Samantha Morales: Howdy everybody, and welcome to as we speak’s webinar presentation entitled Twin Eligible Particular Wants Plans Updates: What California Advocates Must Know. I am Samantha Morales, Senior Coverage Advocate on the Well being Group at Justice in Ageing. Right this moment I am joined by my colleague, Tiffany Huyenh-Cho, Director, California Medicare and Medicaid Advocacy. Subsequent slide, please.
Thanks. And earlier than we start, I want to go over just a few webinar logistics. Once more, welcome to all contributors. You might be all on mute, however we welcome your participation in as we speak’s presentation by way of the Q&A perform within the Zoom management panel. Additionally obtainable within the Zoom management panel is the CC button, which allows closed captioning. I will probably be watching the participant questions as they arrive in all through the webinar, and I’ll uplift excessive degree themes through the Q&A section on the finish of as we speak’s presentation. Any questions unanswered in as we speak’s webinar will probably be addressed by way of electronic mail following the conclusion of the presentation.
You may as well use the Q&A perform to request technical help with Zoom, and our employees will do our greatest to help you. This webinar is being recorded, and after the conclusion of the webinar, the slides and recording of as we speak’s presentation will probably be obtainable on our web site, and will probably be emailed to all registrants. We’d additionally recognize your participation in our post-webinar survey that can pop up in your display following the shut of the webinar. Subsequent slide, please.
Slightly bit about Justice in Ageing. As lots of chances are you’ll know, we’re a nationwide group that makes use of the ability of legislation to combat senior poverty by securing entry to reasonably priced healthcare, financial safety, and the courts, for older adults with restricted assets. Since our founding in 1972, our efforts have centered on combating for individuals who have been traditionally marginalized and excluded from justice, resembling girls, folks of coloration, LGBTQ+ people, and other people with restricted English proficiency. Subsequent slide, please.
Justice in Ageing is dedicated to advancing fairness for low-income older adults in financial safety, healthcare, housing, and elder justice initiatives. We try to deal with the enduring harms and inequities brought on by systematic racism and different types of discrimination that uniquely influence low-income older adults in marginalized communities. Subsequent slide, please.
Justice in Ageing produces a wealth of data just like the webinar you’re viewing as we speak, together with reality sheets, subject briefs, alerts, and different materials to maintain you updated with vital developments. In case you’re not already a member of our community, we encourage you to affix by going to our web site and signing up or just emailing data@justiceinaging.org. Thanks once more for sticking with me by way of the background data, and now I will flip it over to Tiffany who’s going to get us began.
Tiffany Huyenh-Cho: All proper. Thanks, Sam, for being right here with us and moderating our presentation and serving to with as we speak’s webinar. Thanks all for becoming a member of as we speak’s webinar and taking trip of your day. We’re completely satisfied to be right here and supply some updates about what is occurring in twin eligible particular wants plan panorama in California. Our agenda as we speak is packed, we’ll get by way of it, however we’ll cowl what Twin Eligible Particular Wants Plans or D-SNPs are, the differing types that exist, who can enroll, what necessities that these plans have, and the way these plans combine or coordinate with Medi-Cal. We can even talk about at a excessive degree the influence of H.R.1 on state and federal price range adjustments for those that are dually eligible for Medicare and Medi-Cal and establish advocacy alternatives.
Some key factors I wish to share to border our dialog first. Practically 50% of individuals which can be dually eligible for Medicare and Medicaid within the nation obtain their care from a D-SNP or 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. Twin eligibles, or also referred to as dually eligible folks for Medicare and Medicaid navigate two medical insurance applications, Medicare and Medi-Cal, and this implies navigating completely different medical standards below each. Medicare covers the vast majority of look after twin eligibles, however this group are additionally heavy Medi-Cal utilizers. Medi-Cal is a crucial supply of different sorts of care not usually coated by Medicare, issues like in house private care companies or transportation or long-term care in a nursing facility.
D-SNPs can streamline care and advantages, however enrollment is all the time a private resolution. It’s influenced by particular person wants and preferences. In case your most popular supplier will not be in a D-SNP, it might not be clever to affix a D-SNP since you might lose entry to your supplier. It is extremely vital that persons are knowledgeable about the advantages of D-SNPs, but in addition the constraints that include becoming a member of a D-SNP.
What are D-SNPs precisely? They’re Medicare managed care plans. They’re a subset or a sort of Medicare Benefit, however D-SNPs are distinctive in that they’re meant for those that are dually eligible for Medicare and Medicaid solely. Solely twin eligibles can be part of a D-SNP. D-SNPs administer Medicare advantages, and members of those plans should get prior authorizations for companies, and so they’re additionally restricted to the D-SNP plan’s particular community of contracted suppliers. D-SNPs are distinctive in that reality as a result of they solely enroll dually eligible folks, and they’re tailor-made to fulfill this group. They’re designed with the objective of enhancing the standard of care and well being outcomes for this group, in addition to to coordinate the supply of Medicare and Medi-Cal advantages. And to try this, D-SNPs have some core parts that do not exist in different Medicare Benefit plans. Each D-SNP, to be able to function, they have to signal a contract with the state Medicaid company to function in that state.
These contracts are referred to as state Medicaid company contracts or SMACs. These are used to carry the D-SNP to larger requirements and tasks, together with oversight from each CMS and the federal authorities and the state Medicaid company. And state Medicaid companies have an curiosity in these D-SNP plans as a result of the plans enroll numerous their Medicaid inhabitants. States can use the ability of those state contracts to impose extra necessities on the D-SNP, issues like enhancing care supply or offering help with Medicaid annual renewals. And lastly, D-SNPs are required to coordinate or present some degree of coordination with Medicaid advantages. It is a requirement that makes D-SNPs distinctive, and we’ll get extra into what care coordination means in a D-SNP.
However right here on this chart, you may see that there are a number of various kinds of Medicare Benefit plans. It’s a huge panorama nationwide and in California alone. On the left facet, you may see the large umbrella from Medicare Benefit and all of the completely different sort of Medicare Benefit plan which can be obtainable. D-SNPs fall below the particular wants plans class, and we’ll be discussing solely the D-SNPs as we speak.
D-SNP enrollment has grown quickly, each in California and throughout the US. There are 1.8 million folks dually eligible for Medicare and Medi-Cal as we speak residing in California, and 26% of them are enrolled in a D-SNP, and about 50% are in authentic Medicare or conventional fee-for-service Medicare. Twin eligibles as a gaggle have some frequent traits. In California, they’re extra more likely to be Latino, Asian, Black, and have at the least one power medical situation. Twin eligibles additionally make up greater than 75% of In-Residence Supportive Companies recipients or IHSS, and 80% of residents in Medi-Cal expert nursing amenities. Due to their well being wants, twin eligibles use healthcare extra, and this results in larger spending. Nationally, this group makes up 16% of Medicare enrollees, however 31% of Medicare spending. And on the Medicaid facet, twin eligibles are 14% of all Medicaid enrollees, however 29% of Medicaid spending. And partly due to the disproportionate spending for this group in comparison with their inhabitants measurement, there was elevated consideration to the D-SNPs to enhance care and well being outcomes in addition to decreased spending.
All D-SNPs present Medicare Half A and B advantages in addition to prescription protection. It is all offered inside the plan. Individuals enrolled within the D-SNPs will obtain the vast majority of their Medicare companies from the D-SNPs. D-SNPs usually additionally cowl supplemental advantages. These are usually gadgets and companies not coated below conventional Medicare. As you understand, Medicare has some gaps. It doesn’t historically embrace dental, for instance, however dental as a supplemental profit is frequent, in addition to listening to or respite hours for caregivers or different issues like over-the-counter gadgets like first support provides and nutritional vitamins. In California, 91% of all the D-SNPs supply dental care by way of supplemental advantages, however solely 2% provided caregiver respite hours. You possibly can see there could be some variation in what supplemental advantages are provided, and D-SNPs and all Medicare Benefit plans can select what supplemental advantages to supply and whether or not or to not supply them in any respect, actually.
And as you understand, in California, twin eligibles are required to affix Medi-Cal Managed Care so D-SNP members in California usually have two plan memberships D-SNP for the Medicare advantages and a Medi-Cal plan for Medi-Cal managed care. Enrollees can even nonetheless obtain non-Medi-Cal managed care advantages by way of fee-for-service like in house supportive companies or IHSS and different house and community-based applications.
Who regulates D-SNPs precisely? They’re Medicare plans, so they’re regulated by the federal authorities, the Middle for Medicare and Medicaid Companies or CMS. CMS units the minimal floor guidelines that every one D-SNPs should adjust to. And CMS additionally requires D-SNPs to report on all types of measures like efficiency to judge and evaluate the standard of healthcare companies which can be offered. California State Medicaid Company, the Division of Healthcare Companies, or DHCS, additionally has oversight over D-SNPs by way of the state contracts that D-SNP signal with the state Medicaid company. Once more, these state Medicaid contracts or SMACs are required. With the intention to function in California, a D-SNP will need to have signed one with DHCS.
States also can use these state contracts to impose extra necessities which can be larger than the federal minimal. For instance, in California, our D-SNPs are required to additionally report the variety of referrals that the D-SNP makes to Medi-Cal-based applications like IHSS or community-based grownup companies, and twin eligibles are nonetheless entitled to the complete spectrum of their Medicare and Medi-Cal advantages, so connecting members to the suitable companies have to be a precedence. This requirement to doc the variety of referrals could be actually useful in figuring out whether or not the D-SNPs are doing simply that. These state contracts are key and can provide states discretion in how D-SNPs function of their state.
Okay. Let’s discuss who can enroll in a D-SNP. Typically, anybody with full Medicare and Medi-Cal advantages, this implies each Half A and Half B, in addition to full scope Medi-Cal. Individuals with a Medi-Cal share price in California can not be part of a D-SNP since you can not be part of a Medi-Cal managed care plan with a share of price. You additionally have to be 21 years of age or older to affix a D-SNP. States can select to set larger enrollment standards in the event that they wish to by way of that SMAC. In California, we’ve got that requirement that every one members even be part of Medi-Cal managed care.
And as all the time, D-SNPs are voluntary to affix. Dually eligible people have freedom of selection in relation to selecting how they obtain their Medicare advantages, so all Medicare enrollees, together with twin eligibles, have choices to select from. They will stay in conventional or authentic Medicare, or they will decide a managed care choice like a D-SNP or a non D-SNP Medicare benefit plan. PACE or the Program of All-Inclusive Care additionally stays an choice for twin eligibles. It’s not required that twin eligibles be part of a D-SNP or every other program. They will stay in authentic Medicare if they want.
Whereas D-SNPs are voluntary to affix, I do wish to spotlight a type of automated enrollment that can be utilized. This kind of automated enrollment known as default enrollment, and right here, a twin eligible is robotically or default enrolled right into a D-SNP once they first develop into Medicare eligible. This could possibly be by way of turning 65 or by way of incapacity or by way of incapacity after reaching the 24 months ready interval for social safety incapacity advantages. I do wish to be clear that the overwhelming majority of D-SNPs don’t use this default enrollment course of. D-SNPs should first meet sure standards and high quality requirements and should get approval from each the state and federal authorities to make use of default enrollment. In California proper now, solely three plans in two counties use that course of. That is in San Diego and in San Mateo County. In San Diego, it is Neighborhood Well being Group. In San Mateo, it is Kaiser and the Well being Plan of San Mateo.
Exterior of that, default enrollment doesn’t exist. It’s, once more, very restricted. Earlier than a plan can use default enrollment, they have to ship discover at the least three months prematurely, and so they should ship at the least two notices so that people are conscious that that is occurring. Individuals can all the time cancel or decide out of default enrollment earlier than it takes place. Or if you’re enrolled, you may later disenroll from the D-SNP. California can broaden default enrollment to different plans or counties, however proper now it is rather restricted. If the state needs to broaden it additional, plans might want to meet sure requirements first.
Individuals also can select to enroll or disenroll in D-SNPs by way of completely different intervals of the 12 months. Fall Medicare open enrollment is open proper now really, till December seventh. Selections are efficient this January 1st, 2026, and Medicare enrollees can select to affix a D-SNP or one other Medicare Benefit plan, or disenroll from these plans and return to authentic Medicare. There are additionally two new particular enrollment intervals that went into impact earlier this 12 months. There may be the month-to-month particular enrollment interval or built-in particular enrollment interval. These particular enrollment intervals can be utilized to disenroll from a D-SNP as soon as each month and return to authentic Medicare, or it may be used to enroll into sure D-SNPs all year long. We did create a reality sheet on how these new particular enrollment intervals work, it is linked on the web page.
I additionally wish to spotlight that navigating Medicare enrollment is sophisticated. That is the place the state medical insurance help applications could be extremely vital for assist in navigating this enrollment course of. In California, we’ve got HICAPs. They’re an incredible useful resource. They’re free, and supply goal counseling on enrollment choices and Medicare advantages.
Okay. We talked a bit bit about what D-SNPs are, who can enroll, however now we’ll get into the sorts of D-SNPs that exist in California and what the vital variations are between them. D-SNP is an umbrella time period. There are subcategories beneath.
In California, we’ve got three varieties. For probably the most half, the differing types dictate what degree of integration or coordination between Medicare and Medi-Cal the plan is chargeable for. I am highlighting these classes so people perceive that not all D-SNPs are created alike. Some plans do extra to coordinate Medi-Cal advantages, and a few do much less. California’s Medicaid company chooses which kind of D-SNPs can function within the state. So first, we’ve got the totally built-in twin eligible particular wants plan or FIDE-SNP. On this plan, the D-SNP is chargeable for offering each Medicare and Medicaid advantages inside one plan. The FIDE-SNP is the best degree of integration doable as a result of one plan is protecting all advantages. We solely have one FIDE plan in California. It’s SCAN Connections, and concentrated in Southern California.
We even have Coordination-Solely D-SNPs. These plans supply the least quantity of integration and coordination between Medicare and Medi-Cal advantages. These D-SNPs will not be chargeable for straight offering Medi-Cal companies. They supply Medicare advantages and Medicaid is offered by way of different entities. Numerous the plans in California are these Coordination-Solely D-SNPs.
And lastly, we’ve got Relevant Built-in Plans or AIPs. It is a designation given to D-SNPs who’ve aligned enrollment and do cowl at the least some Medicaid advantages like major and acute care and different Medi-Cal companies like house well being, medical tools, or nursing facility care. And these Medi-Cal advantages are offered by way of the Medi-Cal plan. The D-SNP and Medi-Cal plan in a relevant built-in mannequin have to be operated by the identical dad or mum firm. In California, solely the present Medi-Cal insurance coverage firms function are Relevant Built-in Plans. As a result of the identical insurance coverage firm operates each the D-SNP and Medi-Cal plan, there’s administrative simplicity in addition to a monetary incentive for these plans to carry out higher. Each a FIDE-SNP and coordination solely D-SNP could be an AIP in the event that they meet sure necessities. I do know this was sophisticated, so I do encourage folks to learn our twin eligible particular wants plan useful resource information for extra particulars.
In California, that is roughly what twin eligible enrollment seems like right here this 12 months. Roughly 50% of our twin eligibles are in authentic Medicare, and the remaining are in some kind of Medicare benefit or PACE. You possibly can see we’ve got about only one% in that FIDE-SNP that I discussed. 18% are in an everyday Medicare Benefit plan and roughly 26% are in some kind of D-SNP itself.
Let’s dig in a bit bit extra. Within the Coordination-Solely D-SNP, these plans solely should adjust to the fundamental federal minimal necessities until the state has imposed extra necessities by way of their state contracts. In any other case, these D-SNPs have restricted accountability to supply care coordination between Medicare and Medicaid. One particular requirement they do have is that the plan should notify the state Medicaid company when a member is admitted right into a hospital or nursing facility, or when they’re discharged. That is so the Medicaid company is conscious of the admission or discharge and might take steps to coordinate transitions between care settings. And as talked about earlier than, an relevant built-in plan is a D-SNP with extra integration necessities as a result of members are enrolled in a D-SNP and Medi-Cal plan operated by the identical insurance coverage firm. The construction ensures that members obtain each their Medicare and Medi-Cal advantages by way of the identical dad or mum insurance coverage firm.
The Relevant Built-in Plans that we’ve got in California are referred to as Medicare Medi-Cal plans or Medi Medi plans. They began in 2023 and changed our Cal MediConnect demonstration. They’re obtainable in some counties, however not all fairly but.
The Medicare Medi-Cal plans, once more, nonetheless D-SNPs, however they’re a time period used to tell apart them from different D-SNPs which can be obtainable within the state. These plans, the Medi Medi or Medicare Medi-Cal plans can solely be operated by the present Medi-Cal insurance coverage firms. And if you enroll in one among these plans, you’re enrolling in each the D-SNP and the Medi-Cal plan operated by the identical firm. That known as aligned enrollment. For instance, Kaiser has each D-SNPs and Medi-Cal plans. In case you’re in Kaiser’s Medi Medi plan, you’re enrolled in each Kaiser’s D-SNP and their Medi-Cal plan. The D-SNP and Medi-Cal plan match. And since each Medicare and Medi-Cal advantages are offered by way of the identical insurance coverage firm, these plans have single plan supplies, so members of the plan have one well being plan ID card and a single supplier listing that references each Medicare and Medi-Cal suppliers as a substitute of two separate plan directories.
The plans additionally used unified appeals. That is one thing the place requests for companies have to be thought-about below each Medicare and Medi-Cal requirements, not only one. This aligned enrollment construction creates streamlined communications, and it makes it appear to be somebody is enrolled in a single plan versus two separate Medicare and Medi-Cal plans. The MMPs can be found in 12 counties as we speak. They’re increasing this January 2026, so it is vital that people know that these plans are actually additionally obtainable for enrollment beginning January 2026. There isn’t a automated enrollment within the MMPs outdoors of these two counties that I discussed earlier, so these are voluntary to affix. And within the new counties the place these plans are increasing, people can select to affix these plans.
And as you understand, it’s fairly difficult for counselors and people to determine what class of D-SNP a plan is, both on-line or by way of print supplies. The time period MMP is used to tell apart these D-SNPs, it is utilized by the Division of Healthcare Companies, however every insurance coverage firm nonetheless makes use of their very own branding and title. It’s useful to have a look at that hyperlink we’ve got posted on the slide to see the official record of MMP plans obtainable, which of them can be found, and in every county as properly.
Okay, so now let’s discuss a bit concerning the necessities that every one D-SNPs have. If there’s something particular to the Medicare, Medi-Cal plans, the MMP plans, I will notice it, however a number of that is particular to all D-SNPs.
We have coated the sorts of D-SNPs. All D-SNPs are topic to minimal federal necessities. These necessities even prolong past the fundamental necessities that every one Medicare Benefit organizations are topic to. As a result of these plans are particularly designed for twin eligibles, the federal authorities has put extra requirements for them. At a minimal, all D-SNPs should create a mannequin of care. It is a doc that explains how the plans will meet the wants of their members. D-SNPs are additionally required to at the least typically coordinate Medicaid advantages, together with these in payment for service. Care coordination is a spectrum, however it may possibly contain serving to contact the Medicaid facet to rearrange for Medicaid coated transportation or facilitating facilitating a name or serving to with medical data wanted to help a Medicaid attraction.
D-SNPs additionally should display members for housing stability, meals safety by way of assessments. The outcomes of this evaluation are then addressed in every member’s individualized care plan that every one D-SNPs should create. And lastly, all D-SNPs will need to have an enrollee advisory committee to garner suggestions from plan members. These committees should mirror the plan inhabitants for the service space and plans should solicit member enter on many alternative issues, together with enhancing entry to companies, coordination of companies, in addition to well being fairness for underserved populations. These are the minimums, however as beforehand famous, among the completely different D-SNP varieties do have extra necessities that go above and past these baseline necessities.
And as famous, D-SNPs should coordinate Medi-Cal companies for its members. Care coordination is admittedly the substance behind D-SNPs. It is meant to deal with the gaps that twin eligibles face as a result of they navigate two completely different sources of care. This implies all D-SNPs, no matter sort should develop individualized care plans that mirror the member’s wants and use interdisciplinary care groups to supply care and help to handle their member’s care and actualize their care plan. Care groups have to be interdisciplinary and have demonstrated experience and coaching to be able to present care to all kinds of wants. This additionally implies that some subset of members might have extra specialised care resembling folks with dementia or Alzheimer’s. Plans additionally use well being danger assessments to establish danger components, these medical, useful, cognitive, and social wants like meals insecurity or transportation that I discussed earlier.
And in California, most of you understand that our Medi-Cal plans supply Enhanced Care Administration below CalAIM. Enhanced Care Administration is the best type of care administration obtainable to Medi-Cal enrollees, and it’s for folks with excessive wants. For folks enrolled in a D-SNP, they aren’t eligible for Enhanced Care Administration as a result of it might be contradictory and battle with the care administration that is already required by the D-SNP plan. It might be very complicated to have a care supervisor with ECM after which even have a care supervisor with the D-SNP. We wish to guarantee that there’s one care supervisor and one individual chargeable for coordinating care throughout the completely different spectrum of wants.
However to make sure that twin eligibles additionally obtain equal care administration, all D-SNPs nonetheless should present an analogous degree of look after sure teams. It’s referred to as ECM-like care administration proper now. In 2026, the sort of care administration is being renamed to California Built-in Care Administration or CICM. Once more, it is meant for folks with excessive wants and that meet sure populations of focus or sure teams. One other distinction between the care administration offered within the D-SNP versus the Medi-Cal Enhanced Care Administration is that there’s much less emphasis on in individual engagement in comparison with ECM inside a D-SNP.
One different distinction although is that within the D-SNP, in 2026, D-SNPs should additionally present this larger degree of care administration to extra group, adults with documented dementia wants. That is just for the D-SNPs. It doesn’t exist within the Medi-Cal solely plans. This power built-in care administration, once more, it is the brand new time period being utilized in 2026. There are some variations with how care administration is offered as we speak. Numerous it does should do with that in individual care administration and what entity is offering the care administration, whether or not it’s by way of community-based companies or inside the plan itself.
D-SNPs additionally usually supply supplemental advantages like we talked about. These are, once more, these advantages not historically coated below authentic Medicare. Widespread advantages are imaginative and prescient or dental, and most D-SNPs supply supplemental advantages, however there’s concern whether or not members are literally accessing and using these advantages. To fight this, there was rulemaking to reinforce oversight over the use and advertising and marketing of supplemental advantages. Plans now should stabilize eligibility standards, which means that they can’t change the eligibility standards mid-year, and there are additionally new restrictions on how these advantages could be marketed in hopes of enhancing knowledgeable decision-making round D-SNP enrollment.
There was a provision that required a mid-year notification to members of supplemental advantages that individuals have been eligible for however had not used. This was paused indefinitely by CMS. It’s disappointing as a result of it might have helped members use all the advantages their Medicare Benefit or D-SNP plan might need provided. There can nonetheless be advocacy on this space. There is a want for details about these advantages, particularly when supplemental advantages duplicate Medi-Cal. Medi-Cal in California is complete, so supplemental advantages usually duplicate Medi-Cal advantages as properly, like dental, and that may be complicated to navigate, so clear data is required on the way to navigate overlapping advantages.
One other tip is to be careful and guarantee that supplemental advantages will not be getting used to influence Medi-Cal eligibility. The flex playing cards or pay as you go debit playing cards that some D-SNPs supply as supplemental advantages can’t be counted as earnings for Medi-Cal eligibility functions. The cash on these pay as you go playing cards are solely for supplemental advantages. It can’t be counted as earnings for Medi-Cal functions. And in reality, the state really simply launched clear steering confirming this earlier this week. I have not heard of drawback circumstances the place these flex playing cards are used to influence eligibility, however if you’re seeing this, let me know.
One other key function of the Medicare Medi-Cal plans I discussed earlier than was unified appeals. Unified appeals means the D-SNP should take into account each Medicare and Medical requirements once they’re reviewing requests for protection. So usually, Medicare Benefit plans don’t take into account an individual’s Medi-Cal advantages once they resolve whether or not to grant or service or attraction. However within the built-in plans just like the MMPs, the plan should take into account each Medicare and Medi-Cal requirements when deciding medical necessity requests. This unified course of is finished on the preliminary resolution {that a} plan makes and on the first degree of attraction. The plan should take into account each Medicare and Medi-Cal standards of their determinations and ship a single discover to the member. If the member needs to attraction on the plan degree, they solely should handle one attraction course of versus two separate appeals.
One factor to notice although is that after the primary degree attraction inside the plan, the upper ranges will not be built-in, so you’ll then pursue separate Medicare and Medi-Cal go. This unified attraction course of is just current within the Medi Medi plans. Different sorts of D-SNPs or common Medicare Benefit plans shouldn’t have a unified built-in attraction course of. Individuals in these plans nonetheless navigate separate Medicare and Medi-Cal attraction pathways and separate determinations. Unified appeals could be actually useful for twin eligibles as a result of it ensures that the plan is definitely interested by each your Medicare and Medi-Cal entitlement and never only one.
Let’s undergo an instance. Medicare and Medi-Cal usually cowl the identical advantages, however have completely different requirements. Sturdy medical tools is one frequent instance like a wheelchair. Medicare covers sturdy medical tools to be used within the house solely, however Medi-Cal will cowl sturdy medical tools if it is used for the house and outdoors the house, such because the neighborhood. Medicare is not going to cowl sturdy medical tools if a part of the use is supposed to assist somebody in the neighborhood. For instance, Maria is a twin eligible. She lives in San Diego. She’s enrolled in Medi Medi Plan A. She fell just a few months in the past and now has problem strolling for lengthy intervals of time. Earlier than her fall, Maria regularly visited household that lived close to her house. Her doctor has advisable a wheelchair and submits a request to Maria’s Medi Medi plan. The plan denies the request on the grounds that Medicare doesn’t cowl the wheelchair to be used outdoors of the house. So what went mistaken?
First, the plan did not even take into account whether or not Maria would qualify for the wheelchair below Medi-Cal requirements. They did not reference Medi-Cal of their resolution to her. Her Medi-Cal advantages would cowl the wheelchair even when she wanted to make use of it outdoors the house. The plan ought to have thought-about each Medicare and Medi-Cal requirements and subject one single discover that clearly demonstrated that they’d thought-about each Medicare and Medi-Cal standards. Maria’s rights at this level is to file an attraction on the plan and she will file a single attraction. We now have gotten just a few examples of Medi Medi plans not following this unified attraction course of the place as a substitute of 1 single resolution letter, people are despatched two, or the plan will not be contemplating each Medicare and Medi-Cal requirements, so in case you have seen appeals in these new Medi Medi plans, please attain out to me. We wish to guarantee that these plans are following this unified attraction course of, as it’s a requirement.
There are some protections that every one D-SNPs have which can be outlined within the state contract. All D-SNPs in California supply a three-month minimal deeming interval for enrolled members that have a break in Medi-Cal eligibility. Deeming acts like a grace interval and retains somebody enrolled even within the D-SNP, even when the Medi-Cal eligibility is terminated for no matter cause. For instance, if somebody is assessed a share of price or if an annual renewal will not be accomplished. Deeming prevents rapid disruption to care and members can proceed utilizing D-SNP Medicare companies. Twin eligibles can use this three-month interval to revive or repair eligibility whereas nonetheless enrolled. And a few plans even have longer intervals than three months. We have seen six months even. The hyperlink on the web page does element the deeming interval by every particular person plan. And lastly, all twin eligible people are protected against improper billing and Medicare Benefit, whether or not it’s in a D-SNP or common Medicare Benefit plan.
Suppliers that contract with a Medicare Benefit plan should settle for all members of the Medicare Benefit plan and can’t invoice a twin eligible. They’ve protections below each state and federal legislation. One other safety particular to the Medi Medi plans is a 12-month continuity of care interval for brand new members. In case you be part of a Medi Medi plan and your current supplier will not be contracted with the brand new plan, you may nonetheless proceed seeing that prior supplier for 12 months. The plan should grant this request, and it does cowl each major and specialty suppliers.
And as I discussed, these Medi Medi plans are increasing to 29 new counties. The counties are listed on the map. Once more, these are voluntary to affix, however they’re an choice now so people can select whether or not or not they’re applicable for them and in the event that they like them. I am going to notice that some counties is not going to have a Medi Medi plan in 2026. These are primarily in additional rural counties. Partnership HealthPlan is the plan that is not working this Medi Medi plan in 2026. We do anticipate that the extra counties that do not have a MMP plan will probably be prepared in 2027, however the hyperlink on the slide will present you extra particulars of every plan by county.
To sum up, in 2026, twin eligibles have 4 enrollment choices. They will be part of these built-in plans, authentic Medicare. I am going to notice that enrollment into different D-SNPs that are not thought-about aligned is closed, and that’s below state legislation. The one D-SNPs which can be open for enrollment now are the Medi Medi plans and SCAN Connections FIDE-SNP. New enrollment into different D-SNPs is closed. These are the D-SNPs that aren’t thought-about built-in. They are not operated by the Medi-Cal plans. Present members of those different D-SNPs can stay within the plans, however they will stay. They won’t be requested to disenroll, however new members can not be part of. We anticipate that these plans will finally peter out or shut as enrollment numbers lower.
Okay. Subsequent, let’s simply cowl briefly some advocacy areas. One factor to recollect is that twin eligibles and D-SNPs are nonetheless entitled to Medi-Cal companies, even these below CalAIM or fee-for-service, this consists of the neighborhood helps provided by Medi-Cal managed care plans. Members in a D-SNP ought to nonetheless be getting screened for neighborhood helps and the people, their members of the family or caregivers also can request neighborhood helps on their behalf. And as we coated earlier than, improper billing continues to be a subject space we see usually. Twin eligible shouldn’t be billed for medical companies. And if advocates are seeing this, there are ample assets to combat these cases, so please contact me or go to our web site for extra data.
One other advocacy space is when Medicare Benefit supplemental advantages overlap with advantages additionally coated below Medi-Cal, like dental. We frequently hear confusion about navigating this course of both as a result of problem utilizing each coverages or not realizing that they even had dental advantages obtainable to them by way of the Medicare Benefit or D-SNP plan. We additionally hear of circumstances the place a twin eligible is badly billed for dental companies by their Medicare dental supplier, even when these companies would’ve been coated below Medi-Cal. So encouraging plans to proactively assist members navigate these advantages is vital in addition to written communication about advantages within the least. So if you’re seeing some points in these areas, please tell us, we’ve got some tips about the way to navigate.
And lastly, a really wealthy advocacy space proper now’s training across the multitude of state and federal adjustments coming to the Medi-Cal and Medicare program. These adjustments have been handed over the summer season through the price range course of. I will not cowl them intimately for time, however wished to spotlight it so people know that is coming and are ready. One, the Medi-Cal asset restrict, which proper now’s eradicated, is coming again. It will likely be returning for older adults and other people with disabilities. It’s reinstated at 130,000 for a single individual and is efficient January 2026. This solely applies to folks over 65 twin eligibles or folks on disability-based Medi-Cal applications just like the aged and disabled. We can even be releasing a reality sheet on this quickly.
There are additionally some eligibility adjustments for some immigrant teams in 2026 too. First, folks which can be undocumented and over age 19 can not enroll in full scope Medi-Cal after January 2026. Proper now in 2025, Medi-Cal is open to anybody earnings eligible no matter immigration standing, however enrollment for undocumented people will probably be capped or blocked after January 1st, 2026, so new enrollment is capped. Individuals already on Medi-Cal proper now can stay, however new those who wish to apply after January are solely going to get restricted or emergency Medi-Cal.
There’s additionally some adjustments on the federal degree from H.R.1. There’s been a number of assets on this, however H.R.1 makes sweeping adjustments to Medicare and Medicaid, together with what teams of immigrants qualify for Medicare and Medicaid. It additionally imposes work necessities as a situation of eligibility for youthful populations within the enlargement classes. So older adults and twin eligibles will not be topic to work necessities straight, however we wish to ensure that they will not be swept up in work necessities or worry that they are topic to work necessities when they aren’t. That is the place clear and correct data is admittedly wanted.
You possibly can see on our slide we’ve got a useful resource on the Price range Reconciliation Act that covers these provisions. After which lastly, we’ve got a number of assets. These are about D-SNPs, the completely different adjustments, the way to enhance care. After which among the different adjustments that have been talked about, the MMP plans in addition to the state and federal price range adjustments are additionally listed on this slide. And with that, I feel we’ve got time for questions.
Samantha Morales: Sure. Thanks a lot, Tiffany, to your experience. We now have fairly just a few questions, and so I went by way of and tried to uplift just a few themes that stood out to me. The primary units of questions that stood out have been about ranges of built-in care, for instance, that I do know you went over to start with of the webinar. For instance, how can advocates discover out what degree of integration a D-SNP has?
Tiffany Huyenh-Cho: Yeah, thanks for elevating that query. We get that each time we do a webinar and in dialog. It’s tough. It is extremely, very tough. The degrees of integration will not be actually listed on a D-SNP’s member supplies, it simply says D-SNP. It usually does not say if it is a FIDE-SNP or coordination solely, or the MMP D-SNP. For the MMPs, DHCS has listed that web site the place they particularly say which D-SNPs are MMPs in every county. Some counties there’s a couple of. Some counties there’s just one. You possibly can name your D-SNP plan, they need to be capable to let you know.
You may as well have a look at, CMS has a month-to-month spreadsheet that they put out of D-SNP enrollment, and it does record it by integration degree. Clearly, that may be very technical and you need to undergo the Excel spreadsheets, however that’s one other method. I do know that the HICAPs do create their very own lists as properly to find out which D-SNPs are which sorts of D-SNPs can be found. However I do know that they too even have difficulties to find out that data. There’s been a number of push from advocates to CMS to make it extra clear the degrees of integration D-SNPs have. So proper now, it’s imperfect, however there are some methods for it for figuring that out.
Samantha Morales:Thanks, Tiffany. And one other query on this class is, what’s solely aligned enrollment or EAE?
Tiffany Huyenh- Cho: Solely aligned enrollment is the requirement that if you be part of sure D-SNPs, the Medi Medi plans are the proper instance. You might be enrolled within the D-SNP and also you’re required to affix that D-SNP’s matching Medi-Cal plan. All the Medi Medi plans are operated by the present Medi-Cal insurance coverage firms, Kaiser, Neighborhood Well being Group, L.A. Care, there’s a number of them. They’re creating D-SNPs, that is what the MMPs are in 2026. So if you be part of that plan, you’re becoming a member of each the D-SNP and the Medi-Cal plan. You can not have misaligned enrollment. You possibly can’t be in CalOptima D-SNP and Kaiser Medi-Cal plan, you want them to match. That’s what solely aligned enrollment is. Everyone seems to be enrolled in the identical D-SNP and matching Medi-Cal plan.
Samantha Morales: Nice. And one other set of questions has to do with eligibility standards for D-SNP enrollment. For instance, is the ZIP code nonetheless a part of the factors for enrollment in a D-SNP?
Tiffany Huyenh- Cho: It will probably. They are going to be obtainable solely in sure areas, and every D-SNP is allowed to function in sure service areas, and that’s going to be dictated by your ZIP code. So sure, that may nonetheless be a standards for enrollment.
Samantha Morales: And an extra query round eligibility standards for D-SNP enrollment, are enrollees with a share of price or, for instance, expert nursing facility residents mandated to affix a Medi-Cal managed care plan?
Tiffany Huyenh- Cho: That is an incredible query as a result of it’s a little bit complicated. We now have completely different guidelines about who should be part of Medi-Cal managed care in California. If in case you have a share of price and reside in the neighborhood and that you’re not a resident of a talented nursing facility, you can not be part of a Medi-Cal managed care plan. There, you’re prohibited from enrolling right into a Medi-Cal managed care plan. However if you’re half of a talented nursing facility and have a shared price, as most do in these expert nursing amenities, you’re required to affix a Medi-Cal managed care plan. Lengthy-term care grew to become a good thing about Medi-Cal managed care plan, I feel two years in the past, so we have moved the long-term care profit. It’s now the accountability of the Medi-Cal managed care plans. So folks in expert nursing amenities with the share of price are required to affix the Medi-Cal managed care plans for his or her long-term care or expert nursing facility advantages.
Samantha Morales: Thanks, Tiffany. And since we’ve got just a few extra minutes, there are just a few extra questions in that eligibility standards group of questions. Can a member be enrolled in a D-SNP obtain ECM or neighborhood help companies?
Tiffany Huyenh- Cho: Sure and no. That, additionally an excellent query and I feel actually highlights the complicated panorama that we’ve got, however ECM or Enhanced Care Administration is care administration offered by Medi-Cal plans, however we do not need duals which can be in D-SNPs to get conflicting or contradictory care administration by the Medi-Cal plan and by the D-SNP, as a result of once more, D-SNPs themselves already present care administration. Somebody in a D-SNP will not be eligible for Enhanced Care Administration, as a result of care administration is being offered by the D-SNP. It is a related degree. It is not totally an identical, however it’s purported to be equal degree of care administration. The D-SNP care administration is meant to be equal to Enhanced Care Administration. Duals in a D-SNP are nonetheless entitled to care administration, however it’s not referred to as Enhanced Care Administration. And that’s going to be that new title, the California Built-in Care Administration beginning in 2026.
Neighborhood helps, sure, you’re nonetheless entitled to these. That’s offered by the Medi-Cal plan itself. And when you’re in a D-SNP, you need to nonetheless be getting screened by the plan for neighborhood helps. In case you really feel you aren’t getting the neighborhood helps that you simply want, you may also attain out and ask the plan to display you for them as properly. However enrolling in a D-SNP shouldn’t be a barrier to getting neighborhood helps, the distinction is admittedly the Enhanced Care Administration as a result of it may be contradictory to the care administration within the D-SNP itself.
Samantha Morales: Thanks, Tiffany. And simply in a single minute earlier than we wrap up, and that is a associated query is, can members who’re enrolled in a D-SNP even be enrolled within the Multipurpose Senior Companies Program or MSSP, or would this be a duplication of companies?
Tiffany Huyenh- Cho: Good one. It does not bar you from being enrolled as a result of the one standards we’ve got proper now’s round your age, your full scope, however it might probably be thought-about contradictory, so there will probably be balancing of the MSSP and the Enhanced Care Administration. And I feel within the Medi-Cal solely world too, MSSP is taken into account duplicative of Enhanced Care Administration. So there’s fairly a little bit of element on that, and I can comply with up on among the extra specifics. Thankfully, I haven’t got that off the highest of my head.
Samantha Morales: Thanks a lot, Tiffany. And with that, I feel we solely have time for that final query. Thanks once more for all of you for becoming a member of us as we speak. And thanks to Tiffany, our presenter, your wealth of data. And as a reminder, any questions that went unanswered as we speak will probably be adopted up by way of electronic mail and be happy to succeed in out to Tiffany with any extra questions in case you have extra questions later. Do not forget to finish the post-webinar survey. Your suggestions on these applications is vital to us and have an incredible remainder of your day. Thanks a lot.
