Printing Take a look at – Justice in Growing older

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Printing Take a look at – Justice in Growing older


Desk of Contents

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

That is Half III of the toolkit, which offers a sturdy 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 older’s D-SNP Problem Transient, we heart the experiences of dually eligible enrollees and spotlight the challenges confronted by this inhabitants in navigating their medical insurance protection. To information the dialogue, we reference the Justice in Growing older Guiding Rules, 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 older will launch subsequent sections of this toolkit within the coming months.

This publication highlights greatest 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 Absolutely Built-in Twin Eligible Particular Wants Plans (FIDE-SNPs).[1] For this software, in situations the place current SMAC language will not be publicly obtainable or has not but been written, Justice in Growing older offers advised template language to assist advance key shopper protections and rules.

Federal Necessities

Care coordination for dually eligible people is formed by a number of overarching federal necessities, together with Mannequin of Care necessities, the Residence and Group-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 influence.

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 Providers (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 determine 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 particular companies and advantages to be supplied;
  • Interdisciplinary Care Crew: The plan should make the most of an interdisciplinary care crew 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 out of doors the SNP’s community, to assist be sure that enrollees’ well being care wants, preferences for companies, 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 keep continuity of take care of enrollees, in addition to which personnel are liable for coordinating care all through the transition course of. Particular components of the MOC require D-SNPs to elucidate how the plan will coordinate with suppliers of any Medicaid-covered companies throughout a care transition.

2026 Medicare Benefit and Half D Last Rule

The 2026 Medicare Benefit and Half D Last Rule added further 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, quite 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]

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

For people receiving Medicaid dwelling and community-based companies (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 companies is on the heart of the planning course of. The purpose 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 companies and helps which can be necessary to and for the particular person. The plan should additionally mirror the person’s objectives for neighborhood integration, together with the place and the way they need to obtain these companies.

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

The Entry Rule strengthens current 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 limitations for individuals dually eligible, stopping them from accessing the companies they should meet their well being objectives and care wants. Inadequate coordination leads to people experiencing fragmented care and confusion navigating advantages, all of which might worsen well being outcomes and end in pointless and dear expenditures.

This inhabitants additionally tends to have extremely complicated medical and social wants: 90% have not less than one persistent situation, and 37% have three or extra.[8] Individuals dually eligible additionally expertise increased 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 crew.

Robust care coordination necessities in SMACs are important. SMACs ought to comprise specific language to make sure the member is aware of their Care Supervisor, that care is pushed by the member to the best extent potential, and that companies mirror the member’s distinctive objectives and preferences. SMACs must also clearly outline the Care Supervisor’s tasks 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 Advice: The Member Ought to Know Who Their Care Supervisor Is and Easy methods to Contact Them

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

Template Language

Massachusetts

The contract ensures enrollees know easy methods to 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 get in touch with data for the member’s Care Supervisor.

  • The Contractor’s Care Managers shall use a person-centered method concerning the member evaluation and wishes, bearing in mind not solely lined companies, but in addition formal and casual assist companies as relevant. Care Managers shall guarantee all recognized caregiver(s) have the MCO Care Supervisor’s identify and get in touch with data.[12]

SMAC Advice: Care Administration Engagements Prioritize Member Autonomy and Alternative

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

Template Language[13]

Massachusetts

The contract requires care coordination in a fashion accessible and most well-liked by the member.

  • In-person care coordination/care administration engagement happens not less than as soon as per yr:[14]
    • In-person visits should happen not less than yearly for enrollees receiving in-home companies who comply with, and might take part in, a go to. The go to could be within the enrollee’s dwelling or one other location of their selection.
    • If in-person visits will not be potential or most well-liked, care coordinators should keep lively, efficient communication utilizing the enrollee’s most well-liked technique—resembling 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 normal of care coordination primarily based on communication preferences, skills, or the necessity for lodging.

SMAC Advice: Outline Core Obligations for Care Managers in Care Planning and Coordination

SMACs ought to outline minimal Care Supervisor tasks, 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 keep 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 important Medicare, Medicaid, and community-based companies and helps; deal with frequent care coordination challenges stemming from lack of integration between Medicare and Medicaid, together with sturdy medical tools, 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 important 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 assist knowledgeable decision-making.

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

Template Language

Ohio, Massachusetts, New Jersey, California, and Washington

SMACs ought to specify the Care Supervisor’s tasks 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 beneficiary’s programs of care, together with non-clinical assist.[21]

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

    • Serves because the lead skilled liable for growing and updating the person-centered care plan and arranging companies by means of each formal and casual helps.[22]
    • Supplies approval of the ICP and any amendments, as acceptable. 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 obtainable in different codecs and within the member’s most well-liked written or spoken language upon request.[23]

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

    • Preserve enrollee data to make sure that well being plan companies (medical, BH, LTSS, social) are recorded and that requests for companies are appropriately documented, submitted, tracked, and adjudicated.[24]
    • Evaluation and replace the person-centered care plan with the member, share it with the interdisciplinary care crew, and guarantee it’s re-evaluated not less than yearly or upon a major change within the member’s situation.[25]

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

  • Assist 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 companies.[27] Potential actions embrace scheduling appointments, arranging transportation, making referrals, securing crucial authorization(s) for companies to make sure members’ well timed entry to the companies recognized within the ICP, exchanging data with suppliers, and actively partaking in discharge planning;[28]
    • Advocate for community-based alternate options to long-term care and help enrollees in accessing culturally competent dwelling and community-based companies that align with their care objectives; and[29]
    • Monitor the supply of companies 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 liable 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 Crew. Actions embrace however will not be restricted to the next:
    • Help member in sustaining public advantages, together with, at a minimal, SNAP, Medicaid, Medicare Financial savings Packages, power help resembling Low-Earnings Residence Vitality Help (LIHEAP), inexpensive 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 liable 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 important incidents;[34]
    • Guarantee ADA compliance of companies supplied and organize for care within the enrollee’s most well-liked language; and[35]
    • Doc and adjust to Advance Directives in regards to 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 be sure that care selections are pushed by the member’s wants quite 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 unbiased dwelling philosophy and restoration rules. LTS-Cs present conflict-free assist to teach and empower members about their community-based care choices, advocate for his or her care wants, and join members to tailor-made long-term companies and community-based helps. This place is preserved in Massachusetts’ statute.

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

Plans must also be 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 dwelling 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 by means of documented {qualifications} and ongoing coaching, to make sure workers have the talents 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 path coaching;
    • Expertise working with individuals with disabilities, behavioral well being wants, and/or older adults;
    • Information of cultural competency and the flexibility to supply knowledgeable advocacy; and
    • Capability to put in writing an ICP and talk successfully, each verbally and in writing, throughout difficult service and assist 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; unbiased dwelling and restoration; Medicare companies and coordination of twin companies; common behavioral well being; behavioral well being disaster coaching; wellness rules; Individuals with Disabilities Act (ADA)/Olmstead Necessities; and different matters as specified by the state.
  • The Contractor should be sure that care coordinators attend necessary annual coaching on the next matters:[41]
    • Cultural competency/range coaching that displays the range of the plan’s member inhabitants; medicine administration; degree of care standards; State HCBS Waiver; coordinating twin companies; supplier service specs; course of for requesting dwelling and car modifications and adaptive and assistive tools; person-centered planning; self-direction; restraints, seclusion, and restrictive interventions; neighborhood sources; HIPPA; and customer support.
  • D-SNP care managers collaborating within the Interdisciplinary Care Crew (ICT) have to be educated by the plan to determine and perceive the total spectrum of Medicare and Medicaid Lengthy-Time period Providers and Helps (LTSS) packages, together with dwelling and community-based companies and long-term institutional care. The ICT ought to embrace suppliers of any Medicaid companies the member is receiving, together with LTSS and Group Helps.[42]

Extra SMAC Language

  • Care Supervisor should acquire information of well being disparities and the Care Supervisor’s position in lowering disparities and enhancing well being fairness. Care Supervisor should additionally possess information of intersectional identities and their compounding influence on well being outcomes.

SMAC Advice: Staffing and Cultural Illustration Necessities

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

Extra SMAC Language

The Contractor shall recruit, rent, and keep a care coordination workforce, to the best extent potential, that’s culturally and linguistically reflective of the enrollee inhabitants served beneath this Contract. To realize this purpose, the Contractor shall:

  • Develop and implement a recruitment and retention plan that features methods for hiring Care Managers and different care crew members who share, to the best extent potential, the racial, ethnic, cultural, and linguistic backgrounds of the enrollees.
  • Conduct a demographic evaluation of its enrollee inhabitants and care coordination workers not less than yearly and submit a report back to the State Medicaid Company figuring out any disparities and the steps to handle them.
  • Present coaching and assist 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 directly.

Federal Necessities

Per part 1902(a)(25) of the Social Safety Act, states should be sure that Medicaid stays the payer of final resort, such that Medicare pays first at any time when Medicare and Medicaid cowl the identical companies. This is applicable whether or not the advantages are paid for on a fee-for-service or capitated foundation. [43] Moreover, 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 legislation additionally requires D-SNPs to help enrollees with accessing Medicaid lined advantages together with and never restricted to aiding with resolving grievances and navigating the Medicaid appeals and grievances course of. [45] In line with 42 CFR §422.107(c)(3), the contract between the state and the D-SNP should doc the Medicaid advantages lined by the plan or by a Medicaid managed care plan supplied by the identical mother or father group for the contract yr. [46]

SMAC Advice: 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 tools, non-emergency medical transportation) to make sure well timed entry to care. States can and may 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 assist companies.

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 knowledge 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 tasks 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 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, Group Helps, and Behavioral Well being; [50]
  • 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 can be carved out, resembling Medicaid Dental, D-SNP Contractor should additionally observe the laws at 42 CFR part 422.562(a)(5) and 422.629(e) that require D-SNP Contractor to supply members affordable help finishing varieties and taking different procedural steps to help members with appeals and grievances. This contains providing to help members with acquiring Medicaid-covered companies 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, resembling 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 assist a request for Medicaid attraction or grievance, or finishing paperwork that could 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 shortage 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 essentially 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 by means of nursing facility diversion and transition packages.

Federal Necessities

SMAC Advice: Guarantee Care Managers Assist Care Transitions

Template Language

Massachusetts

Massachusetts requires D-SNP plans to prioritize care transition fashions that heart enrollees at dwelling and create programs the place the Care Coordinator and different members of the ICT share data well timed and can be found to supply on-site assist to enrollees in care transition actions.

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

  • Work with the ICT to make sure secure transitions for enrollees transferring between well being care settings;
  • Guarantee post-hospitalization companies are mentioned with enrollees and put into place (for each medical and behavioral well being circumstances);
  • Help enrollees in connecting with restoration helps crucial to forestall hospitalization or re-hospitalization;
  • Observe-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 constructive PASRR degree II screening. [58]

Ohio

Ohio requires plans to supply 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 information 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 liable 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 companies, to make sure continuity of care and assist 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 Advice: Share Enrollee-Particular Knowledge, Incorporate Care Crew, Prioritize HCBS

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

Template Language

Washington

Washington requires plans to develop a system that facilitates coordination of companies, together with LTSS and community-based companies, 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 dwelling.

  • The Contractor shall develop, implement, and keep 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 components resembling, 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 necessary care occasions;
    • Prioritizing return to an acceptable dwelling or community-based setting quite than a facility setting at any time when potential, together with proactive planning to determine and mitigate limitations to successfully supporting an enrollee to return to and stay of their dwelling, and make greatest efforts to make sure a easy transition to the following 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 acceptable training of enrollees, relations, guardians, and caregivers on post-discharge care directions;
    • Culturally and linguistically competent post-discharge training concerning signs which will point out further well being issues or a deteriorating situation; [65]

Extra SMAC Language

The D-SNP Contractor is liable 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 Crew

The Care Supervisor features as a part of a sturdy interdisciplinary crew to assist the member in attaining their care objectives. Clearly outlined crew 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 directly.

SMAC Advice: Contracts Ought to Require Collaboration Amongst the Member’s Care Crew

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 crew liable for growing and implementing the member’s individualized care plan.

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 companies and helps which can be best 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 accredited by the member;
  • Care Supervisor – See specified tasks famous above.
  • Main Care Doctor – A doctor or non-physician medical practitioner beneath the supervision of a doctor, who’s liable 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 Assist Coordinator (LTS-C), as indicated.[69]

The ICT should embrace the aforementioned people to the extent potential. On the discretion of the member, the ICT can also 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 acceptable.[70]

  • ICT Obligations:
    • ICT to assist enrollee, to the extent potential, in main the care plan growth 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 acceptable, promote unbiased functioning of the enrollee and supply companies in essentially the most acceptable, least restrictive surroundings utilizing Unbiased Residing Rules 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 limitations) into 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 acceptable.[75]

Extra SMAC Language

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

SMAC Advice: 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 conscious of 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 acceptable 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 keeping with the chance tiers described beneath 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

Printing Take a look at – Justice in Growing older

Care Supervisor Contact Schedule by Danger Tier.[78]

  1. Justice in Growing older, 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 will not be obtainable to the general public. ↑

  3. See ICRC, Tricks to Enhance Medicare-Medicaid Integration Utilizing D-SNPs: Integrating Medicaid Managed Lengthy-Time period Providers 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 Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” § 2.6.1.1.2 at p. 99. ↑

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

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

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

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

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

  17. Language tailored from: New Jersey Division of Human Providers (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 Providers to Twin Eligible Beneficiaries, pg. 79 (January-December 2025); and ICRC, Pattern Language for State Medicaid Company Contracts with D-SNPs: Non-compulsory Language Relevant to all D-SNPs, p. 4 (January 2024). ↑

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

  19. New Jersey Division of Human Providers (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 components and the encompassing social surroundings 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 Providers to Twin Eligible Beneficiaries, pg. 79 (January-December 2025). ↑

  22. Language tailored from: Ohio Division of Medicaid, “Subsequent Era MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, pp. 167-9. Not obtainable on-line; and New Jersey Division of Human Providers (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 Providers and Helps,” p. 7 (July 2017). ↑

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

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

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

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

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

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

  30. Language tailored from Ohio Division of Medicaid, “Subsequent Era MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, pp. 178-8. Not obtainable 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 older further language. ↑

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

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

  35. Language tailored from Massachusetts Government Workplace of Well being and Human Providers (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. Dignity of threat refers back to the proper of the person to make knowledgeable decisions and their experiences and care, even when they might have destructive penalties. ↑

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

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

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

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

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

  44. 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 Varieties of D-SNPs,” Built-in Care Useful resource Middle (January 2025) p. 3, (Accessed June 5, 2025). ↑

  45. 90 FR 15792; see additionally 42 CFR 422.562(a)(5). ↑

  46. Stringer et al., supra word 43 at 4. ↑

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

  48. Id. ↑

  49. Id. at 166. ↑

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

  51. Id. at 12. ↑

  52. Id. at 16. ↑

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

  54. See CMS, “Group-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). ↑

  55. CMS, supra word 3. ↑

  56. For added 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 Varieties of D-SNPs,” Built-in Care Useful resource Middle (January 2025) p. 11, (Accessed June 12, 2025). ↑

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

  58. Id. at §2.6.1.5. ↑

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

  60. Id. at 160. ↑

  61. Ibid at pg. 160. ↑

  62. Notably, Washington just lately made adjustments to make sure that twin eligible recipients of the Residence 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. ↑

  63. Stringer et al., supra word 2, at 3. ↑

  64. 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). ↑

  65. Massachusetts Government Workplace of Well being and Human Providers (EOHHS), supra word 2, §2.6.3.1.7. ↑

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

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

  68. Ibid. ↑

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

  70. Language tailored from CA DHCS. Ibid. ↑

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

  72. Ibid. ↑

  73. Ibid. ↑

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

  75. Ibid., p. 8. ↑

  76. Ohio Division of Medicaid, “Subsequent Era MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 164. Not obtainable on-line. ↑

  77. Ibid. See pp. 164-5 for threat standards and threshold minimal concerns. ↑

  78. Ohio Division of Medicaid, “Subsequent Era MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 179. Not obtainable on-line. ↑



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