Desk of Contents
This toolkit gives coverage makers, together with State Medicaid Company workers, and advocates, with ideas and corresponding template language to develop State Medicaid Company Contracts (SMACs) which are attentive to the wants of the dually eligible populations they serve. Stakeholders are inspired to make use of this instrument to advance their priorities by tailoring the parts which are most acceptable for his or her state’s built-in environments. For this instrument, in cases the place current SMAC language just isn’t publicly accessible or has not but been written, Justice in Growing older gives urged template language to assist advance key client protections and ideas.
Drawing from Justice in Growing older’s D-SNP Concern Temporary, we middle 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 Ideas, a core set of values and objectives that decision for sturdy client 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. The template language on this toolkit has been tailored from current state SMACs.
Eligibility and Enrollment
Individuals dually eligible usually expertise vital confusion in the course of the D-SNP enrollment course of, particularly relating to the eligibility standards for enrolling in a D-SNP, whether or not they might be topic to default enrollment, and what protections can be found in the event that they lose D-SNP eligibility. Clear and accessible contract language is vital for people to know their rights and choices, and for plans to know their obligations.
Default Enrollment: Alternative
Guiding Precept
Built-in fashions safeguard client alternative and allow knowledgeable and unbiased decision-making.
Supporting Precept
Individuals dually eligible are assured the fitting to decide on their protection.
Federal Requirement
The Facilities for Medicare and Medicaid Providers (CMS) permits default or computerized enrollment right into a D-SNP when a Medicaid enrollee turns into newly eligible for Medicare both by means of age or incapacity, and the person is already enrolled in a Medicaid Managed Care Group (MMCO) operated by the identical sponsor because the D-SNP.1
SMAC Suggestions
States ought to permit folks dually eligible the chance to actively select their protection. Advocates ought to take into account asking states to chorus from default enrollment. If default enrollment is allowed, plans needs to be required to offer a transparent and streamlined opt-out mechanism with out lock-in intervals. SMACs ought to clarify that enrollees retain the fitting to decide on how they obtain their Medicare advantages, even when default enrollment is permitted. States ought to use their SMACs to gather details about default enrollment—who’s default enrolled, what number of people decide out, and what number of complaints have been filed— to raised perceive the implications of default enrollment.
Template Language
Ohio
Regardless of implementing default enrollment, the Ohio SMAC incorporates language round client alternative.
- An eligible particular person’s choice to enroll within the Medicare Benefit Group (MAO) for Medicare advantages shall be choice-based. Whereas default enrollment could also be used to advertise enrollment and alignment, people retain the fitting to decide out, in step with federal rules.2
Arizona
Whereas default enrollment is allowed, Arizona incorporates language about bettering alignment efforts and respecting member alternative.
- The [state medicaid agency] and MAO will proceed to work with stakeholders to ascertain practices which enhance alignment for Full Profit Twin Eligible Members. The beneficiary’s alternative of MAO shall be totally revered, and consequently, misalignment could happen.3
Extra SMAC language
- The D-SNP Contractor shall clearly talk the voluntary nature of plan enrollment and describe various care supply choices to enrollees in beneficiary going through enrollment supplies, together with however not restricted to, enrollment notices and advertising and marketing supplies.
- Upon request, the D-SNP Contractor shall present [the state medicaid agency] with knowledge associated to default enrollment inside timeframes and specs outlined by the Company. This shall embody, at a minimal:
- The quantity and proportion of people who opted out earlier than enrollment turned efficient;
- The quantity and proportion of people who disenrolled inside the first six months of plan enrollment, together with to what extent disenrollment was attributed to the plan not assembly their wants (as self-reported by means of grievances, exit interviews, or different beneficiary suggestions mechanisms);
- Disaggregated demographic knowledge (e.g., age, zip code, race/ethnicity, sexual orientation and gender id, major language, and incapacity standing);
- The quantity and nature of complaints or grievances associated to the default enrollment course of.
- [the state medicaid agency] reserves the fitting to request extra knowledge or reporting to guage the fairness, transparency, and beneficiary expertise related to default enrollment.4
Default Enrollment: Discover
Guiding Precept
Built-in fashions safeguard client alternative and allow knowledgeable and unbiased decision-making.
Supporting Precept
Individuals dually eligible obtain clear, correct supplies that allow knowledgeable enrollment choices.
Federal Requirement
Per 42 CFR 422.66(c)(2)(iv), if default enrollment is allowed, states should require plans to challenge written notification to twin eligible populations impacted no fewer than 60 calendar days previous to the plan efficient date.
SMAC Suggestions
Along with the 60-day discover, D-SNPs needs to be required to challenge a further 30-day discover that’s client examined, meets Medicare’s 5 % (5%) threshold for language translation as outlined in 42 CFR Half 422 Subpart V and any extra language and accessibility requirements required by the state.
Template Language
California
- California requires a further 30-day discover for twin eligible people impacted by default enrollment. This discover informs people of their proper to decide out earlier than the enrollment turns into efficient and gives key particulars, together with methods to decline enrollment, the place to hunt help in making an knowledgeable choice, and the contact data for the State Well being Insurance coverage Help Program (SHIP) and Ombuds program.5
Eligibility Standards for D-SNP Enrollment
Guiding Precept
Built-in fashions safeguard client alternative and allow knowledgeable and unbiased decision-making.
Supporting Precept
Individuals dually eligible obtain clear, correct supplies that allow knowledgeable enrollment choices.
Federal Requirement
States should record D-SNP eligibility standards of their SMAC.6 Whereas federal legislation broadly describes D-SNP eligibility to use to twin eligible people, states have the authority to additional prohibit eligibility to sure teams of twin eligible populations.
SMAC Suggestions
SMACs ought to clearly clarify who’s eligible for D-SNP enrollment in order that people, their caregiver(s) and/or representatives perceive their choices. For instance, states can deny D-SNP eligibility to partial- profit twin eligible people and people who’re in Medicaid with a spend down or share of value (medically needy eligibility). States also needs to embody antidiscrimination language inside their description of D-SNP eligibility.
Template Language
Arizona
Arizona’s SMAC explicitly limits D-SNP enrollment to full profit twin eligibles.
- The Contractor shall enroll an eligible Full Profit Twin Eligible Member solely in accordance with the eligibility, phrases, service space counties and plan profit packages (PBPs) listed for every of the respective built-in managed care contract, and populations as designated by particular contracts, contract phrases, or as in any other case additional specified.7
Washington
Washington’s SMAC gives antidiscrimination language.
- Except a Twin Eligible is in any other case excluded underneath federal Medicare Benefit plan guidelines, the Contractor will settle for all Full Twin Eligible people who meet the state-defined enrollment standards with out regard to bodily or psychological situation, well being standing or want for or receipt of well being care providers, claims expertise, medical historical past, genetic data, incapacity, marital standing, age, intercourse, nationwide origin, race, coloration, or faith, and won’t use any coverage or follow that has the impact of such discrimination.8
Extra SMAC language
The Contractor shall enroll solely these dually eligible members who meet the enrollment standards as outlined by [the state medicaid agency]. The Contractor shall enroll solely full profit dually eligible people. People who qualify for under Medicare Financial savings Program (i.e., partial duals) and who would not have full Medicaid advantages, shall not be eligible for enrollment until explicitly permitted by the State. The Contractor is required to specify populations eligible for enrollment of their beneficiary going through enrollment supplies.
Enrollment and Shopper Help
Guiding Precept
Built-in fashions safeguard client alternative and allow knowledgeable and unbiased decision-making.
Supporting Precept
Individuals dually eligible have entry to unbiased enrollment help.
Federal Requirement
Per 42 CFR 422.562(a)(5), D-SNPs are required to help enrollees in accessing Medicaid advantages and resolving grievances. CMS permits plans to offer help in a number of methods together with referring enrollees to outdoors specialists akin to Ombuds Applications, State Well being Insurance coverage Help Applications (SHIPs), and others.9
SMAC Suggestions
States ought to require plans to assist enrollees in resolving points associated to enrollment. SMACs also needs to specify a clearly outlined position for Ombuds applications to make sure enrollees have entry to goal data, and impartial client help, in order that they and or their caregiver(s) could make knowledgeable enrollment choices. Plan enrollment notices ought to embody the helpline numbers to the Ombuds applications, and different impartial specialists, for twin eligible people who search choices counseling.
Template Language
Ohio
The Ohio SMAC gives clearly outlined roles for the State Ombuds program,10 and the language needs to be broadened to embody extra impartial Ombuds applications:
- Ombuds Applications present core providers to members, together with outreach, member empowerment by means of schooling, criticism investigation, person-centered criticism decision, and the gathering and reporting of casework knowledge and thematic criticism evaluation to CMS on a quarterly foundation.
Extra SMAC language
- D-SNP contractors should prominently function the helpline numbers for Ombuds applications, State Well being Insurance coverage Help program (SHIP), and the Growing older and Incapacity Useful resource Heart(s) (ADRC) in all member enrollment supplies.
Supplemental Advantages
D-SNP supplemental advantages usually duplicate Medicaid advantages already accessible to dually eligible enrollees. In lots of instances, overlapping providers present restricted utility and may be tough for the members to navigate. As well as, details about eligibility and methods to entry supplemental advantages is usually unclear, and transparency points persist when knowledge about who truly receives the advantages just isn’t collected or reported.
Supplemental Profit Choices
Guiding Precept
Built-in fashions enhance entry to care and member expertise throughout the varied twin eligible inhabitants.
Supporting Precept
Built-in plans embody providers past these usually lined by Medicare and Medicaid.
Federal Requirement
D-SNP supplemental advantages encompass necessary and non-compulsory supplemental advantages that should meet CMS necessities together with the requirement that the advantages should not lined by Medicare Components A, B or D.11
SMAC Suggestions
To keep away from cost duplication, states can require plans to submit Medicare bid data.12 States also needs to require D-SNPs to explicitly keep away from profit duplication, fill in gaps in providers, and broaden current advantages.
Template Language
Pennsylvania
Pennsylvania requires D-SNP supplemental advantages to fill gaps in protection:
- The D-SNP will supply at the very least one necessary Supplemental Medicare Profit that’s designed to fill a spot in Medicaid providers for which full duals are eligible. These could embody, however should not restricted to, gaps in listening to or imaginative and prescient providers. D-SNPs could not impose any value sharing to the Supplemental Medicare Advantages supplied.13
New Jersey
New Jersey requires D-SNPs to keep away from duplication with supplemental advantages:
- Supplemental advantages supplied as a element of the Contractor’s FIDE SNP product shall conform to the specs in Chapter 4 of the Medicare Managed Care Guide (in part 30 et seq.), and 42 CFR 100, SSA 1852(a)(3)(D), and shall not be duplicative of providers lined by Medicare or Medicaid as a part of the bottom FIDE SNP advantages bundle.14
Extra SMAC language
- The D-SNP contractor shall supply supplemental advantages that broaden entry to providers past these supplied within the Medicaid state plan and/or Medicaid waivers, together with and never restricted to non-medical transportation, Dwelling and Neighborhood Based mostly Providers (HCBS), caregiver helps, dental providers, and behavioral well being providers.15
Flex Playing cards/Debit Playing cards
Guiding Precept
Built-in fashions enhance entry to care and member expertise throughout the varied twin eligible inhabitants.
Supporting Precept
Built-in plans embody providers past these usually lined by Medicare and Medicaid.
Federal Requirement
CMS not too long ago clarified that Medicare Benefit (MA) supplemental advantages utilizing debit playing cards needs to be excluded from the calculation of revenue when figuring out eligibility for public profit applications.16
SMAC Suggestions
States can require D-SNPs to work instantly with enrollees on supplemental advantages entry, and assign a point-person to help members with accessing supplemental advantages that overlap with current Medicare and Medicaid advantages. SMACs ought to present clear steering and require plans to supply enrollment counseling helps to make sure that supplemental advantages within the type of debit or “versatile” spending playing cards don’t negatively impression enrollees.
Template Language
Pennsylvania
Pennsylvania requires plans to tell enrollees and supply help with entry to supplemental advantages:
- The D-SNP shall assess the member’s wants for providers which are lined by the D-SNP as supplemental advantages akin to dental and/or transportation providers. Additional, the D-SNP shall educate members on methods to entry supplemental advantages.17
Extra SMAC language
- The Contractor shall assign a plan consultant akin to a Care Supervisor to assist enrollees when supplemental advantages overlap with Medicaid advantages together with and never restricted to dental care, sturdy medical tools, and non-medical transportation.18 If supplemental advantages within the type of debit playing cards are supplied, the contractor shall present counseling assist to make sure that these advantages meet the wants of enrollees and don’t negatively impression eligibility for public advantages.19
Supplemental Profit Utilization
Guiding Precept
Built-in fashions enhance entry to care and member expertise throughout the varied twin eligible inhabitants.
Supporting Precept
Members can entry their Medicare and Medicaid advantages immediately.
Federal Requirement
By January 2026, D-SNP plans shall be required to inform enrollees with a mid-year discover if enrollees haven’t used most of their supplemental advantages by June of that yr.20
SMAC Suggestions
Many SMACs already set up extra necessities for supplemental advantages, akin to requiring plans to report advantages utilization and clearly outline eligibility standards. States ought to guarantee D-SNPs present supplemental advantages equitably and transparently.
Template Language
Ohio
Ohio requires plans to report knowledge on supplemental advantages utilization:
- All knowledge on any providers supplied to members that aren’t mirrored as claims or encounters shall be reported to the state through [include specific reporting system]. This contains however just isn’t restricted to care coordination, non-emergency transportation, Medicare supplemental advantages, and different value- added or extra providers.21
Washington
Washington requires plans to delineate which supplemental advantages can be found to particular twin eligible populations:
- Upon receiving written approval from the State, the Contractor could function separate Plan Profit Packages (PBP) for full twin eligible Members and partial twin eligible Members. The Contractor’s PBPs and eligible Members are detailed in [insert smac section].22
Extra SMAC language
- The D-SNP Contractor shall report quarterly disaggregated demographic knowledge (e.g., age, zip code, race/ethnicity, sexual orientation and gender id, and so forth.) for all enrollees who make the most of supplemental advantages. The Contractor shall embody all eligibility necessities for supplemental advantages in a public-facing web site.
Advertising and marketing and Communications
Individuals dually eligible are sometimes overwhelmed by the separate and complicated notices they obtain from their Medicare managed care plan, akin to a Twin Eligible Particular Wants Plan (D-SNP), and their Medicaid Managed Care plan (MMC). This confusion is worsened when plan notices should not client examined, should not supplied within the member’s most popular language, or fail to account for the well being literacy wants of dually eligible members.
Communications and Advertising and marketing Supplies Accessibility
Guiding Precept
Built-in fashions present sturdy client protections.
Supporting Precept
Members obtain clear, well timed, and accessible communications.
Federal Requirement
All Medicare Benefit plans should adhere to the communication and advertising and marketing necessities supplied in 42 CFR Half 422 Subpart V and 42 CFR 438.10. Many states require D-SNP plans to fulfill extra necessities to make sure supplies are accessible and acceptable for the dually eligible populations they serve.
SMAC Suggestions
To satisfy the well being literacy and accessibility wants of dually eligible enrollees, states ought to require D-SNPs to client check all advertising and marketing and communication supplies earlier than distribution. States also needs to impose extra necessities to make sure plan written supplies are accessible, culturally and linguistically acceptable, and embody nondiscrimination data.23
Template Language
Massachusetts
Massachusetts requires D-SNPs to make sure entry to lined providers by sustaining insurance policies that assure affordable lodging for enrollees and potential enrollees:
- D-SNP Contractors will guarantee enrollees are supplied with affordable lodging to ensure efficient communication, together with auxiliary aids and providers, which shall be made accessible upon request of the potential enrollee or enrollee for gratis and that enrollees could make standing requests for affordable lodging. Affordable lodging will rely upon the actual wants of the person and embody:
- Offering giant print (at the very least eighteen (18)-point font) or Braille of all written supplies to people with visible impairments, as requested;
- Making certain efficient communication to and from enrollees in accordance with their communication preferences, together with by means of e-mail, phone, textual content, and different digital means;
- Making certain efficient communication to and from people who’re Deaf or onerous of listening to, or who’ve disabilities impacting their speech or communication wants, by utilizing these people’ most popular modes of communication entry by means of e-mail, textual content, phone, and different digital means, and thru providers and applied sciences akin to TTY, Video Relay Providers (VRS), computer-aided transcription providers, phone handset amplifiers, assistive listening methods, closed caption decoders, videotext shows, certified interpreters (together with ASL interpreters), and different auxiliary aids and providers;
- Offering interpreters or translators for enrollees whose major language just isn’t English.24
California
California requires plans to offer enrollees with nondiscrimination notices:
- D-SNP Contractor should submit (1) a state-approved nondiscrimination discover, and (2) language taglines in a conspicuously seen font dimension in English, the edge languages, and at the very least the highest 15 non English languages within the state, and every other languages, as decided by the state, explaining the supply of free language help providers, together with written translation and oral interpretation, and knowledge on methods to request Auxiliary Aids and providers, together with supplies in various codecs. The nondiscrimination discover and taglines shall embody D-SNP Contractor’s toll-free and TTY/TDD phone quantity for acquiring these providers, and shall be posted within the Member Providers Information/Proof of Protection, and in all Member data, informational notices, and supplies important to acquiring providers focused to Members, potential members, candidates, and members of the general public.25
California requires plans to incorporate details about methods to file a grievance with the CA Division of Well being Care Providers (DHCS) Workplace of Civil Rights and the HHS Workplace of Civil Rights in plan nondiscrimination notices:
- All Managed Care Plan nondiscrimination notices should embody details about methods to file a discrimination grievance instantly with the State’s Workplace of Civil Rights, along with details about methods to file a discrimination grievance with the plan and HHS Workplace of Civil Rights (i.e., file a grievance with HHS Workplace of Civil Rights if there’s a concern of discrimination based mostly on race, coloration, nationwide origin, age, incapacity, or intercourse). Managed Care Plans are required to make the nondiscrimination discover accessible, upon request or as in any other case required by legislation, within the threshold and focus languages, or in an ADA-compliant, accessible format.26
Extra SMAC language
The D-SNP Contractor shall collect and incorporate suggestions from members serving on the Enrollee Advisory Committee and out of doors specialists (e.g., suppliers, client advocates, commerce associations, enrollees and caregivers) to provide client supplies that meet the well being literacy and accessibility wants of the twin eligible inhabitants.27 Moreover, all written supplies and enrollee communications shall be in plain language and on the seventh grade studying stage, utilizing the Flesch scale evaluation readability rating.28
Language and Accessibility
Guiding Precept
Built-in fashions present sturdy client protections.
Supporting Precept
Members obtain clear, well timed, and accessible communications.
Federal Requirement
All Medicare Benefit plans should adhere to the language and accessibility necessities outlined in 42 CFR 422.2267 together with and never restricted to translating required supplies to any non-English language that’s the major language of at the very least 5 % of the people within the plan service space. As well as, plans should make these translated supplies accessible in any non-English language or accessible format on a standing foundation as soon as the plan receives a request or upon studying of enrollees’ language and/or accessibility wants. Plans should additionally adhere to language and format necessities outlined in 42 CFR 438.10(d) together with making oral interpretation in all languages and American Signal Language accessible to people and members at no expense.29: Absolutely built-in twin eligible (FIDE) SNPs, extremely built-in twin eligible (HIDE) SNPs, or relevant built-in plan (AIP) should additionally meet any extra language necessities outlined within the SMAC.30
SMAC Suggestions
States ought to require plans to offer written data to members describing methods to request language or incapacity lodging and methods to file a grievance with the plan, the state, and the Well being and Human Providers (HHS) Workplace of Civil Rights. States with stronger language entry guidelines than the federal minimal ought to require plans to stick to each the federal and state necessities.
Template Language
California
California requires plans to stick to language thresholds past federal minimums.
- Managed Care Plans are required to offer translated written member data, utilizing a professional translator based on the State’s necessities for certified translators, to the next language teams inside their service areas, as decided by the State:
- A inhabitants group of eligible beneficiaries residing within the Managed Care Plan’s (MCP) service space who point out their major language as a language apart from English, and that meet a numeric threshold of three,000 or five-percent (5%) of the eligible beneficiary inhabitants, whichever is decrease (Threshold Customary Language); and
- A inhabitants group of eligible beneficiaries residing within the MCP’s service space who point out their major language as a language apart from English and who meet the focus requirements of 1,000 in a single ZIP code or 1,500 in two contiguous ZIP codes (Focus Customary Language).31
Built-in Supplies Overview
Guiding Precept
Built-in fashions present sturdy client protections.
Supporting Precept
Built-in fashions simplify procedures, so members expertise a single system inclusive of essentially the most complete protections supplied by each Medicare and Medicaid.
Federal Necessities
Medicare Benefit plans should submit communication and advertising and marketing supplies outlined in 42 CFR 422.2261 for approval to CMS earlier than distributing to enrollees. Per 42 CFR 422.107(e), states can use SMACs to require D-SNPs that function with completely aligned enrollment (EAE) to ascertain (and function inside) contracts with CMS that solely embody D-SNPs inside a state (“D-SNP-only contracts”), and combine sure supplies and notices for D-SNP enrollees.32 Moreover, State Medicaid Companies that require contracted D-SNPs with EAE to function inside state-specific, D-SNP solely contracts with CMS, are granted entry to the CMS Well being Plan Administration System (HPMS) to evaluate plan submitted supplies.33 States can thus train better oversight once they require plans to function with EAE and a D-SNP solely contract as this permits them to collectively evaluate D-SNP built-in communication and advertising and marketing supplies alongside CMS.
SMAC Suggestions
To make sure that plan advertising and marketing and communications supplies adhere to state requirements, states ought to require plans to submit all, or sure varieties, of selling and communication supplies for evaluate and/or approval previous to distribution.
Template Language
Minnesota
Minnesota requires D-SNPs to submit “Enrollee Supplies” to the state for approval previous to distribution and requires session with tribal governments when advertising and marketing supplies goal American Indian populations:
- If the advertising and marketing supplies goal American Indian Beneficiaries, the State shall seek the advice of with tribal governments inside an inexpensive time period earlier than approval. The State should approve all data for enrollees that requires approval prior to make use of of the supplies. The Managed Care Group should submit its enrollee supplies in a ultimate format earlier than approval from the State may be given. The State agrees to tell the Managed Care Group of its approval or denial of paperwork inside thirty (30) days of receipt of those paperwork.34
Massachusetts
Massachusetts requires D-SNPs submit for approval all “Outreach and Enrollees Supplies” together with supplies in non-English languages previous to distribution:
- The D-SNP Contractor shall undergo the State all types of outreach and enrollee supplies, together with non-English outreach supplies together with an English translation, an attestation from an authorized translation company, and a signature of the Managed Care Group Director, for evaluate and approval earlier than use or distribution. The State should additionally approve any adjustments or updates to outreach supplies earlier than use or distribution.35
Built-in Supplies and Processes
Guiding Precept
Built-in fashions present sturdy client protections.
Supporting Precept
Built-in fashions simplify procedures so members expertise a single system inclusive of essentially the most complete protections supplied by each Medicare and Medicaid.
Federal Necessities
As famous within the dialogue above in reference to 42 CFR 422.107(e), CMS affords states the flexibleness to require D-SNPs with completely aligned enrollment (EAE) to combine supplies together with and never restricted to the abstract of advantages; formulary; and mixed Supplier and Pharmacy Listing.36 Moreover, relevant built-in D-SNPs are required to make use of an built-in appeals and grievance course of.37
SMAC Suggestions
To simplify the outline of advantages, states ought to require D-SNPs with EAE to offer enrollees with a single set of totally built-in supplies that describe each the Medicare and Medicaid advantages lined by the D-SNP (and its affiliated Medicaid plan, when relevant). For D-SNPs with out EAE, states ought to require plans to offer descriptions of Medicare and Medicaid advantages in a extra unified format. For instance, states might require non-EAE D-SNPs to current Medicare and Medicaid appeals and grievances descriptions collectively within the member handbook, plan letters to enrollees, and in different communications as acceptable. To make sure dually eligible members are totally knowledgeable about the advantages they’re entitled to, states ought to require D-SNPs to incorporate details about Medicaid State Plan advantages in communications and advertising and marketing supplies.
Template Language
Wisconsin
Along with requiring D-SNPs with EAE to combine enrollee data, Wisconsin requires D-SNPs to incorporate Medicaid State Plan profit data within the abstract of advantages:
- The MA Plan agrees to make use of insurance policies and procedures authorised by CMS and the State to coordinate and combine enrollee communication supplies, together with enrollment communications, grievance and appeals, and high quality assurance.
- The MA Plan will determine within the MA Plan’s Abstract of Advantages these advantages the member could also be eligible for underneath the State Plan that aren’t lined providers underneath the Member’s MA Plan.38
California
California requires choose D-SNPs to offer built-in supplies and a single customer support quantity:
- D-SNP Contractor is answerable for offering built-in Member supplies to Members. Required built-in Member supplies will embody: 1) Annual Discover of Change (ANOC); 2) Member Handbook; 3) Abstract of Advantages; 4) Member Identification (ID) Card; 5) Supplier/Pharmacy listing; and 6) Record of Coated Medication (Formulary).
- D-SNP Contractor should have a single Member providers/customer support telephone quantity for Members to contact D-SNP Contractor relating to their Medicare or State plan advantages. D-SNP Contractor should use the one Member providers telephone quantity in all built-in Member supplies. D-SNP Contractor should have a single Software Programming Interface (API) for Members to entry each Medicare and Medicaid data.39
Value-sharing Protections Disclosures
Guiding Precept
Built-in fashions present sturdy client protections.
Supporting Precept
Members are shielded from cost-sharing that exceeds what they’d pay in Medicaid or Medicare fee-for- service for a similar service.
Federal Requirement
Per 42 CFR 422.107(c(4), SMACs are required to incorporate the cost-sharing protections lined underneath )the D-SNP.40
SMAC Suggestions
To make sure dually eligible enrollees are totally knowledgeable about cost-sharing protections, states ought to require D-SNPs to incorporate details about monetary legal responsibility protections in communication and advertising and marketing supplies.41
Template Language
Wisconsin
Wisconsin requires D-SNPs to speak enrollee monetary legal responsibility protections:
- The MA Plan shall talk totally built-in Medicare-Medicaid protection to all members, suppliers, MA Plan workers, and different stakeholders, together with assure of full member safety from monetary legal responsibility – which means all deductibles, premiums, coinsurance, copayments, and price sharing of any type, with exception for member post-eligibility therapy of revenue cost, if relevant.42
Minnesota
Minnesota requires D-SNPs to speak enrollee value sharing obligations within the plan handbook doc and in different supplies:
- The Managed Care Group (MCO) shall clarify the cost-sharing coverage within the MCO’s handbook and different supplies for Enrollees. The MCO shall not supply waiver of cost-sharing as an inducement to enroll within the D-SNP plan until CMS has authorised waiver of cost of cost-sharing by the MCO as a further profit within the MCO’s Medicare bid course of, and such waiver can’t be described in any of the MCO’s Advertising and marketing Materials.43
Endnotes
1: See CMS, “Default Enrollment Coverage and Knowledge on Accredited Medicare Benefit Plans,” (October 23, 2023) (Accessed February 12, 2025).
2: Ohio Division of Medicaid, “Next Technology MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Attachment A, p. 41, (Accessed January 27, 2025). Not accessible on-line.
3: Arizona Well being Care Value Containment System (AHCCCS),”Medicare D-SNP Agreements: UnitedHealthcare Neighborhood Plan,” §2.1.13 at 6. (Accessed February 24, 2025)
4: This language was tailored from the Arizona SMAC, see id. §2.1.12, at 6.
5: CA Division of Well being Care Providers (DHCS), “CalAIM Managed Lengthy Time period Providers and Helps (MLTSS) and Duals Integration Workgroup,” p. 18 (Accessed February 11, 2025); see additionally DHCS, “Medi-Medi Plan (EAE D-SNP) Default Enrollment Pilot” (Accessed February 24, 2025).
6: For extra data, see CMS, “Medicare Managed Care Guide Chapter 16-B: Particular Wants Plans,” § 20.2.2 at 18, (Rev. 131; Issued: 11-22-24), (Accessed January 17, 2025).
7: Arizona AHCCCS, supra notice 7, § 4 at 29.
8: Washington State Well being Care Authority, “Amended and Restated State Medicaid Company Contract,” Revised Could 2022 (Accessed January 17, 2025).
9: CMS, supra notice 10 § 20.2.10 at 38.
10: Ohio Division of Medicaid, supra notice 6, at 53.
11: 42 CFR 422.100(c)(2)(ii); 42 CFR 422.102
12: To study extra about how states can make the most of Medicare bid data, see Ryan Stringer et al., “Pattern Language for State Medicaid Company Contracts with Twin Eligible Particular Wants Plans (D-SNPs): Non-compulsory Language Relevant to All D-SNPs,” Built-in Care Useful resource Heart (January 2024) p. 13, (Accessed February 12, 2025).
13: Pennsylvania Division of Human Providers (DHS), “Medicare Enhancements for Sufferers and Suppliers Act Contract,” (2025), p. 14-15, (Accessed February 13, 2025).
14: New Jersey Division of Human Providers (DHS), “New Jersey FIDE SNP Mannequin MIPPA Contract,” § 10.4.1.7. at 19 (January 2022), (Accessed February 24, 2025).
15: For extra language round expanded advantages, see Massachusetts, Govt Workplace of Well being and Human Providers (HHS), “MassHealth Part 1115 Demonstration Modification Request,” (October 11, 2024), (Accessed February 28, 2025).
16: See Heart for Medicare Advocacy, “CMS Clarifies Therapy of Medicare Benefit “Flex Playing cards” For Public Profit Functions,” (January 9, 2025) (Accessed February 24, 2025).
17: Pennsylvania DHS, supra notice 17.
18: This language also needs to be cross-referenced within the SMAC provisions outlining the obligations of a care supervisor.
19: To learn extra about how supplemental advantages akin to flex playing cards can have an effect on an individual’s HUD advantages, see Regularly Requested Questions (FAQ): HUD-assisted Housing and Medicare Benefit Supplemental Advantages | HUD USER. Accessed January 22,2025.
20: 89 FR 30448
21: Ohio Division of Medicaid, supra notice 6.
22: Washington State Well being Care Authority, supra notice 12 at 32.
23: Nondiscrimination notices inform the general public on the entity’s compliance with Federal Civil Rights legal guidelines and supply details about how people can file complaints or grievances once they have skilled discriminatory practices. See the Facilities for Medicare and Medicaid Service (CMS) and Well being and Human Providers (HHS) nondiscrimination notices. See additionally, the California Division of Well being Care Providers (DHCS) nondiscrimination discover template for managed care plans that reference Federal Civil Rights and state legal guidelines.
24: Massachusetts Govt Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” §2.10.8.2, at 207-208. (Accessed March 19, 2025).
25: California Division of Well being Care Providers (DHCS), “Boilerplate 2025 SMAC Completely Aligned Enrollment D-SNP,” Exhibit E, Attachment 2 at 21, (July 8, 2024) (Accessed March 6, 2025); See additionally CA DHCS, “All Plan Letter 21-004(Revised),” at 2, (May3, 2022) (Accessed March 6, 2025).
26: CA DHCS, “All Plan Letter 21-004 (Revised),” at 2, (Could 3, 2022) (Accessed March 6, 2025).
27: Language tailored from CA DHCS, “2024 Medi-Cal Managed Care Plan (MCP) Transition,” at 13 (November 2, 2023) (Entry March 7, 2025); see additionally Lida Momeni, et al., “Integrating Twin Eligible Particular Wants Plan Supplies to Promote Enrollee Understanding of and Entry to Advantages,” Built-in Care Useful resource Heart at 5, (February 2024) (Accessed Could 7, 2025).
28: Language tailored from Minnesota Division of Human Providers (DHS),”Mannequin Template for 2025 Contracts with MCOs for Seniors,” §3.10.5 at 49, (January 1, 2025) (Accessed March 6, 2025).
29: See additionally Part 1557 of the Inexpensive Care Act (ACA) (part 1557), 42 U.S.C. 18116 and Title VI of the Civil Rights Act of 1964 (title VI), 42 U.S.C. 2000d et seq., Part 504 of the Rehabilitation Act of 1973 (part 504), 29 U.S.C. 794.
30: 42 CFR 422.2267(a)(4)
31: Id. at 4.
32: For extra data on D-SNP-only contracts and built-in supplies, see Built-in Care Useful resource Heart, “D-SNP-Solely Contracts: Advantages and Key Steps for States,” (March 19, 2024) (Accessed March 6, 2025).
33: Ryan Stringer, et al., “Pattern Language for State Medicaid Company Contracts with Twin Eligible Particular Wants Plans (D-SNPs): Non-compulsory Language Relevant to Sure D-SNPs,” Built-in Care Useful resource Heart at 11, (January 2025) (Accessed March 6, 2025).
34: Minnesota DHS, supra notice 5, §3.12.9 and three.13 at 52.
35: Massachusetts EOHHS, supra notice 1, §2.10 at 93.
36: 87 FR 27704
37: 42 CFR 422.107(c)(9); see additionally Ryan Stringer and Alena Tourtellotte, “Built-in Attraction and Grievance Processes for Built-in D-SNPs with “Completely Aligned Enrollment,” Built-in Care Useful resource Heart (July 2022) (Accessed March 6, 2025).
38: Wisconsin Division of Well being Providers (DHS), “State of Wisconsin Division of Well being Providers (DHS) and (MCO) for Twin Eligible Particular Wants Medicare Benefit Well being Plan,” §5 at 6-7 (2025), (Accessed March 6, 2025).
39: California DHCS, supra notice 2, Exhibit A, Attachment 1 at 5-7.
40: See CMS, “Medicare Managed Care Guide,” Ch.16b, §20.2.2 at 18 (Re-issued 02-28-2014), (Accessed March 06, 2025).
41: This language also needs to be cross referenced within the SMAC provisions outlining care coordination necessities.
42: Wisconsin DHS, supra notice 13, §5.3 at 7.
43: Minnesota DHS, supra notice 5, §4.9.2 at 79.
