Care Coordination for D-SNP State Medicaid Company Contracts

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Care Coordination for D-SNP State Medicaid Company Contracts


Desk of Contents

This toolkit supplies policymakers, together with State Medicaid Company workers, and advocates, with rules and corresponding template language to develop State Medicaid Company Contracts (SMACs) which are attentive to the wants of the dually eligible populations they serve. Stakeholders are inspired to make use of this instrument to advance their priorities by tailoring the elements which are most applicable for his or her state’s built-in environments.

That is Half III of the toolkit, which supplies a strong dialogue on Care Coordination. Half 1 of this toolkit covers Eligibility and Enrollment in addition to Supplemental Advantages, whereas Half II of this toolkit focuses on Advertising and marketing and Communications. Drawing from Justice in Growing old’s D-SNP Subject Transient, we middle the experiences of dually eligible enrollees and spotlight the challenges confronted by this inhabitants in navigating their medical health insurance protection. To information the dialogue, we reference the Justice in Growing old Guiding Ideas, a core set of values and objectives that decision for strong shopper protections, well being fairness, person-centered care, and extra oversight and accountability in integration fashions. Justice in Growing old will launch subsequent sections of this toolkit within the coming months.

This publication highlights finest practices drawn from D-SNP mannequin contracts, Monetary Alignment mannequin contracts, and state long-term care necessities, aligning most intently with the federal requirements for Totally Built-in Twin Eligible Particular Wants Plans (FIDE-SNPs).[1] For this instrument, in situations the place present SMAC language will not be publicly accessible or has not but been written, Justice in Growing old supplies urged template language to assist advance key shopper protections and rules.

Federal Necessities

Care coordination for individuals dually eligible is formed by a number of overarching federal necessities, together with Mannequin of Care necessities, the House and Neighborhood-Based mostly Settings Rule, and the Medicaid Entry Rule. As a result of these necessities have broad applicability throughout the SMAC suggestions contained on this toolkit, a devoted part has been created to spotlight their significance and impression.

Mannequin Of Care

D-SNPs should implement an evidence-based Mannequin of Care (MOC) tailor-made to the traits and wishes of the inhabitants they serve.[2] D-SNPs are required to submit their MOCs to the Facilities for Medicare and Medicaid Companies (CMS) and the Nationwide Committee for High quality Assurance (NCQA) for analysis and approval.

The MOC outlines how the plan will coordinate an enrollee’s Medicare and Medicaid advantages. Notably, state Medicaid businesses can require D-SNPs to submit their MOCs to the state Medicaid company previous to, or concurrent with, federal submission of the total D-SNP bid, offering states with a chance to tailor the MOC necessities to state-specific inhabitants wants and establish potential inconsistencies between the MOC and SMAC care coordination necessities.[3]

At a minimal, D-SNPs should meet the mannequin of care necessities outlined in 42 CFR 422.101(f) and the Medicare Benefit Mannequin of Care Submission Necessities, together with, and never restricted to, the next:[4]

  • Well being Danger Assessments: The plan should assess every enrollee’s medical, practical, cognitive, psychosocial, psychological well being, and social determinants of well being wants, together with screening for housing stability, meals safety, and entry to transportation. The outcomes of this evaluation are addressed within the member’s individualized care plan;
  • Individualized Care Plan: The plan should develop a complete person-centered care plan that outlines the enrollee’s objectives and aims, together with measurable outcomes and the precise providers and advantages to be supplied;
  • Interdisciplinary Care Workforce: The plan should make the most of an interdisciplinary care staff with demonstrated experience and coaching to handle the enrollee’s care;
  • Care Coordination: The plan should coordinate the supply of care (together with Medicaid advantages) and communication of well being care actions with stakeholders, together with suppliers each inside and outdoors the SNP’s community, to assist make sure that enrollees’ well being care wants, preferences for providers, and data sharing throughout well being care settings are met; and
  • Care Transition Protocols: The plan should describe, of their MOCs, how care transition protocols will preserve continuity of take care of enrollees, in addition to which personnel are accountable for coordinating care all through the transition course of. Particular parts of the MOC require D-SNPs to clarify how the plan will coordinate with suppliers of any Medicaid-covered providers throughout a care transition.

2026 Medicare Benefit and Half D Closing Rule

The 2026 Medicare Benefit and Half D Closing Rule added extra care coordination necessities for D-SNPs. The Rule requires particular forms of D-SNPs to conduct a single, built-in well being threat evaluation for Medicare and Medicaid, fairly than separate assessments for every program. The Rule additionally codifies timeframes for the event of members’ individualized care plans and prioritizes the involvement of the enrollee or the enrollee’s consultant of their care planning course of.[5]

House and Neighborhood-Based mostly Settings Rule: Particular person-Centered Service Planning Course of and Service Plan[6]

For people receiving Medicaid house and community-based providers (HCBS), the Medicaid Settings Rule establishes necessities for each the person-centered service planning course of and the ensuing person-centered service plan. The Rule advances efforts to make sure the person receiving providers is on the middle of the planning course of. The objective is to develop a plan that displays the person’s strengths, preferences, and wishes, together with these associated to well being, security, and well-being, and descriptions providers and helps which are vital to and for the particular person. The plan should additionally replicate the person’s objectives for neighborhood integration, together with the place and the way they wish to obtain these providers.

Making certain Entry to Medicaid Companies: Particular person-Centered Service Plans[7]

The Entry Rule strengthens present person-centered planning necessities to extra clearly affirm that the person, or if relevant, the person and the person’s approved consultant, lead the person-centered planning course of.

Particular person-Centered Care

Lack of coordination between Medicare and Medicaid typically creates important obstacles for individuals dually eligible, stopping them from accessing the providers they should meet their well being objectives and care wants. Inadequate coordination ends in people experiencing fragmented care and confusion navigating advantages, all of which might worsen well being outcomes and lead to pointless and expensive expenditures.

This inhabitants additionally tends to have extremely advanced medical and social wants: 90% have a minimum of one power situation, and 37% have three or extra.[8] Folks dually eligible additionally expertise larger charges of bodily and behavioral well being circumstances, practical and cognitive wants,[9] and the bulk survive on very restricted incomes.[10] These intersecting challenges make it important to have person-centered care delivered by a well-coordinated staff.

Sturdy care coordination necessities in SMACs are important. SMACs ought to include specific language to make sure the member is aware of their Care Supervisor, that care is pushed by the member to the best extent doable, and that providers replicate the member’s distinctive objectives and preferences. SMACs must also clearly outline the Care Supervisor’s obligations in supporting the member and guaranteeing their care plan is successfully carried out.

Guiding Precept

  • Built-in fashions enhance entry to care and member expertise throughout the various dually eligible inhabitants.

Supporting Precept

  • Members have entry to high quality, person-centered care coordination.

SMAC Suggestion: The Member Ought to Know Who Their Care Supervisor Is and Find out how to Contact Them

  • States ought to require D-SNPs to maintain enrollees up to date on who their Care Supervisor is and contact them. The first Care Supervisor ought to comply with enrollees throughout care settings to help transitions in care.

Template Language

Massachusetts

The contract ensures enrollees know contact their Care Supervisor and that communication is accessible to the member.

New Jersey

The contract requires a plan to make sure that caregivers have the identify and make contact with data for the member’s Care Supervisor.

  • The Contractor’s Care Managers shall use a person-centered method relating to the member evaluation and wishes, taking into consideration not solely coated providers, but additionally formal and casual help providers as relevant. Care Managers shall guarantee all recognized caregiver(s) have the MCO Care Supervisor’s identify and make contact with data.[12]

SMAC Suggestion: Care Administration Engagements Prioritize Member Autonomy and Selection

  • States ought to require D-SNPs to make sure that enrollees obtain care coordination/care administration within the location and modality of their alternative.

Template Language[13]

Massachusetts

The contract requires care coordination in a fashion accessible and most popular by the member.

  • In-person care coordination/care administration engagement happens a minimum of as soon as per yr:[14]
    • In-person visits should happen a minimum of yearly for enrollees receiving in-home providers who conform to, and might take part in, a go to. The go to could be within the enrollee’s house or one other location of their alternative.
    • If in-person visits usually are not doable or most popular, Care Coordinators should preserve energetic, efficient communication utilizing the enrollee’s most popular technique—akin to cellphone, e-mail, digital conferences, or written correspondence. Communication helps, together with assistive applied sciences, have to be supplied as wanted. No enrollee shall obtain a decrease customary of care coordination primarily based on communication preferences, skills, or the necessity for lodging.

SMAC Suggestion: Outline Core Duties for Care Managers in Care Planning and Coordination

SMACs ought to outline minimal Care Supervisor obligations, together with however not restricted to: answering questions, navigating care challenges, and facilitating entry to advantages and helps reflective of individuals’s wants, objectives, and high quality of life aims. Amongst different necessities, Care Managers ought to assist individuals preserve Medicaid eligibility, together with help with renewals; full appeals and grievances and collect supporting paperwork; advocate for his or her wants and objectives; hook up with crucial Medicare, Medicaid, and community-based providers and helps; tackle frequent care coordination challenges stemming from lack of integration between Medicare and Medicaid, together with sturdy medical gear, transportation and pharmacy protection; and advance rebalancing efforts by working with members to find out community-based alternate options to institutionalized care.[15]

Template Language

Massachusetts, New Jersey, California, and Washington

The Care Supervisor performs a crucial position in serving to members entry the care and advantages they want. Contract language ought to require Care Managers to speak successfully with members and supply academic counseling to help knowledgeable decision-making.

The contractor shall incorporate the next obligations within the Care Supervisor position:

Template Language

Ohio, Massachusetts, New Jersey, California, and Washington

SMACs ought to specify the Care Supervisor’s obligations for growing, updating, and implementing the member’s individualized care plan whereas additionally emphasizing the Care Supervisor’s position in addressing the member’s psychosocial wants and upholding key shopper protections.[20] Care coordination bridges the member’s programs of care, together with non-clinical help.[21]

The Care Supervisor shall be accountable for growing their individualized care plan (ICP).

    • Serves because the lead skilled accountable for growing and updating the person-centered care plan and arranging providers via each formal and casual helps.[22]
    • Supplies approval of the ICP and any amendments, as applicable. The member have to be supplied and supplied, upon request, a replica of the ICP and any amendments to the ICP. The ICP have to be made accessible in various codecs and within the member’s most popular written or spoken language upon request.[23]

The Care Supervisor shall be accountable for updating the member’s ICP.

    • Preserve enrollee data to make sure that well being plan providers (medical, BH, LTSS, social) are recorded and that requests for providers are appropriately documented, submitted, tracked, and adjudicated.[24]
    • Evaluate and replace the person-centered care plan with the member, share it with the interdisciplinary care staff, and guarantee it’s re-evaluated a minimum of yearly or upon a major change within the member’s situation.[25]

The Care Supervisor shall be accountable for the execution of the member’s ICP.

  • Help the enrollee, or if relevant, the enrollee and their approved consultant, in main the person-centered planning course of;[26]
    • Coordinate the member’s Medicaid and Medicare providers.[27] Potential actions embrace scheduling appointments, arranging transportation, making referrals, securing essential authorization(s) for providers to make sure members’ well timed entry to the providers recognized within the ICP, exchanging data with suppliers, and actively participating in discharge planning;[28]
    • Advocate for community-based alternate options to long-term care and help enrollees in accessing culturally competent house and community-based providers that align with their care objectives; and[29]
    • Monitor the supply of providers and assess the member’s progress in attaining ICP objectives and take motion to shut service gaps and replace the ICP as wanted.[30]

The Care Supervisor shall be accountable for supporting the psychosocial wants of the member.[31]

  • Social Determinants of Well being (SDOH) shall be addressed by the Care Supervisor and different members of the Care Workforce. Actions embrace however usually are not restricted to the next:
    • Help member in sustaining public advantages, together with, at a minimal, SNAP, Medicaid, Medicare Financial savings Packages, power help akin to Low-Revenue House Vitality Help (LIHEAP), reasonably priced housing, and incapacity advantages;[32]
    • Join members to related referrals and neighborhood sources that meet their social and transportation wants and preferences.[33]  

The Care Supervisor shall be accountable for shopper protections:

    • Help enrollees in submitting grievances associated to their care, Medicare and Medicaid-related appeals, and navigating well being plan escalation procedures and state processes for reporting crucial incidents;[34]
    • Guarantee ADA compliance of providers supplied and organize for care within the enrollee’s most popular language; and[35]
    • Doc and adjust to Advance Directives concerning the enrollee’s needs for future therapy and designate a healthcare proxy if the enrollee desires one.[36]

Battle-Free, Lengthy-Time period Helps Coordination Place:[37]

Numerous states require plans to subcontract with entities with specialised experience in coordinating long-term care advantages. This structural separation between the plan and Care Supervisor helps make sure that care choices are pushed by the member’s wants fairly than the plan’s monetary pursuits.

For instance, Massachusetts One Care members can obtain care coordination from a Lengthy-Time period Helps Coordinator (LTS-C) for his or her long-term care advantages. LTS-Cs are supplied by community-based organizations separate from plans, with experience within the impartial dwelling philosophy and restoration rules. LTS-Cs present conflict-free help to coach and empower members about their community-based care choices, advocate for his or her care wants, and join members to tailor-made long-term care providers and community-based helps. This place is preserved in Massachusetts’ statute.

SMAC Suggestion: Care Supervisor Core Competencies Ought to Be Tailor-made to the Wants of Folks Dually Eligible

Plans must also make sure that Care Managers possess core competencies tailor-made to the wants of individuals dually eligible, together with experience in neighborhood integration, person-centered planning, culturally competent and trauma-informed care, Medicaid HCBS and Medicare house well being advantages, health-related social wants, dignity of threat, and well being fairness. Moreover, Care Managers ought to have coaching and expertise working with older adults and people with bodily disabilities, cognitive, mental, and developmental disabilities, and behavioral well being wants.[38]

Template Language

Ohio, Massachusetts, and California

SMACs outline specific Care Supervisor competencies, demonstrated via documented {qualifications} and ongoing coaching, to make sure workers have the abilities and experience to successfully serve the plan’s twin eligible inhabitants.

  • The Contractor shall set up written {qualifications} for Care Managers employed by the plan, together with, at a minimal:[39]
    • Completion of person-centered planning and person-centered route coaching;
    • Expertise working with individuals with disabilities, behavioral well being wants, and/or older adults;
    • Information of cultural competency and the power to offer knowledgeable advocacy; and
    • Skill to write down an ICP and talk successfully, each verbally and in writing, throughout difficult service and help programs.
  • The Contractor should present onboarding and ongoing coaching for all care coordination workers on the next:[40]
    • Well being fairness and implicit bias; cultural and incapacity competency; person-centered care planning; trauma-informed care; motivational interviewing; fraud, waste, and abuse; communication; grievance and appeals processes and procedures; neighborhood sources; methods for addressing any disease-specific processes; incident reporting necessities; Well being Insurance coverage Portability and Accountability (HIPPA) necessities; self-direction; impartial dwelling and restoration; Medicare providers and coordination of twin providers; common behavioral well being and well being disaster coaching; wellness rules; Individuals with Disabilities Act (ADA)/Olmstead Necessities; and different matters as specified by the state.
  • The Contractor should make sure that Care Coordinators attend obligatory annual coaching on the next matters:[41]
    • Cultural competency/range coaching that displays the variety of the plan’s member inhabitants; treatment administration; stage of care standards; State HCBS Waiver; coordinating twin providers; supplier service specs; course of for requesting house and car modifications and adaptive and assistive gear; person-centered planning; self-direction; neighborhood sources; HIPPA; and customer support.
  • D-SNP care managers collaborating within the Interdisciplinary Care Workforce (ICT) have to be skilled by the plan to establish and perceive the total spectrum of Medicare and Medicaid Lengthy-Time period Companies and Helps (LTSS) applications, together with house and community-based providers and long-term institutional care. The ICT ought to embrace suppliers of any Medicaid providers the member is receiving, together with LTSS and neighborhood helps.[42]

Extra SMAC Language

  • Care Supervisor should get hold of data of well being disparities and the Care Supervisor’s position in lowering disparities and enhancing well being fairness. Care Supervisor should additionally possess data of intersectional identities and their compounding impression on well being outcomes.

SMAC Suggestion: Staffing and Cultural Illustration Necessities

  • To the best extent doable, states ought to require D-SNPs to make sure Care Managers replicate the demographic make-up of the dually eligible inhabitants throughout the plan’s service space.

Extra SMAC Language

The Contractor shall recruit, rent, and preserve a care coordination workforce, to the best extent doable, that’s culturally and linguistically reflective of the enrollee inhabitants served below this Contract. To realize this objective, the Contractor shall:

  • Develop and implement a recruitment and retention plan that features methods for hiring Care Managers and different care staff members who share, to the best extent doable, the racial, ethnic, cultural, and linguistic backgrounds of the enrollees.
  • Conduct a demographic evaluation of its enrollee inhabitants and care coordination workers a minimum of yearly and submit a report back to the State Medicaid Company figuring out any disparities and the steps to handle them.
  • Present coaching and help to care coordination workers to strengthen cultural competency, implicit bias consciousness, and responsiveness to the wants of populations served by the plan, together with however not restricted to individuals dually eligible for Medicare and Medicaid, older adults, individuals with disabilities, LGBTQ+ people, and people with restricted English proficiency.

Overlapping and Carved-Out Advantages

Guiding Precept

Built-in fashions enhance entry to care and member expertise throughout the various dually eligible inhabitants.

Supporting Precept

Members can entry their Medicare and Medicaid advantages immediately.

Federal Necessities

Per part 1902(a)(25) of the Social Safety Act, states should make sure that Medicaid stays the payer of final resort, such that Medicare pays first at any time when Medicare and Medicaid cowl the identical providers. This is applicable whether or not the advantages are paid for on a fee-for-service or capitated foundation. [43] Moreover, per 42 CFR 422.107(c)(1), D-SNPs should coordinate the supply of Medicaid advantages to enrollees who’re eligible to obtain these advantages. [44] Federal regulation additionally requires D-SNPs to help enrollees with accessing Medicaid coated advantages together with and never restricted to helping with resolving grievances and navigating the Medicaid appeals and grievances course of. [45] In response to 42 CFR §422.107(c)(3), the contract between the state and the D-SNP should doc the Medicaid advantages coated by the plan or by a Medicaid managed care plan supplied by the identical dad or mum group for the contract yr. [46]

SMAC Suggestion: Necessities for Coordinating Overlapping and Carved-Out Advantages

States ought to incorporate care coordination necessities directing D-SNPs to take specific actions when coordinating overlapping and carved-out advantages (e.g., dental, behavioral well being advantages, sturdy medical gear, non-emergency medical transportation) to make sure well timed entry to care. States can and will require plans to create streamlined programs that facilitate efficient communication and collaboration between care and utilization administration groups to make sure enrollees have well timed entry to advantages and care administration help providers.

Template Language

Ohio

To keep away from duplication of advantages and guarantee efficient service supply, Ohio requires D-SNPs to implement programs that facilitate efficient sharing of member information and require plans to make sure all members obtain care coordination, no matter whether or not different entities are concerned in overseeing particular elements of their care. Moreover, Ohio delineates particular information-sharing obligations to the broad vary of actions assigned to the D-SNP Care Coordinator position.

California

For sure D-SNPs, California requires plans to trace enrollee supplemental advantages to make sure that plan advantages are exhausted earlier than Medicaid protection of any overlapping advantages. Moreover, California requires D-SNPs with Completely Aligned Enrollment (EAE) to report back to the state the extent of overlapping dental supplier community data. Lastly, California requires D-SNP Care Coordinators to help enrollees with accessing Medicaid advantages, appeals, and grievances.

  • If the D-SNP Contractor gives supplemental advantages as referenced on this contract, member use of supplemental advantages and exhausts supplemental advantages previous to or concurrent with authorization of or referral for Medicaid advantages, together with however not restricted to dental, imaginative and prescient, transportation, neighborhood helps, and behavioral well being; [50]
  • A D-SNP Contractor that provides dental supplemental advantages should report back to the state on the extent of overlap for his or her Medicare dental community and the Medicaid dental community, as outlined on this contract; [51]
  • For advantages which are carved out, akin to Medicaid Dental, the D-SNP Contractor should additionally comply with the rules at 42 CFR part 422.562(a)(5) and 422.629(e) that require the D-SNP Contractor to offer members affordable help finishing types and taking different procedural steps to help members with appeals and grievances. This contains providing to help members with acquiring Medicaid-covered providers and navigating Medicaid appeals and grievances in reference to the member’s personal Medicaid protection, no matter whether or not such protection is in Medicaid fee-for-service or a separate Medicaid dental managed care plan. If the member accepts the help, the D-SNP Contractor ought to help the member as wanted, akin to by figuring out and reaching out to a Medicaid fee-for-service level of contact, offering help in submitting an attraction or grievance, serving to to acquire documentation to help a request for Medicaid attraction or grievance, or finishing paperwork which may be wanted in submitting an attraction or grievance. [52]

Extra Template Language

The D-SNP Contractor will take the next actions to make sure members use plan advantages earlier than utilizing overlapping Medicaid advantages:

Care Transitions

The confusion ensuing from the dearth of coordination between Medicare and Medicaid is most acute when people transition from one healthcare setting to a different. Poorly deliberate and administered care transitions trigger undue stress for dually eligible people and their caregivers, and may end up in expensive hospital readmissions and poor well being outcomes. [54] D-SNPs ought to embrace strong care transition necessities to make sure enrollees are supported and guarded throughout probably the most difficult moments of their well being care continuum.

Care Transitions: Roles and Coaching Necessities

Guiding Precept

  • Built-in fashions enhance entry to care and member expertise throughout the various dually eligible inhabitants.

Supporting Precept

  • Built-in plans advance rebalancing efforts via nursing facility diversion and transition applications.

Federal Necessities

SMAC Suggestion: Guarantee Care Managers Help Care Transitions

Template Language

Massachusetts

Massachusetts requires D-SNPs to prioritize care transition fashions that middle enrollees at house and create programs the place the Care Coordinator and different members of the ICT share data well timed and can be found to offer on-site help to enrollees in care transition actions.

As a part of the Care Coordination position, Massachusetts requires plans to delineate particular scientific obligations that embrace:

  • Work with the ICT to make sure protected transitions for enrollees transferring between well being care settings;
  • Guarantee post-hospitalization providers are mentioned with enrollees and put into place (for each medical and behavioral well being circumstances);
  • Help enrollees in connecting with restoration helps essential to stop hospitalization or re-hospitalization;
  • Comply with-up inside twenty-four (24) hours of an enrollee’s admission to an acute inpatient hospital, and coordinate with the enrollee and hospital workers to facilitate hospital discharges; and
  • Present care coordination/care administration to enrollees residing in a talented nursing facility or nursing facility that has a optimistic PASRR stage II screening. [58]

Ohio

Ohio requires plans to offer detailed descriptions of care administration workers, together with an organizational chart, the variety of workers per position, {qualifications}, and their bodily location. The state additionally mandates plans to report on coaching matters, frequency of coaching, and the way workers coaching is tracked.[59]

  • The Managed Care Group (MCO) care coordination workers should embrace a spread of disciplines with complementary expertise and data to ship a complete, built-in care coordination program absolutely able to addressing members’ bodily, behavioral, LTSS, and psychosocial wants. [60]
  • The plan’s care coordination program submission should embrace: an organizational chart and the variety of workers by position, {qualifications}, and bodily location; coaching matters and frequency of preliminary and ongoing coaching. [61]

Extra Template Language

  • The member’s Main Care Supervisor shall be accountable for coordinating the member’s care throughout all settings, together with however not restricted to acute care, post-acute care, outpatient, and long-term care providers, to make sure continuity of care and help efficient care transitions. [62]

Care Transitions: Discharge Planning Necessities

Guiding Precept

Built-in fashions enhance entry to care and member expertise throughout the various dually eligible inhabitants.

Supporting Precept

Members have entry to high quality, person-centered care coordination.

Federal Necessities

SMAC Suggestion: Share Enrollee-Particular Knowledge, Incorporate Care Workforce, Prioritize HCBS

  • As a part of the discharge planning necessities, states ought to require D-SNPs to facilitate the sharing of enrollee-specific information with the state, the ICT, and related suppliers to make sure enrollees have entry to long-term care providers and helps and HCBS as applicable. States can and will require plans to include enrollees and their caregivers, relations, or designated representatives within the discharge planning course of. Lastly, plans ought to prioritize house and community-based settings post-discharge when applicable.

Template Language

Washington

Washington requires plans to develop a system that facilitates coordination of providers, together with LTSS and community-based providers, throughout discharge and transition planning.

Massachusetts

Massachusetts requires plans to develop a system for efficient person-centered discharge planning that prioritizes the person within the house.

  • The Contractor shall develop, implement, and preserve written protocols for facilitating well timed and efficient care transitions between settings, together with with all community hospitals and nursing amenities. Such protocols shall embrace parts akin to, however not restricted to, the next:
    • Occasion notification written protocols that guarantee key suppliers and people concerned in an enrollee’s care are notified of admission, switch, discharge, and different vital care occasions;
    • Prioritizing return to an applicable house or community-based setting fairly than a facility setting at any time when doable, together with proactive planning to establish and mitigate obstacles to successfully help an enrollee to return to and stay of their house, and make finest efforts to make sure a clean transition to the subsequent service or to the neighborhood;
    • Insurance policies and procedures to make sure inclusion of enrollees and enrollees’ relations/guardians and caregivers, as relevant, in discharge planning and follow-up, and to make sure applicable training of enrollees, relations, guardians, and caregivers on post-discharge care directions; and
    • Culturally and linguistically competent post-discharge training relating to signs which will point out extra well being issues or a deteriorating situation; [65]

Extra SMAC Language

The D-SNP Contractor is accountable for effectuating discharge planning that facilities enrollees’ medical, behavioral well being, and social wants, together with, however not restricted to, the next:

Care Supervisor as A part of an Interdisciplinary Care Workforce

The Care Supervisor features as a part of a strong interdisciplinary staff to help the member in attaining their care objectives. Clearly outlined staff composition, roles, and Care-Supervisor-to-member ratios are important to make sure coordination, communication, and collaboration in assembly members’ wants.

Guiding Precept

  • Built-in fashions enhance entry to care and member expertise throughout the various dually eligible inhabitants.

Supporting Precept

  • Members can entry their Medicare and Medicaid advantages immediately.

SMAC Suggestion: Contracts Ought to Require Collaboration Amongst the Member’s Care Workforce

To make sure well timed advantages approval and care administration actions, states ought to require D-SNPs to collaborate with care and utilization administration groups.

Template Language

California and Massachusetts

The SMAC specifies the required members of the interdisciplinary care staff (ICT) accountable for growing and implementing the member’s individualized care plan (ICP).

The ICT have to be person-centered and developed across the member’s particular preferences and wishes, together with language and tradition, and guarantee integration of the member’s medical and LTSS care. The member has the first decision-making position in figuring out their wants, preferences, and strengths and has a shared decision-making position in figuring out the providers and helps which are handiest and useful for his or her care.[67]

The ICT have to be led by professionally educated and credentialed personnel, and at a minimal, be comprised of the next core people.[68]

  • The member and/or their approved consultant, if the member consents to the participation of the approved consultant;
  • Household and/or caregiver, if authorised by the member;
  • Care Supervisor – See specified obligations famous above.
  • Main Care Doctor – A doctor or non-physician medical practitioner below the supervision of a doctor, who’s accountable for supervising, coordinating, and offering preliminary and first care to sufferers, initiating referrals, and sustaining the continuity of affected person care;
  • Specialist, together with behavioral Well being supplier and Lengthy-Time period Help Coordinator (LTS-C), as indicated.[69]

The ICT should embrace the aforementioned people to the extent doable. On the discretion of the member, the ICT may additionally embrace different people or suppliers actively concerned of their care, together with a hospital discharge planner, nurse, social employee, nursing facility consultant, and different suppliers as applicable.[70]

  • ICT Duties:
    • ICT to help enrollee, to the extent doable, in main the care plan improvement course of to develop an ICP that displays their therapy objectives (medical, practical, behavioral, and social);[71]
    • ICT to measure progress and success in assembly ICT objectives and the objectives of every ICT member in supporting therapy objectives;[72]
    • With the help of the Care Coordinator and/or LTS-C as applicable, promote impartial functioning of the enrollee and supply providers in probably the most applicable, least restrictive setting utilizing impartial dwelling and restoration rules;[73]
    • Conduct ICT conferences periodically, together with on the member’s request. The ICT should take the member’s particular person wants (e.g., communication, cognitive, and different obstacles) under consideration when speaking with the member; and[74]
    • Preserve a name line or different mechanism for member inquiries and enter, and a course of for referring to different businesses, as applicable.[75]

Extra SMAC Language

  • The ICT shall coordinate internally to make sure alignment and follow-through on the objectives and providers outlined within the ICP; and
  • The ICT shall clearly outline member roles and obligations throughout the staff to keep away from duplication and guarantee continuity of care.

SMAC Suggestion: Care Supervisor Ratios Ought to Allow Particular person-Centered Care

States ought to require D-SNPs to make sure Care Supervisor ratios allow individualized consideration attentive to the distinctive wants of every member. These ratios account for the medical and psychosocial wants of members in addition to their geographic location relative to the Care Supervisor.

Template Language[76]

Ohio

SMAC comprises Care Supervisor-to-member ratios adjusted primarily based on members’ threat ranges and corresponding go to schedules.

  • The plan should use individual-level threat stratification as one issue when figuring out the extent of care coordination that’s applicable for every member;
  • The plan should assign a threat tier to every member. The plan should develop a threat stratification framework as a part of its care coordination program that’s comprised of 4 tiers (i.e., from lowest to highest: low monitoring threat [Tier 1], medium threat [Tier 2], excessive threat [Tier 3], and intensive threat [Tier 4]). The plan’s threat framework should embrace the standards and thresholds for every tier to find out member assignments;[77] and
  • The plan should stratify members in response to the chance tiers described under and adjust to the next ratios for its care coordination program, together with plan care coordinators and waiver service coordinators.

Care Supervisor to Member Ratios by Danger Tier

Care Supervisor Contact Schedule by Danger Tier.[78]

Endnotes

  1. Justice in Growing old, Twin Eligible Particular Wants Plans (D-SNPs): What Advocates Must Know; 42 C.F.R. § 422.2. ↑

  2. 42 C.F.R. 422.101(f)(1-3). 42 U.S.C. § 1395w-28(f)(5)(A) and (7) (§ 1895(f)(5)(A) and (7) of the Social Safety Act); see additionally CMS webpage “Mannequin of Care” NCQA webpage “What’s a Mannequin of Care?.” See additionally Breslin, Ellen and Dennis Heaphy. A Name for Fairness: Re-Committing to an Unbiased Residing Restoration-Centered Mannequin of Care, February 2024. Notably, most MOCs usually are not accessible to the general public. ↑

  3. See ICRC, Tricks to Enhance Medicare-Medicaid Integration Utilizing D-SNPs: Integrating Medicaid Managed Lengthy-Time period Companies and Helps into D-SNP Fashions of Care, June 2019. ↑

  4. 42 C.F.R. 422.101(f)(1-3); CMS, Medicare Benefit Mannequin of Care Submission Necessities, June 2025. ↑

  5. 42 C.F.R § 422.101(f) ↑

  6. 42 C.F.R. § 441.725 ↑

  7. 42 C.F.R. § 441.301(c) ↑

  8. KFF, A Profile of Medicare-Medicaid Enrollees (Twin Eligibles), January 2023. ↑

  9. ATI, A Profile of Medicare-Medicaid Twin Beneficiaries, June 2022. ↑

  10. KFF, A Profile of Medicare-Medicaid Enrollees (Twin Eligibles), January 2023. ↑

  11. Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.1.1.2 at p. 99. ↑

  12. New Jersey Division of Human Companies (DHS), “New Jersey FIDE SNP Mannequin MIPPA Contract,” Article 9 § 9.6.3 at p. 37 (January 2022). ↑

  13. Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.1.2 at pp. 99-100. ↑

  14. Language tailored from the Massachusetts Three-Method Contract. Ibid. ↑

  15. Rebalancing refers to efforts to “obtain a extra equitable steadiness between the share of spending and use of providers and helps delivered in house and community-based settings relative to institutional care.” See CMS, Lengthy-Time period Companies and Helps Rebalancing Toolkit, p. 1 (November 2020). ↑

  16. Language tailored from: Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.1.4 at p. 100. ↑

  17. Language tailored from: New Jersey Division of Human Companies (DHS), “New Jersey FIDE SNP Mannequin MIPPA Contract,” § 9.6.3 and 9.6.4 at pg. 24, 36, and 38-39 (January 2022); Washington Well being Care Authority, Lined Well being Care Companies to Twin Eligible Beneficiaries, pg. 79 (January-December 2025); and ICRC, Pattern Language for State Medicaid Company Contracts with D-SNPs: Non-obligatory Language Relevant to all D-SNPs, p. 4 (January 2024). ↑

  18. CA DHCS, “Care Coordination Necessities for Managed Lengthy-Time period Companies and Helps,” pg. 6 (July 2017). ↑

  19. New Jersey Division of Human Companies (DHS), “New Jersey FIDE SNP Mannequin MIPPA Contract,” Article 9 § 9.6.3 at p. 36 (January 2022). ↑

  20. Psychosocial refers back to the mixed affect of psychological elements and the encompassing social setting on bodily, emotional, and/or psychological wellness. See CMS, Psychosocial Severity Information, October 2022. ↑

  21. This language is tailored from: Washington Well being Care Authority, Lined Well being Care Companies to Twin Eligible Beneficiaries, pg. 79 (January-December 2025). ↑

  22. Language tailored from: Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, pp. 167-9. Not accessible on-line; and New Jersey Division of Human Companies (DHS), “New Jersey FIDE SNP Mannequin MIPPA Contract,” Article 9 § 9.6.3 at p. 36 (January 2022). ↑

  23. CA DHCS, “Care Coordination Necessities for Managed Lengthy-Time period Companies and Helps,” p. 7 (July 2017). ↑

  24. Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.1.4 at p. 100. ↑

  25. Language tailored from: Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 178. Not accessible on-line and CA DHCS, “Care Coordination Necessities for Managed Lengthy-Time period Companies and Helps,” p. 8 (July 2017). ↑

  26. Language tailored from: Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 178. Not accessible on-line and extra language from Justice in Growing old . ↑

  27. Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 156. Not accessible on-line. ↑

  28. Ibid., pp. 168-70. See subsequent sections for dialogue on carved out advantages, discharge planning, and care transitions. ↑

  29. Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.1.4 at pp. 104-7. ↑

  30. Language tailored from Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, pp. 178-8. Not accessible on-line. ↑

  31. D-SNPs should assess the enrollee’s bodily, psychosocial, and practical wants. CMS requires D-SNPs to ask questions on housing stability, meals safety, and entry to transportation. See C.F.R. § 422.101(f)(1)(i). ↑

  32. Justice in Growing old extra language. ↑

  33. CA DHCS, “Care Coordination Necessities for Managed Lengthy-Time period Companies and Helps,” p. 6 (July 2017). ↑

  34. Language tailored from: Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” pp. 100-109 and Justice in Growing old added language. ↑

  35. Language tailored from Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” pp. 100-109. ↑

  36. Ibid. ↑

  37. Ohio requires Plans to contract with the AAAs as the first waiver service coordination entity for members age 60 and older who’re enrolled within the state’s HCBS waiver. ↑

  38. Massachusetts Basic Legal guidelines Half 1 Title XVII Chapter 118E Part 9F. https://malegislature.gov/Legal guidelines/GeneralLaws/PartI/TitleXVII/Chapter118E/Section9F ↑

  39. Dignity of threat refers back to the proper of the person to make knowledgeable selections and their experiences and care, even when they might have unfavourable penalties. ↑

  40. Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.1.4 at p. 103-4. ↑

  41. Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, pp. 161-2. Not accessible on-line. ↑

  42. Language tailored from Ibid., p. 162. ↑

  43. DHCS, CalAim Twin Eligible Particular Wants Plans Coverage Information, June 2022. ↑

  44. See CMS, “Ceaselessly Requested Questions on Coordinating Medicaid Advantages and Twin Eligible Particular Wants Plans Supplemental Advantages,” pp. 2-3 (Could 21, 2021) (Accessed June 6, 2025). ↑

  45. See Ryan Stringer et al., “Pattern Language for State Medicaid Company Contracts with Twin Eligible Particular Wants Plans (D-SNPs): Required Language Relevant to All Forms of D-SNPs,” Built-in Care Useful resource Heart (January 2025) p. 3, (Accessed June 5, 2025). ↑

  46. 90 FR 15792; see additionally 42 CFR 422.562(a)(5). ↑

  47. Stringer et al., supra be aware 43 at 4. ↑

  48. Ohio Division of Medicaid, “Next Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 159, (Accessed June 09, 2025). Not accessible on-line. ↑

  49. Id. ↑

  50. Id. at 166. ↑

  51. California Division of Well being Care Companies (DHCS), “Boilerplate 2025 SMAC Completely Aligned Enrollment D-SNP,” Exhibit A, Attachment 1 at 2, (July 8, 2024) (Accessed June 9, 2025). ↑

  52. Id. at 12. ↑

  53. Id. at 16. ↑

  54. This language is tailored from CMS, “Ceaselessly Requested Questions on Coordinating Medicaid Advantages and Twin Eligible Particular Wants Plans Supplemental Advantages,” (Could 21, 2021) (Accessed June 6, 2025). ↑

  55. See CMS, “Neighborhood-based Care Transitions Program,” (Accessed June 3, 2025); See additionally HealthStream, “The Financial & Emotional Value of Hospital Readmissions,” Weblog (April 21, 2025) (Accessed June 3, 2025). ↑

  56. CMS, supra be aware 3. ↑

  57. For extra pattern language, see Ryan Stringer et al., “Pattern Language for State Medicaid Company Contracts with Twin Eligible Particular Wants Plans (D-SNPs): Required Language Relevant to All Forms of D-SNPs,” Built-in Care Useful resource Heart (January 2025) p. 11, (Accessed June 12, 2025). ↑

  58. Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” §2.6.3, at 110-111. (Accessed June 4, 2025). ↑

  59. Id. at §2.6.1.5. ↑

  60. Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 160-161, (Accessed June 04, 2025). Not accessible on-line. For extra data on care supervisor coaching necessities, see additionally Justice in Growing old, “Twin Eligible Particular Wants Plans (D-SNP) State Medicaid Company Contract Toolkit,” § Care Coordination (Could 2025). ↑

  61. Id. at 160. ↑

  62. Ibid at pg. 160. ↑

  63. Notably, Washington not too long ago made adjustments to make sure that twin eligible recipients of the House Well being profit will obtain a single care coordination throughout settings. See Well being Affairs, How Washington State Used Twin Eligible Beneficiary Survey Outcomes to Perceive Enrollment Choices, June 2025. ↑

  64. Stringer et al., supra be aware 2, at 3. ↑

  65. Washington State Well being Care Authority, “Amended and Restated State Medicaid Company Contract,” §1.5.1.4.3, Revised Could 2022 (Accessed July 25, 2025). ↑

  66. Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), supra be aware 2, §2.6.3.1.7. ↑

  67. Language tailored from CA DHCS, “DUALs Plan Letter 16-003,” at 2, (July 25, 2016) (Accessed June 5, 2025). ↑

  68. CA DHCS, “Care Coordination Necessities for Managed Lengthy-Time period Companies and Helps,” p. 9 (July 2017). ↑

  69. Ibid. ↑

  70. Language tailored from CA DHCS, “Care Coordination Necessities for Managed Lengthy-Time period Companies and Helps,” p. 9 (July 2017). ↑

  71. Language tailored from CA DHCS. Ibid. ↑

  72. Language tailored from Massachusetts Govt Workplace of Well being and Human Companies (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.2.6.3 at p. 109. ↑

  73. Ibid. ↑

  74. Ibid. ↑

  75. CA DHCS, “Care Coordination Necessities for Managed Lengthy-Time period Companies and Helps,” pp.8- 9 (July 2017). ↑

  76. Ibid., p. 8. ↑

  77. Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 164. Not accessible on-line. ↑

  78. Ibid. See pp. 164-5 for threat standards and threshold minimal issues. ↑

  79. Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 179. Not accessible on-line. ↑



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