beneficiary (QMB) and non-QMB full-benefit dually eligible FIDE SNP enrollees. This change will simplify claims processing between Medicare and Medicaid by having the State Medicaid agency make a capitated payment for Medicaid coverage of Medicare cost-sharing to the MA plan in which the dually eligible individual is enrolled. Consequently, a provider would submit a single claim to the FIDE SNP for both Medicare and Medicaid coverage of the service, instead of having to submit claims to both the MA plan and the State Medicaid agency or Medicaid MCO. This would enable the FIDE SNP to adjudicate the claim for applicable Medicare payment, Medicaid payment, and Medicaid payment for Medicare cost-sharing in one streamlined process. 

CMS further seeks to clarify the scope of Medicaid services covered by FIDE SNPs by requiring FIDE SNPs to cover Medicaid primary and acute care services, home health, durable medical equipment, and behavioral health services through a capitated contract with the State Medicaid agency. While many FIDE SNPs already cover these benefits, the proposed requirement would enable CMS to more easily distinguish the difference between FIDE SNPs and HIDE SNPs. Under the proposed revisions, FIDE SNPs would cover the vast of Medicaid behavioral health benefits and Medicaid LTSS benefits (and only allow for limited carve-outs of Medicaid behavioral health services), whereas HIDE SNPs would cover the vast majority of Medicaid behavioral health benefits or Medicaid LTSS benefits. 

Highly Integrated Dual Eligible Special Needs Plans

A HIDE-SNP is currently defined as a D-SNP offered by an MA organization who has a capitated contract with the State Medicaid agency in which the D-SNP operates and includes coverage of Medicaid LTSS, and/or Medicaid behavioral health services, consistent with State policy. CMS proposes to modify the definition of a HIDE-SNP to clearly articulate the minimum scope of Medicaid services that must be covered by a HIDE SNP, and indicate that HIDE-SNPs are required to cover, at a minimum, the full scope of the Medicaid benefit for Medicaid LTSS or Medicaid behavioral health services (subject to limited carve outs).

Carve-Outs of Benefits under FIDE SNPs and HIDE SNPs

While the proposed revisions to the definitions of FIDE SNPs and HIDE SNPs require the plans to cover the full scope of Medicaid services available for the Medicaid LTSS benefit and/or the behavioral health services benefit, CMS also proposes to codify current CMS policy that permits limited carve-outs for these services. Specifically, the D-SNP may carve out some of Medicaid LTSS or behavioral health services as long as the carve-out either: 1) applies primarily to a minority of beneficiaries eligible to enroll in the D-SNP who utilize these services, or 2) constitutes a small part of the total scope of services provided to the majority of eligible beneficiaries. 

Service Area Alignment Between D-SNP and a Medicaid Managed Care Plan

One final proposed revision to promote the integration of Medicare and Medicaid benefits includes a proposed amendment to the definitions of FIDE SNP and HIDE SNP to require that the capitated contracts with the state Medicaid agency cover the entire service area for the D-SNP plan. This ensures that all FIDE SNP and HIDE SNP enrollees may access both their Medicare and Medicaid benefits from a single parent organization.

Enrollee Participation in Plan Governance

CMS is proposing that all D-SNPs (regardless of whether it is a FIDE SNP, HIDE SNP, or Coordination-Only D-SNP) must create an enrollee advisory committee that will include a representative sample of individuals (or their representatives) enrolled in the MA organization’s D-SNPs. This is a requirement of MMPs and Programs of All-Inclusive Care for the Elderly (PACE) plans, and CMS stated that these enrollee advisory committees have provided significant value and improvement to enrollee experience. CMS seeks similar success with the D-SNP enrollee advisory committees, and will require the committees to solicit feedback from enrollee experiences to identify ways to improve access to covered services, coordination of services, and health equity for underserved populations, and to address barriers to care for dually eligible individuals.

Standardized Housing, Food Insecurity, and Transportation Questions on HRAs

All types of special needs plan (SNPs), which include chronic condition special needs plans, dual-eligible special needs plans, and institutional special needs plans, are required to conduct annual HRAs of an enrollee’s physical, psychosocial and functional status, which are used to create individualized plans for enrollee care. D-SNP are currently not required to ask about social needs, such as food insecurity, homelessness, lack of access to transportation and low levels of health literacy. Unmet social needs can have a significant impact on the enrollee’s physical, psychosocial, and functional wellbeing. CMS proposes to require all SNPs to include standardized questions regarding housing stability, food security, and transportation in their initial and annual HRA of enrollees. Given the direct impact of these social risk factors on beneficiary health outcomes, the information gathered through these questions would help SNPs to develop more effective plans of care for each enrollee that are tailored to both their health status and social circumstances and connect enrollees to covered benefits and other social services that may improve health outcomes.  

Additional Opportunities for Integration through State Medicaid Contracts

In furtherance of efforts to eliminate the fragmented delivery of Medicare and Medicaid benefits via D-SNPs, CMS has proposed a number of regulatory pathways to enhance integration through the contracts D-SNPs are required to hold with a State Medicaid Agency. Again, many of these proposals are informed by CMS’ success with MMPs. These include: 

• Stand-Alone D-SNP Contracts.  The first proposed mechanism would allow for stand-alone D-SNP contracts on the MA side.  Currently, Medicare Advantage contracts are held at the legal entity level, with multiple plan benefit packages (PBPs) under one contract.  As such, SNPs and non-SNPs may be PBPs in the same contract, so long as they are the same product type (for example, SNP HMO and non-SNP HMO PBPs can be in the same contract). Certain data reporting, including medical loss ratio and certain Star Measures are collected at the contract level. This makes it difficult to track and evaluate the D-SNP’s performance separate from a contractor’s other PBPs.  Under this proposal, CMS would provide states with this option to require stand-alone D-SNP contracts, and would allow states to utilize the MA application process for D-SNPs to apply for these stand-alone contracts.  Allowing states to establish D-SNP-only contracts would provide both states and the greater public with transparency into plan performance, quality ratings for the D-SNP, and the experiences of dually eligible individuals in comparison to other beneficiaries.

• Integrated Materials.  The second proposed mechanism would allow D-SNPs to combine required materials and notices for seamless communication of information about Medicare and Medicaid coverage to beneficiaries.

• Joint Oversight.  The final proposed mechanism includes multiple opportunities for states to collaborate with CMS in performance of oversight over D-SNPs. This includes providing states access to the Health Plan Management System (HPMS), establishing a process for coordination between CMS and state Medicaid officials in the performance of program audits, and requesting state input with regards to an MA organization’s compliance with network adequacy standards. 

Comments on these proposals are due to CMS by March 7, 2022