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With CY 2021 Medicare Advantage deadlines rapidly approaching, state Medicaid agencies and Medicare Advantage plans offering Dual Eligible Special Needs Plans must quickly determine how to fulfill new integration requirements mandated by the Bipartisan Budget Act of 2018.
This white paper summarizes the new requirements and discusses stakeholder considerations.
Dual eligible special needs plans (D-SNPs) are Medicare Advantage (MA) plans that only enroll beneficiaries who are dually eligible for Medicare and Medicaid. D-SNPs have become increasingly popular among both MA organizations (MAOs) and dual eligible beneficiaries because of their ability to tailor benefit designs to the needs of this population. Approximately one-quarter of the nation’s 11 million dual eligible beneficiaries are enrolled in one of the 550+ D-SNPs offered throughout the country as of January 2020. 1,2 Figure 1 shows the proportion of dual eligible beneficiaries, by state, enrolled in D-SNPs as of January 2020.
In addition to limiting enrollment to dual eligible beneficiaries, D-SNPs are required to have a model of care approved by the National Committee for Quality Assurance (NCQA) and a state Medicaid agency contract (SMAC) or a Medicare Improvements for Patients and Providers Act (MIPPA) contract. The SMAC outlines various contractual and integration details such as dual eligible categories eligible for enrollment (e.g., full duals, partial duals, Qualified Medicare Beneficiaries) and Medicaid benefits to be covered by the D-SNP, if any. 3 Each state Medicaid agency has the authority to define the terms in the SMAC and decide which MAOs it permits to offer D-SNPs within the state.
As the CY 2021 MA bid submission deadline approaches, state Medicaid agencies and MA plans offering D-SNPs must quickly determine how to fulfill the new D-SNP integration requirements.
As the CY 2021 MA bid submission and D-SNP SMAC deadlines approach, state Medicaid agencies and MAOs offering D-SNPs must quickly determine how to fulfill the new D-SNP integration requirements. This is an ideal time for states and MAOs to reconsider longer-term strategies around dual integration.
The opinions stated in this article are those of the authors and do not represent the viewpoint of Milliman.
Guidelines issued by the American Academy of Actuaries require actuaries to include their professional qualifications in all actuarial communications. Nick Johnson, Chris Kunkel, and Annie Hallum are members of the American Academy of Actuaries and meet the qualification standards for sharing the information in this article. To the best of their knowledge and belief, this information is complete and accurate.
This information is intended to provide an overview of the new D-SNP integration requirements for state Medicaid agencies and Medicare Advantage plans. The list of considerations outlined in this article and the discussion of each consideration are not exhaustive. State Medicaid agencies and MAOs should give careful consideration to their own situations and determine how the new D-SNP integration requirements impact them. This information may not be appropriate, and should not be used, for other purposes.
Milliman does not intend to benefit and assumes no duty of liability to parties who receive this information. Any recipient of this information should engage qualified professionals for advice appropriate to its own specific needs.
1CMS. SNP Comprehensive Report – January 2020. Retrieved February 18, 2020, from https://www.cms.gov/research-statistics-data-and-systemsstatistics-trends-and-reportsmcradvpartdenroldataspecial-needs/snp-comprehensive-report-2020-01.
2CMS. MMCO Statistical and Analytic Reports. Retrieved February 18, 2020, from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Analytics.
3Office of Assistant Secretary for Planning and Evaluation (April 8, 2019). Integrating Care Through Dual Eligible Special Needs Plans (D-SNPs): Opportunities and Challenges. Retrieved February 18, 2020, from https://aspe.hhs.gov/basic-report/integrating-care-through-dual-eligible-special-needs-plans-d-snps-opportunities-and-challenges.
4CMS (October 7, 2019). CY 2021 Medicare-Medicaid Integration and Unified Appeals and Grievance Requirements for Dual Eligible Special Needs Plans (D-SNPs). Medicare-Medicaid Coordination Office. Retrieved February 18, 2020, from https://www.arabhealthonline.com/content/dam/Informa/arabhealthonline/
5CMS (January 17, 2020). Additional Guidance on CY 2021 Medicare-Medicaid Integration Requirements for Dual Eligible Special Needs Plans (D-SNPs). Medicare-Medicaid Coordination Office. Retrieved February 18, 2020, from https://www.cms.gov/files/document/CY2021dsnpsmedicaremedicaidintegrationrequirements.pdf.
7CMS (February 18, 2020). Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly. Retrieved February 21, 2020, from https://www.federalregister.gov/documents/2020/02/18/2020-02085/medicare-and-medicaid-programs-contract-year-2021-and-2022-policy-and-technical-changes-to-the.
8Verma, S. (April 24, 2019). Three New Opportunities to Test Innovative Models of Integrated Care for Individuals Dually Eligible for Medicaid and Medicare. CMS SMDL #19-002. Retrieved February 18, 2020, from https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/smd19002.pdf.
Changing how Medicare and Medicaid talk to each other
With calendar year 2021 Medicare Advantage (MA) deadlines approaching, state Medicaid agencies and MA plans offering Dual Eligible Special Needs Plans must quickly determine how to fulfill new integration requirements mandated by the Bipartisan Budget Act of 2018.