This toolkit gives policymakers, together with State Medicaid Company employees, and advocates, with rules and corresponding template language to develop State Medicaid Company Contracts (SMACs) which are aware of 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.
Components IV and V of the toolkit present a sturdy dialogue on shopper protections inside D-SNPs, together with Member Engagement and Assist (e.g., Enrollee Advisory Committees and Ombuds Packages) and Member Rights (e.g., Sustaining Protection and Appeals and Grievances). Half I of this toolkit covers Eligibility and Enrollment in addition to Supplemental Advantages, Half II of this toolkit focuses on Advertising and Communications, and Half III of this toolkit encompasses Care Coordination.
Drawing from Justice in Growing older’s D-SNP Problem Temporary, 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 older Guiding Ideas, a core set of values and objectives that decision for sturdy 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 in 2026.
This publication highlights greatest practices drawn from D-SNP mannequin contracts and Monetary Alignment mannequin contracts. For this instrument, in cases the place current SMAC language shouldn’t be publicly obtainable or has not but been written, Justice in Growing older gives steered template language to assist advance key shopper protections and rules.
Enrollee Advisory Committee
Too typically, coverage and providers are designed with out enter from care recipients. Enrollee Advisory Committees (EACs) present built-in fashions with a structured platform to include the lived expertise and experience of members into the design and supply of plan choices, enhancing the flexibility of plans to supply providers which are aware of the needs and wishes of members.
Guiding Precept
Built-in fashions present sturdy shopper protections.
Supporting Precept
Built-in fashions incorporate members in mannequin design, implementation, and oversight processes.
Federal Requirement
Underneath 42 C.F.R. § 422.107(f), any Medicare Benefit (MA) group providing a number of D-SNPs should set up and keep a number of Enrollee Advisory Committees (EACs) to serve the D-SNPs it gives within the state.[1] EAC membership should replicate the plan’s enrollee inhabitants to supply enter on methods to “enhance entry to lined providers, coordination of providers, and well being fairness for underserved populations.”[2]
SMAC Suggestions
To allow significant participation, built-in fashions should set up and maintain shopper advisory teams which are supported with technical help, administrative and accessibility help, and shopper stipends. Contract language should specify that plans reply to member suggestions and take into account learn how to incorporate it into the design and supply of plan choices.
Template Language
Arizona[3]
The Arizona SMAC demonstrates frequent contract language to satisfy federal necessities.
- Medicare Benefit Group (MAO) shall set up and conduct on a periodic foundation, not less than one Enrollee Advisory Committee (EAC) in accordance with the necessities of 42 CFR Part 422.107(f) and this Settlement.
- MAO’s EAC shall meet with the identical frequency as its companion well being plan Member Advocacy Council (as relevant) as per the necessities of 42 CFR 438.110.
- Membership of the MAO’s EAC shall be consultant of and replicate the enrolled populations, the communities and the Geographic Service Areas (GSAs) served by MAO. A plan consultant shall attend every assembly.
New York[4] and Massachusetts[5]
Each state contracts exceed federal necessities by defining particular accessibility requirements to make sure significant enrollee participation, requiring plans to actively solicit and incorporate member options, and mandating member suggestions on designated subjects.
- The Plan shall be required to have not less than one EAC open to all individuals and household representatives, in addition to to the participant Ombuds.[6] The EAC shall meet each (1) Medicaid managed care necessities for a Member Advisory Committee as described at 42 CFR 438.110; and (2) Medicare D-SNP necessities for an EAC as described at 42 CFR 422.107(f).[7]
- Composition: The EAC shall be comprised of enrollees, members of the family, and different enrollee caregivers. The composition of the EAC shall replicate the range of the plan’s member inhabitants, together with people with varied disabilities, with a membership that considers cultural, linguistic, racial, incapacity, sexual orientation, and gender identities, amongst others.[8]
- Assembly Frequency/Discover: The EAC should meet not less than quarterly. The EAC conferences should be open to all individuals and their household representatives; all individuals and household representatives ought to obtain discover of the EAC conferences.[9]
- Plan Necessities: The plan should set up a course of for the EAC to supply enter to the plan.[10] The Contractor shall conduct advertising and marketing and outreach to plan members (or their members of the family or caregivers, as relevant) to make sure enrollees are conscious of the chance to use, to affix or in any other case take part.[11] The plan should share any updates or proposed modifications in addition to details about the quantity and nature of grievances and appeals, details about high quality assurance and enchancment, details about enrollments and disenrollments, and extra.[12] The plan shall additionally evaluation and talk about participant ombuds studies in quarterly updates to the EAC and shall take part in all statewide stakeholder and oversight convenings as requested by the State and/or CMS.[13]
- Accessibility: The Contractor shall proactively guarantee: cheap lodging and interpreter providers, in addition to different assets, are offered as could also be wanted to help full participation by enrollees, their members of the family, and caregivers within the EAC, and that the method and alternative for becoming a member of the EAC is publicized.[14]
- Member Enter: Duties of the EAC embody, however will not be restricted to: offering common suggestions to the plan on problems with the plan administration, enrollee care and providers, and on different solicited enter; figuring out and advocating for preventive care practices to be utilized by the Contractor; being concerned with the event and updating of cultural and linguistic insurance policies and procedures, together with these associated to high quality enchancment, training, Contractor advertising and marketing supplies and campaigns, and operational and cultural competency points affecting teams who communicate a main language aside from English; and offering enter and recommendation on member expertise survey outcomes, methods to enhance entry to lined providers, coordination and integration of providers, and well being fairness for enrolled and particular underserved sub-populations and different applicable knowledge and assessments, amongst different subjects.[15]
- Along with EAC quarterly conferences, the plan should conduct not less than two participant suggestions periods in its service space every year. These periods present individuals with in-person and distant alternatives to supply constructive suggestions and lift issues and issues. The plan should summarize every session and publicly put up the assembly document promptly.[16]
Ohio[17]
As a part of its EAC necessities, Ohio’s contract requires plans to doc all suggestions made by the EAC and to report on the plan’s corresponding responses.
- The plan should report the next EAC info to the State Medicaid Company: a listing of attending members through the prior quarter for every council; assembly dates, agenda, and the minutes from every council assembly that occurred through the prior quarter; enchancment suggestions developed by every council; the plan’s response to or implementation of the council’s enchancment suggestions; and plan’s methodology for figuring out that the council’s membership displays the range of the plan’s enrolled inhabitants.
One Care’s Implementation Council[18]
Classes realized from One Care’s (Massachusetts’ built-in providing for individuals dually eligible beneath the age of 65) Implementation Council (IC) helped to tell federal necessities for EACs. The IC engages in systemic advocacy to watch service high quality, champion well being fairness in service supply and design, promote transparency from plans and the state Medicaid company, and maintain plans accountable for person-centered care.
Whereas EACs maintain important potential to collect insights that form plan service supply, their effectiveness could also be constrained by plan oversight. In distinction, the IC assumes a definite position that units it aside from EACs, because it operates individually from plans. This separation ensures that the IC can supply conflict-free and neutral suggestions, unburdened by potential conflicts of curiosity.
To allow significant participation, the IC additionally receives intensive help and technical help from the UMass Chan Medical Faculty, together with full-time employees to supply technical help, administrative help, and accessibility help to allow significant involvement of IC members.
Classes Discovered from D-SNP EAC Strategic Conversations[19]
The Medicare-Medicaid Coordination Workplace (MMCO) on the Facilities for Medicare and Medicaid Providers (CMS) carried out strategic conversations with Medicare Benefit Organizations to establish greatest practices for supporting EACs. Key findings spotlight the significance of sturdy recruitment and engagement practices to make sure committees replicate plan membership. Efficient methods embody proactive, culturally and linguistically accessible outreach with trusted neighborhood companions, over-recruitment to offset attrition, direct follow-up with individuals, and permissible stipends to acknowledge members’ experience.
EAC conferences ought to replicate each geographic and linguistic range, providing hybrid, in-person, and digital codecs to advertise accessibility. Members should have significant alternatives to form agendas, and plans ought to report again on how member suggestions is integrated into plan operations. For organizations working a number of EACs, periodic management convenings have proved helpful to align greatest practices and help reporting EAC-specific outcomes to the State.
Ombuds Packages
Given the complexities of Medicare and Medicaid protection standards, the inherent energy dynamics between plans and members, and components like low literacy charges and language limitations impacting members’ social determinants of well being, ombuds providers are important for dually eligible individuals to beat limitations to care. Ombuds applications present important help to enrollees by serving to them navigate particular person care issues and addressing systemic challenges associated to plan choices. They help shoppers in resolving complaints and in navigating grievance and attraction processes.
Criticism knowledge collected by ombuds applications is essential for figuring out tendencies and informing care enhancements at each the state and federal ranges. Ombuds ceaselessly meet with state Medicaid company employees to deal with systemic points, and as famous within the Enrollee Advisory Committee (EAC) SMAC template toolkit part, typically take part in member advisory boards. Additionally they play a significant position in member training and outreach, explaining enrollee rights and protections, and connecting members to providers that help their wants and community-integration objectives.
Guiding Precept
Built-in fashions present sturdy shopper protections.
Supporting Precept
Members have entry to unbiased help, separate from plans, to navigate challenges related to their care via totally funded ombuds providers.
Federal Necessities
The Monetary Alignment Initiative (FAI), an built-in mannequin testing demonstration, supported states in creating built-in care fashions aimed toward enhancing care, enhancing coordination, and decreasing prices for people dually eligible for Medicare and Medicaid.
As a part of this demonstration, states might leverage current Lengthy-Time period Care ombuds infrastructure, construct new applications, or contract with current non-profits, together with authorized providers, to supply ombuds help, serving to enrollees to resolve particular person care issues, conduct member outreach and training, and handle systemic points associated to plan choices.[20]
Presently, federal necessities don’t mandate that built-in fashions lengthen ombuds help to D-SNP enrollees. Accordingly, this toolkit highlights FAI contract language, regardless of these fashions sunsetting in December 2025 (or earlier).
Notably, the ombuds applications included within the FAI demonstrations constructed upon the present state Lengthy-Time period Care (LTC) Ombudsman Packages, that are approved beneath the Older People Act and function in each state.
These applications are designed to guard the well being, security, welfare, and rights of residents in long-term care services, together with nursing properties and assisted residing services. They’re answerable for figuring out, investigating, and resolving resident complaints; offering training and details about residents’ rights and obtainable advantages; making certain residents have entry to ombuds help; representing residents’ pursuits to safe cures that safeguard their well being and well-being; and conducting systemic advocacy to enhance the standard of care and providers in long-term care settings.[21]
SMAC Suggestion
SMAC comprises express language to make sure members have entry to ombuds providers that empower members about their rights and work with plans to resolve care disruptions and limitations to care, together with aiding with appeals and grievances, in addition to resolving systemic challenges impacting members.
Template Language
Ohio[22]
Ohio’s contract specifies member entry to ombuds help.
- The State Lengthy-Time period Care Ombuds Program gives core ombuds providers to members, together with outreach, member empowerment via training, criticism investigation, and person-centered criticism decision. Ombuds representatives shall be accessible to the member and enrollee advisory council and different member advisory boards and can take part in all statewide stakeholder and oversight actions.
Massachusetts[23]
Massachusetts’ contract specifies the position of an unbiased ombuds program, contracted by the state Medicaid company, to supply help to plan enrollees. It additionally establishes particular necessities for plans to work with the ombuds to resolve each particular person and systemic enrollee issues.
- Ombuds Definition: A impartial entity that has been contracted by the State Medicaid Company to help Enrollees and some other Medicaid members (together with their households, caregivers, representatives, and/or advocates) with info, points, or issues associated to D-SNP or different Medicaid well being plans, advantages, or providers. Ombuds employees fulfill each particular person and systemic advocacy roles.
- The Contractor shall help Enrollee entry to, and work with, the Ombuds to deal with Enrollee requests for info, points, or issues associated to the plan, together with:
- Educating Enrollees in regards to the availability of Ombuds providers.
- Speaking and cooperating with Ombuds employees as wanted for them to analyze and resolve Enrollee requests for info, points, or issues associated to the plan, together with by: Designating a employees individual because the Contractor’s Ombuds liaison; Offering Ombuds employees with entry to data wanted to analyze and resolve Enrollee Grievances (with the enrollee’s approval); and Guaranteeing ongoing communication and cooperation of plan employees with ombuds employees in working to analyze and resolve enrollee grievances, together with updates on progress made in direction of decision, till such time because the grievances have been resolved.
- The Contractor shall additionally embody ombuds studies, as obtainable, in quarterly updates to the Enrollee Advisory Committee.
Further SMAC Language
The D-SNP will contract with an exterior entity, unbiased of the plan and with demonstrated experience in serving the plan’s member inhabitants, to function and supply Ombuds providers to enrollees. The Ombuds will present enrollees with an array of providers, together with, however not restricted to: training, advantages counseling, help with appeals and grievances, and, when requested by the enrollee, direct illustration in such processes.
Massachusetts’ My Ombudsman Program
My Ombudsman is the ombuds program for One Care enrollees (the state’s built-in providing for individuals dually eligible for Medicare and Medicaid beneath age 65) and Medicaid recipients in Massachusetts. My Ombudsman educates One Care members about their rights, negotiates with plans to resolve care disruptions, and informs plan enchancment actions primarily based on My Ombudsman consumption and criticism knowledge.
Importantly, My Ombudsman is operated by the Incapacity Coverage Consortium (DPC), a incapacity rights group with a majority disabled workforce. Along with their lived expertise with incapacity, My Ombudsman employees obtain intensive coaching on delivering culturally and linguistically competent providers.
The background of DPC employees allows sturdy rapport constructing with One Care members, minimizes biases contributing to well being disparities, and promotes innovation in member-specific providers and outreach. The truth that My Ombudsman is operated by a nonprofit group, distinct from the plans themselves, ensures that members obtain unbiased counseling and help aligned with their greatest pursuits reasonably than the priorities of plans.
A present limitation of this system, based on Massachusetts’ advocates, is that though My Ombudsman can educate and inform members about their rights, it can’t legally symbolize members in appeals and grievances. Whereas this system’s employees refers members to exterior entities comparable to authorized help suppliers, advocates notice that these entities typically have restricted capability and can’t all the time present wanted help.
Endnotes
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The Medicare Managed Care Guide Chapter 16-B: Particular Wants Plan Part 20.2.9-2 reiterates regulatory necessities whereas providing some further editorial language. See CMS, Medicare Managed Care Guide Sections 20.2.9-20.2.9.1, November 2024. ↑
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Arizona Well being Care Value Containment System (AHCCCS), ”MEDICARE ADVANTAGE ORGANIZATION AGREEMENT BETWEEN AHCCCS AND Bridgeway Well being Options of Arizona, In,” pp. 19-20, 41. ↑
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Language is tailored from New York Division of Well being, FIDA-IDD Mannequin Contract, pp. 105-7. ↑
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Language is tailored from Massachusetts Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” pp. 34-36. ↑
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Language is tailored from New York Division of Well being, FIDA-IDD Mannequin Contract, pp. 105-7. ↑
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Language is tailored from Massachusetts Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” pp. 34-36. ↑
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Ibid. ↑
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Language is tailored from New York Division of Well being, FIDA-IDD Mannequin Contract, pp. 105-7. ↑
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Ibid. ↑
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Language is tailored from Massachusetts Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” pp. 34-36. ↑
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Language is tailored from New York Division of Well being, FIDA-IDD Mannequin Contract, pp. 105-7. ↑
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Language is tailored from New York Division of Well being, FIDA-IDD Mannequin Contract, pp. 105-7; Language is tailored from Massachusetts Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” pp. 34-36. ↑
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Language is tailored from Massachusetts Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” pp. 34-36. ↑
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Ibid. ↑
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Language is tailored from New York Division of Well being, FIDA-IDD Mannequin Contract, pp. 105-7. ↑
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Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” p. 53. Not obtainable on-line. ↑
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Mass.gov, One Care Implementation Council. ↑
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Primarily based on options from MMCO, Classes Discovered from Twin Eligible Particular Wants Plans Enrollee Advisory Committee Strategic Dialog, June 2024. ↑
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ICRC, State Approaches to Creating and Working Ombudsman Packages for Demonstrations beneath the Monetary Alignment Initiative, March 2021. ↑
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45 C.F.R. § 1324.13; See additionally ACL, “Lengthy-Time period Care Ombudsman Program.” ↑
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Ohio Division of Medicaid, “Subsequent Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” p. 53. Not obtainable on-line. ↑
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Massachusetts Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” pp. 22, 36, 118-9. ↑
