Samantha Morales: Whats up everybody, and welcome to immediately’s webinar presentation entitled State Medicaid Company Contract (SMAC) Template Toolkit: What Client Protections Advocates Want To Know. I am Samantha Morales, Senior Coverage Advocate on the Well being Crew at Justice in Getting old. And immediately I am joined by my colleague, Hannah Diamond, Senior Coverage Advocate on the Well being Crew.
Subsequent slide, please. Earlier than we start, I want to go over a number of webinar logistics. Once more, welcome to all individuals. You might be all on mute, however we welcome your participation in immediately’s presentation via the Q&A operate within the Zoom management panel. Additionally obtainable within the Zoom management panel is the CC button, which allows closed captioning. We will probably be watching the participant questions as they arrive in all through the webinar, and we’ll uplift excessive degree themes in the course of the Q&A phase on the finish of immediately’s presentation. Any questions unanswered in immediately’s webinar will probably be addressed by way of e mail following the conclusion of the presentation.
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A bit of bit about Justice in Getting old. As a lot of you could know, we’re a nationwide group that makes use of the ability of legislation to battle senior poverty by securing entry to inexpensive healthcare, financial safety, and the courts for older adults with restricted sources. Since our founding in 1972, our efforts have targeted on preventing for individuals who have been traditionally marginalized and excluded from justice, corresponding to ladies, individuals of colour, LGBTQ+ people, and folks with restricted English proficiency.
Subsequent slide, please. Justice in Getting old is dedicated to advancing fairness for low-income older adults in financial safety, healthcare, housing, and elder justice initiatives. We try to handle the enduring harms and inequities attributable to systemic racism and different types of discrimination that uniquely impression low-income older adults in marginalized communities. Subsequent slide, please.
Thanks. So Justice in Getting old produces a wealth of knowledge just like the webinar you are viewing immediately, together with truth sheets, situation briefs, alerts, and different materials to maintain you updated with essential developments. If you happen to’re not already a member of our community, we encourage you to hitch by going to our web site and signing up or just emailing data@justiceinaging.org. Thanks for sticking with me via this background info, and now let’s evaluation the agenda for immediately’s presentation.
So we’ll do a really excessive degree overview of twin eligible particular wants plans or D-SNPs. And for a extra in-depth dialogue on D-SNPs with the complete alphabet soup, we encourage you to view the recording of our August 2025 webinar on D-SNPs, What Advocates Must Know. For the coaching immediately, we’ll present an outline of the State Medicaid company contracts or SMACs and uplift advocacy alternatives.
We’ll spend nearly all of our time delving into the SMAC template toolkit, particularly our newest publication targeted on shopper protections. Lastly, we’ll finish our dialogue by uplifting essential reminders and key takeaways. Subsequent slide, please. And now we’ll delve into high traces for advocates. Subsequent slide, please.
So right here we now have some key factors to border the dialogue. So almost 50% of individuals which can be dually eligible for Medicare and Medicaid within the nation obtain their care from a D-SNP or a twin eligible particular wants plan. Due to this, it is vital that advocates perceive these plans to assist people make knowledgeable choices, in addition to to carry plans accountable to regulatory necessities and to form insurance policies on the state and federal ranges. And we’ll level out the way you as advocates can actually uplift a few of these shopper protections all through this presentation.
Secondly, individuals dually eligible for Medicare and Medicaid navigate two medical health insurance packages, and this implies navigating completely different medical standards underneath each. Medicare covers nearly all of look after dually eligible people, however this group additionally makes use of Medicaid providers. Medicaid is a vital supply of different sorts of care not usually lined by Medicare.
Issues like in house private care providers, transportation, dental, long-term care in a nursing facility, simply to call a number of. Lastly, D-SNPs can streamline care and advantages, however enrollment is all the time a private determination. It’s influenced by an individual’s particular person wants and preferences. In case your most well-liked supplier, for instance, will not be in a D-SNP, it will not be clever to hitch that plan since you may lose your supplier. So it is essential that individuals are knowledgeable about the advantages of D-SNPs in addition to the constraints that include becoming a member of that form of Medicare Benefit plan. Subsequent slide, please.
So what are D-SNPs? In order a lot of you recognize, D-SNPs are a kind of Medicare Benefit plan particularly designed for people who find themselves dually eligible for Medicare and Medicaid. D-SNPs are meant to handle the obstacles that the dually eligible inhabitants faces on account of having two separate medical health insurance payers. Medicare and Medicaid, as you all know, weren’t designed to work collectively, and dually eligible populations usually report confusion and obstacles to getting wanted care. D-SNPs have been meant to handle these issues. Like different Medicare Benefit plans, D-SNPs are a type of managed healthcare.
In contrast to different Medicare Benefit plans, there are some core options that make some of these plans basically completely different. I want to uplift the core components that make D-SNPs completely different than different Medicare Benefit plans. So primary, enrollment is restricted to dually eligible people or a subset. And now the state, once more, has a variety of energy right here to restrict this additional.
So for instance, the state can restrict enrollment in a D-SNP to dually eligible people who’ve full Medicaid advantages, often known as full duals. Secondly, once more, the State Medicaid company contract or SMAC. In contrast to different Medicare Benefit plans, D-SNPs are required to have a SMAC. That is the place the state can actually leverage its energy with D-SNPs and incorporate extra shopper protections. Lastly, federal necessities for some coordination with Medicaid providers.
This, once more, makes D-SNPs distinctive and in contrast to different Medicare Benefit plans that don’t have this requirement. After we converse of coordination with Medicaid providers, it is vital once more to grasp the spectrum of coordination that exists within the D-SNP panorama. Subsequent slide, please. Thanks.
So when it comes to who regulates D-SNPs, each the Facilities for Medicare and Medicaid Providers, CMS, and the State Medicaid Businesses the place these plans function regulates D-SNPs. An essential level to uplift is the State Medicaid Company Contract, once more, the SMAC, as that is the car states can use to impose extra necessities and shopper protections that transcend the minimal to make sure the wants of dually eligible people are met.
The contracts or SMACs are used to set the factors for enrollment, plan supplies, and the extent of care coordination between Medicare and Medicaid that the D-SNP can have. Whereas all D-SNP enrollees will need to have Medicare and Medicaid, as I’ve talked about earlier than, states can select to additional restrict enrollment to a smaller subset of the inhabitants by placing this within the provisions of their SMAC, to allow them to restrict enrollment to solely dually eligible people who require a nursing facility degree of care for instance.
So to drive house the purpose, SMACs have a major impression. They’re extremely essential. On our web site, we now have a number of sources obtainable to help advocates across the matter of D-SNPs, together with the SMAC toolkit linked on this slide. On this webinar, we will probably be delving into the SMAC Template Toolkit and Uplift Client Safety Language. Subsequent slide, please.
So now we’ll talk about the impression of HR1 on individuals dually eligible. Whereas HR1 or the One Massive Stunning Invoice Act, as some individuals are referring to it, doesn’t immediately make modifications to D-SNPs, it accommodates almost a trillion {dollars} in cuts to Medicaid which can be going to shift the burden of price from the federal authorities to the states. The legislation additionally accommodates important modifications that can impression the Medicaid enlargement inhabitants.
These are adults underneath the age of 65 who should not enrolled in Medicare. So a few of this consists of, for instance, work necessities, extra eligibility determinations and price sharing necessities. And we imagine though individuals dually eligible should not within the Medicaid enlargement inhabitants, individuals dually eligible might be impacted by these modifications. So for instance, there’s a variety of confusion about what’s within the legislation. There’s a variety of misinformation. And in addition as a result of this legislation is so burdensome to implement for states, it may trigger system pressure, which can impression different populations.
So moreover, individuals dually eligible might use a caregiver or depend on a caregiver that’s within the Medicaid enlargement inhabitants. So if there are destructive penalties for them, it may negatively impression individuals dually eligible. The legislation additionally accommodates in depth administrative necessities that states should implement. So it will scale back the state’s capability general to concentrate on duals integration and oversee D-SNP efficiency.
So as a result of states need to stability their budgets, there are issues about states lowering or slicing non-compulsory advantages, so particularly house and community-based providers, imaginative and prescient, dental, and listening to advantages might be on the chopping block. So now I’ll go it over to Hannah, who will present an outline of the State Medicaid Company Contracts or SMACS.
Hannah Diamond: Thanks a lot, Sam. So what are State Medicaid Company Contracts or SMACs? You are listening to us check with them because the acronym SMACS. These are contracts between the D-SNPs, so the plan and the state Medicaid company wherein the plan operates. CMS, the Facilities for Medicare and Medicaid Providers, require SMACs to comprise baseline necessities. That stated, states can go above and past the federal ground established by CMS to incorporate stronger shopper protections.
So along with the patron protections that we’ll discuss immediately, SMACS accommodates some actually nice primary details about plan providing. So it is a good place to go to search out out what the plan gives and who the plan gives these providers to. So for instance, the SMAC will define whether or not or not the plan will enroll full and/or partial duals. So SMACs, if they’re publicly obtainable, are place to go to find out about D-SNP necessities and choices.
So the place can you discover SMACS? Sadly, not all SMACs are publicly obtainable. If they’re obtainable, they are going to be on-line. And truly, we simply up to date a useful resource yesterday, our DSNP FAQ useful resource, the place inside the appendix of that useful resource, we now have consolidated the entire publicly obtainable SMACs that we’re conscious of. So I might encourage you to go there to see in case your state SMAC is publicly obtainable.
In case your state doesn’t put up their SMAC, this can be a excellent spot to start out. And truly, on the following slide, I’ll cowl engagement alternatives. So the place do you start your integration advocacy journey? We now have some strategies for you right here. First, I might recommend contacting your state Medicaid company and discovering out who’s liable for creating and overseeing your state’s SMACs. This can show you how to higher perceive who you are focusing on on the state degree. In case your SMAC will not be publicly obtainable, that is the place to start out.
Request a duplicate of your SMAC and ask when it will likely be launched and use the framing of transparency. You wish to see your SMAC as a way to maintain your state and the plans accountable for what they’ve promised to ship, and you then additionally wish to see the SMAC as a way to make enhancements. In order that results in our subsequent advice right here, which in case your state publishes their SMAC, that is nice. We encourage you to evaluation it after which submit suggestions to your Medicaid company. So we encourage you to think about uplifting the content material inside our SMAC toolkit, which you are going to hear about in a minute from Sam and what we’re presenting in immediately’s webinar.
Now, this SMAC toolkit is fairly complete. It has a number of sections which you are going to find out about out, consider it as a menu in which you’ll be able to choose and select to uplift the content material that’s most acceptable on your state’s integration surroundings.
After which moreover, in case your state holds public listening classes, we might actually encourage you to take part in these classes. Present up, elevate the member expertise, elevate the advocate expertise, excuse me, and encourage your networks to share their views. This can be a nice alternative with confirmed demonstrated impression of success, which we’ll share with you.
So when to have interaction. SMACs are required to be up to date on an annual foundation. CMS, the Facilities for Medicare and Medicaid Providers requires Medicare Benefit organizations to add their SMACs by July of yearly. This permits the federal authorities to observe the contracts for primary compliance with federal necessities.
So working backwards, in an effort to meet this July deadline, it signifies that states are starting the drafting course of and modification technique of their SMACs a lot earlier. So due to this fact, we recommend that as advocates, you all are partaking together with your state Medicaid company within the fall previous to that June deadline. This can enable time for the state to include advocates’ strategies as they replace their SMAC after which negotiate with plans.
And right here is an instance of the ability of advocacy that we wish to uplift, and I hope our Ohio pals are on this name. In Ohio, advocates participated in a sequence of public listening classes carried out by their state Medicaid company to tell their state’s transition of a duals demonstration to a [inaudible 00:16:52] D-SNP. And we just lately realized that advocate suggestions was accepted by the state and is mirrored on this yr’s mannequin SMAC.
So advocates have been in a position to efficiently embed stronger shopper protections into their D-SNP choices by way of this advocacy lever, so by way of collaborating in public listening classes and by way of the SMAC. So simply to summarize this part and what you have heard thus far, D-SNPs are serving increasingly individuals dually eligible, and the SMACs are a robust coverage lever wherein to form integration on the state degree. And we now have confirmed examples of success when advocates take part.
We see stronger shopper protections in these choices. And with that, I’ll go it again to my colleague, Sam.
Samantha Morales: Thanks a lot, Hannah. So on this subsequent part, we’ll take a deep dive within the Justice in Getting old SMAC Template Toolkit. So earlier than we will start discussing the SMAC Template Toolkit, we actually need to scaffold ideas and construct on the dialog with the Guiding Rules doc. We launched this doc in September of 2024, the Guiding Rules Doc gives a core set of values and targets that decision for strong shopper protections, well being fairness, person-centered care, and extra oversight and accountability and integration fashions.
So advocates can use the Guiding Rules Doc to information their advocacy round D-SNPs and SMACs. And you’ll see that it’s linked on this slide. So when you obtain the supplies put up this webinar, you’ll have entry as effectively. Subsequent slide, please. Thanks. So constructing off of the Guiding Rules Doc, we printed a toolkit which includes SMAC template language with an emphasis on sturdy shopper protections.
And right here I present an outline of the construction and the aim of the toolkit. So when it comes to the aim, the toolkit is meant to assist advocates as they push for stronger shopper protections in D-SNPs of their states. The toolkit incorporates the Justice in Getting old guiding ideas to information advocates and supply user-friendly language that might be included into SMACS to make sure strong shopper protections.
When it comes to construction, the toolkit encompasses 5 sections with template language overlaying the matters listed right here on this slide. So enrollment eligibility, supplemental advantages, advertising and marketing and communications, care coordination, and our two very just lately launched publications on shopper protections, together with member rights and member engagement and help, which we will probably be specializing in within the final a part of this presentation. Subsequent slide, please.
So we’re uplifting D-SNPs as a chance to consider them as a mitigation technique in relation to HR1. The explanation D-SNPs present this chance has to do with the SMACs. We now have a robust coverage lever by way of the SMACs on the state degree. That stated, as a result of earlier than I can get into a few of these examples, it is actually essential for us to state that D-SNPs can not fill the void that’s attributable to the HR1 Medicaid cuts.
It is actually essential that in our collective advocacy, you contemplate uplifting D-SNPs as a coverage lever, as a mitigation instrument, and that you simply’re additionally forming coalitions to guard current Medicaid advantages and develop Medicaid choices to handle gaps in protection as there actually is not any substitute for funding in house and community-based providers and Medicaid general.
So right here we now have some concepts to spotlight. As we mentioned about plan supplemental advantages, D-SNPs can supply advantages that go above and past these supplied by Medicare and Medicaid.
That is essential to uplift as you are contemplating mitigation methods, and in addition by way of the SMAC, you will get detailed and strong care coordination necessities that may assist to make sure that a person does not lose their Medicaid advantages or prevents it to the perfect extent potential, which is very essential given the modifications in HR1. The final level is very essential, as deeming durations can actually present enrollees with the chance to handle their Medicaid standing earlier than they lose D-SNP protection altogether. As Hannah will get into later, advocates can actually push to get deeming interval protections with their state Medicaid businesses. Subsequent slide, please.
In order a lot of you recognize, a serious situation with D-SNP enrollment is the confusion as a consequence of advanced enrollment processes and eligibility standards that’s not all the time clear. That is very true if individuals are robotically enrolled in D-SNPs by way of the default enrollment course of. CMS permits default enrollment in particular conditions, so not all plans are allowed to robotically enroll individuals. To handle the confusion round eligibility and enrollment, we increase some suggestions within the SMAC template toolkit for advocates to think about. So we checklist a number of of these suggestions right here on this slide.
So primary, on the finish of the day, states ought to enable dually eligible individuals the chance to actively select their protection. SMAC ought to be clear concerning the voluntary nature of enrollment in D-SNPs. Quantity two, if default enrollment is allowed, plans ought to be required to offer a transparent and streamlined opt-out mechanism with out lock-in durations.
These opt-out mechanisms ought to be clearly outlined within the SMAC. Quantity three, to make sure individuals impacted by default enrollment are totally knowledgeable and may make knowledgeable choices about their care well timed, an extra 30-day shopper examined discover that meets language and accessibility requirements ought to be issued to those people.
In order we’ll see within the subsequent slide, some states are already doing this. Lastly, to make sure dually eligible individuals have entry to unbiased and goal info to make knowledgeable choices, SMAC ought to outline the function of OMBUDS packages. Subsequent slide, please.
Right here, we needed to offer examples of states that incorporate sturdy protections of their SMACs. For instance, Ohio incorporates language round shopper selection regardless of implementing default enrollment. California requires an extra 30-day discover for people impacted by default enrollment. For template language, we uplifted language that emphasizes the voluntary nature of D-SNP enrollment and the significance of offering entry to the impartial shopper advocacy teams that may present enrollees with unbiased help round their Medicare protection.
Subsequent slide, please. As a lot of you recognize, via your work with purchasers, D-SNPs usually duplicate advantages that dually eligible individuals have already got entry to via their Medicaid program. So to handle this situation that may make it difficult for individuals to entry the Medicaid advantages they’re already eligible for, states can require D-SNPs to explicitly keep away from duplicating Medicaid advantages, and as a substitute mandate the plan’s fill in gaps in providers or develop current advantages.
Pennsylvania and New Jersey are two states that already incorporate anti-duplication language in reference to D-SNP supplemental advantages of their SMACs. From the template language, you possibly can see how SMACS can actually function a instrument to mitigate the HR1 federal cuts. By incorporating the sort of template language the place states can require D-SNPs to develop current advantages lined underneath Medicaid, corresponding to HCBS, dental providers, providers offered underneath Medicaid waivers, et cetera, states can actually scale back the harms of HR1. Subsequent slide, please.
Medicare enrollees are sometimes inundated with plan advertising and marketing supplies and notices. For dually eligible people who could also be enrolled in a D-SNP after which in a separate Medicaid managed care plan, the difficulty is way more magnified as a result of they’re seemingly getting double the notices and plan supplies. The SMAC suggestions that we uplift right here is to emphasise the significance for states to require D-SNPs to streamline plan supplies as a lot as potential, even for these plans that aren’t required to offer built-in supplies as a result of they don’t meet the factors as working with completely aligned enrollment.
Now, completely aligned enrollment happens when a state limits DSNP enrollment to full profit dually eligible people who obtain their Medicaid advantages from the D-SNP or an affiliated Medicaid managed care plan supplied by the identical mother or father group because the D-SNP. Plans with completely aligned enrollment are federally required to offer built-in supplies, together with an built-in appeals and grievance course of on the plan degree for all Medicare and Medicaid advantages.
States can, in fact, go above and past these federal minimums. Subsequent slide, please.
Right here we uplift the state of Wisconsin and their necessities that D-SNPs with completely aligned enrollment not solely combine enrollee info, which they’re required to do, however that additionally they require plans to incorporate the Medicaid state plan profit info within the abstract of advantages. That is essential as a result of enrollees will be capable to see the advantages they need to have entry to by way of their Medicaid protection. The template language that we offer on the backside of this slide comes immediately from the Wisconsin SMAC. And now I’ll go it again to Hannah who’s going to delve into care coordination.
Hannah Diamond: Thanks, Sam. In order Sam talked about, I’ll discuss care coordination. Care coordination is admittedly the meat and potatoes of D-SNPs. All the level of those plans is to higher combine Medicare and Medicaid choices, and strong coordination necessities are a main car of reaching the identical. So inside this part, we’re that includes 4 care coordination SMAC strategies, however our toolkit for this part is kind of complete, so we encourage you to go to our complete toolkit, however particularly this portion to see extra suggestions.
So D-SNPs are required to display screen for what’s referred to as health-related social wants or social determinants of well being. And though they display screen for these wants, they usually fail to really deal with the holistic wants of a person, in order that they fail to attach a person to neighborhood sources and different sources that they should deal with their wants. So our SMAC advice right here is to obviously outline tasks for care managers to handle the social determinants of well being wants of members, so their psychosocial wants.
So we’re that includes suggestions right here from a number of states that require care managers to help the member in “sustaining public advantages, together with at a minimal, SNAP, Medicaid, Medicare financial savings packages, vitality help corresponding to LIHEAP, inexpensive housing and incapacity advantages.” And we even have template language right here that requires connection and related referrals to satisfy the social and transportation wants and preferences of the member.
So by being express inside the SMAC and holding plans accountable to the SMAC’s necessities, we will higher make sure that members don’t lose entry to crucial advantages, which is very essential inside the surroundings of HR1, the place we’re involved concerning the legislation’s implications on Medicaid, excuse me, and SNAP entry. And by being express, after we’re calling out specific useful resource wants like transportation, for instance, which is a standard concern for individuals dually eligible, care supervisor necessities is usually a instrument to extend entry to those providers.
So individuals dually eligible expertise entry challenges stemming from overlapping protection standards between Medicare and Medicaid. A typical instance that we see is challenges accessing sturdy medical gear. Duals additionally expertise important challenges when a profit is carved out from a D-SNP’s providing. For instance, when long-term care advantages or behavioral well being advantages are carved out.
So to handle this concern, care coordination necessities ought to immediately require plans to take express motion to coordinate overlapping and carved-out advantages. Right here, we’re uplifting an instance from California. California requires plans to trace D-SNP supplemental choices, so that you heard about supplemental choices earlier from Sam, in an effort to make sure that all advantages are exhausted previous to Medicaid protection of any overlapping advantages.
This ensures that supplemental advantages are in reality additive versus duplicative of the members’ current advantages, their Medicare and Medicaid advantages, and it additionally preserves state Medicaid {dollars}, which is very essential inside the context, once more, of HR1 and price range constraints.
One other crucial space that we’re specializing in in relation to care coordination and care supervisor necessities is to concentrate on care transition. So for instance, when a person is transitioning from the hospital, again to the neighborhood, this can be a time when with out express care supervisor necessities that the member is at specific threat of elevated institutionalization or repeat hospitalization.
So due to this fact, it is important that the SMAC prioritizes a member’s entry to house and community-based providers throughout their discharge planning processes. So right here we function an instance from Washington State, which requires prioritization of community-based providers within the discharge and transition planning processes. Their SMAC requires transition protocols to concentrate on enabling entry to house and community-based providers in an effort to forestall pointless institutionalization.
One other instance that I wish to uplift that is not on the slide, however one thing that is crucial and backed in analysis is the significance of medicine administration and reconciliation throughout this time of care transitions.
So principally, we wish to guarantee and make the most of care coordination necessities to make sure that members haven’t got conflicting drugs, that they’ll entry their drugs, and that they perceive how and when to take their drugs. After we see strong medicine administration and reconciliation necessities in place within the SMAC, it has been proven to vastly scale back institutionalization and subsequent hospitalizations post-discharge. So this is a vital space for care coordination necessities inside the SMAC to stipulate.
A further care coordination requirement that we’re uplifting is the significance of care supervisor to member ratios that allow person-centered care. So when these ratios are too excessive, it limits the workers’s capability to have the ability to present individualized consideration to the member, which prevents a well timed response when it comes to entry to providers. So once more, the advice is to require care supervisor ratios that allow person-centered care.
And our advice right here is that includes Ohio SMAC. Ohio SMAC requires express care supervisor to member ratios with differing ratios primarily based on the member’s threat degree. So now I’ll transition us from care coordination necessities to member engagement and help strategies. So the strategies right here on this slide spotlight alternatives to meaningfully have interaction members in advisory committees.
Too usually, individuals with lived expertise should not included into the design and the supply of built-in choices. And regardless of these plans, having member engagement necessities via what’s referred to as an enrollee advisory committee, guaranteeing that these our bodies stay consultant of the member populations and in addition supply a significant platform for suggestions that the plan truly incorporates, continues to be a problem for a lot of plans.
So we now have two sources that we uplift inside our toolkit that I would wish to provide you with a warning to. The primary is admittedly to check out Massachusetts One Care, One Care is one in every of their built-in choices, their implementation council. This council gives the inspiration for federal necessities for enrollee advisory committees. What’s distinctive concerning the implementation council is that not like an enrollee advisory committee, it operates individually from plans, which addresses a number of the energy dynamics and battle of curiosity issues that exist doubtlessly inside an enrollee advisory committee that comes from the plan.
Moreover, the council receives state funded help from the UMass Chan Medical College. This help gives technical help and lodging help to higher allow significant participation from the implementation council members themselves.
Moreover, CMS, once more, the Facilities for Medicare and Medicaid Providers, has put collectively a useful resource, which we have linked on this slide, the place they’ve recognized greatest practices for member engagement in enrollee advisory committees. So some examples of those greatest practices embrace partaking proactively and interesting in a culturally competent and linguistically competent outreach to members, conducting recruitment to offset attrition, providing permissible stipends to acknowledge members’ experience and to compensate them for his or her participation in these advisory councils, after which additionally providing these conferences in varied codecs, together with hybrid, in individual and digital codecs in an effort to make engagement extra accessible.
After which lastly right here, you heard Sam discuss earlier the significance of ombudsman packages, and I am utilizing Ombuds as a gender-neutral time period for Ombudsman. Ombudsmen are crucial in providing help to members in resolving complaints, in navigating difficult grievance and appeals processes, and in addition in addressing systemic challenges confronted by members. So inside the SMAC, it’s endorsed to advocate for language that ensures that each one members have entry to Ombud providers to make sure that members can obtain help with addressing their private obstacles to care and that they are conscious of their rights, and that additionally the Ombudsman can work on addressing systemic challenges confronted by all members. And right here we’re that includes an instance from Massachusetts.
Massachusetts SMAC requires the function of an impartial Ombuds program contracted by the state Medicaid company to help plan enrollees, and the contract additionally explicitly requires plans to work with the Ombuds to resolve particular person and systemic enrollee issues.
So for our remaining part of the toolkit, we’ll be speaking about two strategies to uplift and shield member rights. Right here, we uplift the priority that as a result of many individuals dually eligible lose their Medicaid protection as a consequence of procedural or administrative causes, not as a result of they’re not eligible for care, we’re involved about them, A, dropping their protection, but additionally B, inside the context of HR1, there are extra pressures that may trigger them to lose protection.
So right here we’re offering a suggestion to assist individuals preserve their enrollment inside a D-SNP. So SMACS can make the most of one thing referred to as Deeming protections. Deeming protections allow short-term sustained enrollment in a D-SNP, in a plan, within the occasion of Medicaid loss for a interval of 1 to 6 months. So deeming protections acknowledge that the lack of Medicaid protection amongst members is usually short-term. So by offering these protections, it prevents disruption for each the member and in addition the plan.
So right here we’re uplifting SMAC examples from Virginia, from Indiana and Pennsylvania, all of which require their D-SNPs to offer the utmost deeming interval safety of six months. So this is the language, which I believe is admittedly simple. When a member loses Medicaid eligibility and the contractor determines the person is more likely to regain Medicaid eligibility inside six months of the termination date, the contractor should retain the member for the complete six months.
And at last right here, we’re speaking about separate Medicare and Medicaid appeals processes. When there are separate appeals processes, it is very complicated for members and it could possibly usually delay entry to care. So it is truly a federal requirement for sure sorts of D-SNPs to make use of built-in appeals and grievances processes, so at that preliminary willpower degree after which on the first degree of enchantment.
In these circumstances, plans might solely recuperate for Medicaid service prices after a remaining determination has been made. We suggest by way of the SMAC that protections go additional than the federal minimums and require plans to combine appeals processes in any respect ranges, not simply the preliminary determination and the preliminary enchantment degree.
Plans must also be required to proceed advantages all through the whole appeals course of. And within the occasion that the willpower doesn’t go within the enrollee’s favor, the enrollee shouldn’t be accountable for providers obtained when the enchantment is pending.
And New York is the instance that we’re uplifting right here. That they had an built-in appeals and grievance course of of their duals demonstration, so their duals demonstration gives classes realized that may be mimicked by different states to have a completely built-in appeals course of. And with that, I’ll hand it again to Sam to do essential reminders and key takeaways.
Samantha Morales: Thanks a lot, Hannah. So on this final part of the webinar, we want to evaluation, once more, essential reminders and key takeaways. Subsequent slide, please. So right here we want to uplift some essential reminders that we talked about all through the presentation that we wish to be certain to emphasise.
So first, it is vital for dually eligible people to do not forget that they’ve the liberty of option to resolve the way to obtain their Medicare advantages. Nobody can take that away from them. Second, and linked to the primary level, D-SNP enrollment is totally voluntary. Even when dually eligible people are robotically enrolled in a D-SNP by way of the default enrollment course of, they are going to be allowed to choose out. Lastly, it’s important for dually eligible people to get entry to impartial and unbiased counseling to make sure they’ll perceive their choices and make knowledgeable choices about how they want to obtain their care.
Right here, I want to acknowledge the essential work that the state Ombuds packages, the state medical health insurance help packages, the SHIPS, the Getting old and Incapacity Useful resource Facilities, the ADRCs, and the entire impartial specialists who work to make sure that dually eligible individuals are getting dependable details about their Medicare choices. Subsequent slide, please.
So right here we now have the crux of the difficulty. We would like you to remove these key factors. First, SMACs are a robust instrument for shaping D-SNP coverage and strengthening shopper protections. Second, as a result of SMACs are so crucial, advocates ought to actively have interaction with their state Medicaid businesses within the improvement and within the revision of their state SMACs. The Justice in Getting old SMAC toolkits are linked on the slide. These present sturdy shopper safety language, as Hannah has gone over, that may be included into current state SMACs. Subsequent slide, please. And right here we offered you with a hyperlink or a number of hyperlinks to the Justice in Getting old Assets targeted on D-SNPs, SMACS, and Duals integration. Subsequent slide, please.
Moreover, we offered hyperlinks to the Built-in Care Useful resource Heart, the ICRC supplies that present a wealth of knowledge on D-SNPs, Duals integration, and SMACS. And once more, you’ll obtain the slides and webinar recording after the webinar. Subsequent slide, please.
And with that, thanks on your participation and engagement. We now have fairly a number of questions. We now have a while to go over your questions. Hannah and I’ll do our greatest to decide on excessive degree themes. So there’s a query, Hannah, that got here up that I believed actually connects to your part on care coordination. And the query is, do dually eligible individuals have caseworkers or coordinators to work with via their insurance coverage plan?
Hannah Diamond: Sure. The reply is sure, however I’ll say that many people who find themselves enrolled in these plans should not conscious that they’ve entry to care managers and that they are assigned one. So there are express federal necessities for SMACs and in addition an extra doc referred to as Mannequin of Care that form of overviews how these plans are going to offer providers to individuals dually eligible. A kind of necessities is that they’ve a person-centered plan, and that plan is developed in partnership with the member and carried out by an interdisciplinary care staff.
And the care supervisor is part of that care staff. So every particular person ought to have entry to a care supervisor. Once more, these plans by way of the SMAC, the SMAC accommodates the necessities for the care supervisor. And the truth that a member won’t know who their care supervisor is, we even have suggestions inside our SMAC toolkit of necessities for plans to do proactive outreach, outreach on a well timed foundation to make sure that members know who their care supervisor is.
So the reply is sure. And that is an space that we’re attempting to handle lack of awareness on behalf of the member by way of the SMAC. In order that’s a fantastic query.
Samantha Morales: One other query that can also be actually essential given the content material of what we simply delved into is, do you’ve got any suggestions for the way SMACs can require plans to be clear about Medicare financial savings packages restrictions?
And this individual writes that there is a plan of their state that’s MSP-restricted, however the restrictions aren’t seen in Planfinder and the plan’s personal paperwork are poorly worded. And it looks like the plan does not actually perceive their restriction and erroneously enrolls individuals who haven’t got the proper Medicare financial savings program after which disenrolls them after the six-month grace interval.
And so any suggestions on that. I can take a stab after which Hannah, be happy so as to add extra to this. So that is undoubtedly a priority as a result of sadly eligibility standards for D-SNPs, as we talked about throughout this presentation, might be very complicated for these causes that this participant listed right here on this query.
One of many issues that advocates can push for when it comes to shopper protections is ensuring that state Medicaid businesses are requiring D-SNPs to include clear eligibility standards of their D-SNPs, of their SMACs, excuse me. So in these contracts, it ought to be clear what populations of duals are eligible to enroll within the plan, within the D-SNP plan. So if it is a full twin that is eligible, solely full duals, which means people who’re dually eligible people enrolled in full Medicaid advantages, or if the plan can also be accepting partial duals. These are the oldsters which have, for instance, a Medicare financial savings program, however they are not enrolled in full Medicaid advantages.
So partial duals have a Medicare financial savings program, however not full Medicaid advantages, so not entry to the entire Medicaid, for instance, the medical, the long-term care, they solely have the MSP. So it is essential to get these sorts of eligibility items within the SMAC in order that it is simpler for advocates and shoppers to navigate.
Hannah, did I miss something on that?
Hannah Diamond: I might simply, to handle the complicated notices which can be coming from plans, and forgive me if you happen to stated this, Sam, however you possibly can require, and we now have this inside our SMAC toolkit, the SMACs can require that plans submit their notices to the state Medicaid company and for advocates to evaluation previous to launch to members. And in order that’s a very essential manner, A, to make sure that the supplies are right, and B, to make sure that the language as written is having its meant impression.
So after I say stakeholders, that might be advocates, however that may be a fantastic function for the enrollee advisory committees, for instance, that are comprised of members. Their evaluation of supplies earlier than launched to the complete plan may assist make sure that these supplies are accessible and are relaying acceptable info. So would encourage you to take a look at our communications-specific toolkit for extra suggestions to enhance how info is being offered to members.
Samantha Morales: So this is one other query that additionally touches on simply the impartial shopper advocacy teams that we reference in several components of our presentation when it comes to offering help to dually eligible people with their Medicare choices. So this query from a California advocate, for instance, asks, “Could not the realm businesses on ageing be useful resource for an advisory council since they have already got one? Perhaps the Older People Act would must be revised.”
Hannah Diamond: I might say that as sources of unbiased info for individuals dually eligible, there are businesses on ageing are nice. SILs are great. SHIPs are unbelievable. And so I might actually encourage you, particularly when making a call about whether or not or to not enroll in a D-SNP within the first place, unbiased counseling is extraordinarily essential when navigating that course of.
And when it comes to uplifting greatest practices, sure, I believe leveraging classes realized from current enrollee advisory committees in different areas, just like the strategies we outlined from CMS that they’ve consolidated, but additionally varied councils which have been profitable. So we uplift the significance of the implementation council in Massachusetts One Care plan. Inside that built-in providing, there are many concepts for greatest practices to tug from and make the most of. So sure, in case you have a fantastic instance in your state that is working, we encourage you to take these suggestions and supply them to your Medicaid company by way of your SMAC advocacy.
Samantha Morales: There’s one other query particular to transportation advantages, for instance, and this will get to, are plans going to exclude transportation of their D-SNPs? And I can take a stab at this, and Hannah, please add extra info. So within the presentation after we’re overlaying these supplemental advantages and actually D-SNPs as a chance for states to mitigate HR1 cuts, we reference transportation advantages. We additionally reference dental advantages, for instance, HCBS providers, however actually D-SNPs should not essentially going to exclude transportation of their protection.
The purpose of the dialogue is that advocates working with their state Medicaid businesses can actually push the state to require D-SNPs which can be working within the state to include transportation advantages that go above and past what the state Medicaid advantages are being supplied to dually enrolled people. So actually it is about seeing the D-SNP and seeing the SMAC as a chance to include and develop if there are current transportation advantages, not duplicate these advantages, however actually develop and add extra in order that dually eligible people are protected, particularly with the looming Medicaid cuts.
Hannah, something you needed so as to add there?
Hannah Diamond: I might simply add at a really excessive degree, there’s nothing inside HR1 that requires the providers that we have talked about, these non-compulsory Medicaid advantages, so transportation, house and community-based providers, supplier reimbursement charges, enhanced eligibility pathways. There may be nothing inside the legislation that requires these advantages to be reduce. And in order that’s why it is actually essential that those that are listening in on this name are collaborating in advocacy alternatives with their state Medicaid company, with their state legislature, with their federal lawmakers, all to uplift the significance of house and community-based providers, to uplift the significance of built-in choices, to uplift the significance of the distinctive wants of individuals dually eligible of their state. Once more, there’s nothing that requires the state to make these cuts. It might be a selection on behalf of the state.
Samantha Morales: And there’s a query on HR1, Hannah. Does HR1 prohibit notices in languages apart from English?
Hannah Diamond: No, it doesn’t. I’ll say that typically we see the Medicaid necessities when it comes to language entry to be extra strong than the federal Medicare necessities. In order that’s one thing that you simply wish to be advocating for on the state degree, is essentially the most strong language entry protections which can be obtainable. And once more, inside our SMAC toolkit, inside the communication part, we now have language that you could pull from to make sure that that’s the most complete providing potential. However no, there’s nothing inside HR1 that requires notices to simply be offered in English.
Samantha Morales: After which lastly, we now have time for yet another query. There’s a query from an individual who’s a dually eligible recipient on an HCBS waiver, and the priority is that their revenue might make them ineligible for Medicaid. And the query is, there isn’t any manner that this individual will be capable to afford, for instance, their care on their revenue. Any advocacy suggestions for an individual on this scenario?
Hannah Diamond: I can take a stab at this. So your state might have what’s referred to as spend down, so you possibly can spend down your extra revenue in an effort to qualify for a Medicaid pathway. I believe that this individual… I want to take it slightly bit extra macro. This individual raises a very good level about the truth that the revenue and asset restrictions which can be related to long-term care and Medicaid eligibility are very, very low. And so this is a chance if we’re working not solely to guard what we now have, but additionally to develop entry, growing these thresholds is a very essential option to improve entry to crucial care.
So that is what I might say. I might concentrate on attempting to develop eligibility and in addition seeing what paths your state presents in an effort to present entry for many who could be barely over revenue.
Samantha Morales: Thanks a lot, Hannah. And thanks once more to all of you for becoming a member of us immediately. As a reminder, any questions that went unanswered immediately will probably be adopted up on by way of e mail, and be happy to succeed in out to us. Our contact info is right here on the slide with any extra questions that come up later. Do not forget to finish the post-webinar survey. Your suggestions is far appreciated and is essential for us to enhance our providers and have a fantastic remainder of your day. Thanks a lot.
Hannah Diamond: Thanks.
