Hannah Diamond: Welcome everybody. Thanks for becoming a member of us for right this moment’s webinar, Twin Eligible Particular Wants Plans – What Advocates Have to Know. My identify is Hannah Diamond. I’m a senior coverage advocate on our well being group, and I’m joined by my colleague Samantha Morales, additionally a senior coverage advocate on our well being group.
So some logistics earlier than we start. All members are on mute. You should use the questions operate to ask us questions all through this webinar. We’ll attempt our greatest to permit for time on the finish to reply some questions. After which people who we don’t reply right this moment, Sam and I’ll observe up with you through e-mail. If you happen to’re having issues with getting on the webinar, you possibly can ship an e-mail to trainings@justiceinaging.org. And the supplies for this coaching in addition to previous trainings may be discovered on our useful resource library, and the recording for right this moment’s presentation shall be posted to our Justice in Getting old Vimeo web page. And to allow shut captioning, you are able to do so by deciding on CC from the Zoom Management Panel.
Justice in Getting old is 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. We’ve been doing this work for over 50 years. Our efforts have been primarily centered on combating for individuals who have been marginalized and excluded from justice, reminiscent of girls, reminiscent of folks of colour, LGBTQ+ people, and other people with restricted English proficiency.
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Okay, and right here is our agenda for right this moment. It’s fairly formidable. We’re going to supply a excessive degree overview of Twin Eligible Particular Wants Plans or D-SNPs. Particularly, we’re going to debate what these plans are, who can enroll, the varied classes of D-SNPs and their corresponding ranges of integration, and the advantages and coordination necessities which can be obligatory for all, after which particular necessities for numerous classes of D-SNPs. We can even focus on at a excessive degree the affect of H.R.1 or OBBA on folks dually eligible, and establish advocacy alternatives for you all to enhance built-in care on the state degree.
Just a few high traces that we wished to share with you to border our dialog right this moment. Practically half of individuals dually eligible for Medicare and Medicaid obtain their care from a twin eligible particular wants plan or a D-SNP. Due to this fact, it’s crucial that advocates perceive these plans to assist people make knowledgeable choices about their enrollments, to carry plans accountable to regulatory necessities and to form insurance policies on the state and federal ranges. And we’re going to level out how you are able to do that as advocates.
Moreover, we need to clearly state that D-SNPs should not for everybody. It’s a really private choice about whether or not or not a person ought to enroll in a D-SNP. There are particular concerns like well being and prescription drug wants, supplier networks, prior authorizations and plan choices, and we’re going to deal with this query concerning enrollments and a few of these concerns all through the presentation.
So now I’m going to move it off to my colleague Samantha Morales to stroll us by means of the following part of our presentation.
Samantha Morales: Thanks, Hannah, and thanks all for attending this webinar. So let’s start our dialogue about D-SNPs. As lots of you realize, Twin Eligible Particular Wants Plans or D-SNPs are a sort of Medicare Benefit plan particularly designed for people who find themselves dually eligible for Medicare and Medicaid. D-SNPs are meant to deal with the limitations that dually eligible populations face on account of having two separate medical insurance payers. Medicare and Medicaid weren’t designed to work collectively, and this group typically reviews confusion and limitations to getting wanted care. So D-SNPs had been meant to deal with these issues.
So like different Medicare Benefit plans, it is very important do not forget that D-SNPs are a type of managed healthcare. Meaning supplier networks restrictions for instance and utilization administration restrictions. In contrast to different Medicare Benefit plans, there are some core options that make D-SNPs essentially totally different. So I wish to uplift the core parts that make D-SNPs totally different from different MA plans.
Primary, enrollment is proscribed to dually eligible people or a subset of this group. States have numerous energy right here to restrict this additional. So for instance, states can restrict enrollment in D-SNPs to dually eligible people who’ve full Medicaid advantages, also called Full Duals. The second piece that makes them totally different is the State Medicaid Company Contracts or SMACs. In contrast to different MA plans, D-SNPs are required to have a SMAC within the state the place they function. So that is the place states can actually leverage the ability with D-SNPs and incorporate extra client protections, as actually the SMAC is a contract between the D-SNP and the state.
Federal necessities for some coordination of Medicaid providers additionally make D-SNPs totally different than different MA plans. So this once more, is exclusive and in contrast to different MA plans that do not need to observe this requirement. So once we converse of coordination with Medicaid providers, it is very important perceive the spectrum of coordination that exists within the D-SNP panorama. So I shall be offering extra particulars on this spectrum of coordination as we undergo the presentation. Subsequent slide, please. Thanks.
So it is a map of the Medicare protection choices from the Built-in Care Useful resource Middle or ICRC, which is a nationwide initiative of the Facilities for Medicare and Medicaid Providers, CMS, particularly their Medicare-Medicaid Coordination Workplace or MMCO. So you possibly can see that D-SNPs are positioned inside the Medicare Benefit Managed Care plan protection possibility for those who are eligible for each Medicare and Medicaid advantages. As we’ll get into later on this presentation, there are some D-SNPs that limit enrollment to particular populations reminiscent of dually eligible people with full Medicaid advantages for instance. Subsequent slide please.
So right here you possibly can see the expansion of D-SNPs from a nationwide perspective. So D-SNPs are proliferating throughout the nation with over 5 million folks enrolled nationwide. If you happen to work with low-income older adults, you actually need to learn about D-SNPs as a result of they’re rising, and so they could be coming to your state in the event that they’re not already in your state already. So these plans had been first launched in 2006 and have become everlasting choices in 2018. So notably, enrollment in D-SNPs have doubled since 2018.
So D-SNPs function in nearly each state in addition to DC and Puerto Rico. So there are solely 5 states right this moment who do not need D-SNPs, and people states embrace Alaska, Illinois, New Hampshire, North Dakota, and Vermont. I’ll be aware that Illinois shall be providing D-SNP protection to dually eligible inhabitants beginning in January of subsequent yr.
You will need to uplift this level on demographics. In comparison with their Medicare-only counterparts, dually eligible people usually tend to have a power sickness, they’re extra more likely to be admitted to a hospital, and they’re extra more likely to be an individual of colour. Greater than half of all dually eligible people are folks of colour, in contrast with 20% of those that are in Medicare-only. And about one quarter of dually eligible people report having 5 or extra power situations. So D-SNPs serve a various inhabitants, lots of whom have excessive healthcare wants. Subsequent slide please.
When it comes to who regulates D-SNPs, each the Facilities for Medicare and Medicaid Providers, CMS, so the federal authorities, and the states through the Medicaid companies regulate D-SNPs. An vital level to uplift right here is once more, the State Medicaid Company Contract, the SMAC, as that is actually the car that states can make the most of to impose extra necessities and client protections that transcend the minimal to make sure the wants of dually eligible people are met.
So the contracts or SMACs are used to set the factors for enrollment, plan supplies and the extent of care coordination between the Medicare and the Medicaid sides that the D-SNPs shall be required to supply. So whereas all D-SNPs enrollees will need to have Medicare and Medicaid, as I’ve already talked about states can select to additional restrict enrollment to a smaller subset by placing in provisions of their SMACs. To allow them to restrict enrollment, for instance, to solely dually eligible people who require a nursing facility degree of care.
On our web site, we now have a number of sources obtainable to help advocates, together with a SMAC toolkit that gives template language on numerous vital matters that advocates can use to push for stronger client protections of their states. We even have a D-SNPs temporary with hyperlinks to some SMAC contracts to offer you an thought of what SMACs can do. To drive residence the purpose, SMACs have a big affect within the sorts of D-SNPs merchandise which can be provided within the states. Subsequent slide, please.
Thanks. On this part, we undergo who can enroll in a D-SNPs, when folks can enroll, and the basic alternative that every one Medicare enrollees should determine the best way they obtain their Medicare advantages. Subsequent slide, please. Thanks.
So to recap, Full Duals are individuals who have Medicare and full Medicaid advantages. Partial Duals are composed of people who’ve Medicare, have a Medicare Financial savings Program, or MSP, and never full Medicaid advantages. The MSP assists with the Medicare Half B premium. And for people who’re eligible, one of many MSPs referred to as QMB offers help with Medicare-related value sharing, that features co-insurances, co-payments and deductibles.
So it is very important be aware that not all D-SNPs enable enrollment of Partial Duals. Whereas federal guidelines enable enrollment of partial twin eligible people in D-SNPs, states can slender eligibility standards as I’ve talked about earlier than. So for instance, the extra built-in D-SNP merchandise that we are going to be discussing limit enrollment to Full Duals. So I’ll present, once more, extra data on enrollment guidelines later. On this slide. You will need to uplift that dually eligible folks might or might not have entry to full Medicaid advantages. Subsequent slide please.
On this slide, we need to emphasize the liberty of alternative that dually eligible people have in terms of selecting the best way they obtain their Medicare advantages. So much like different Medicare enrollees, people who find themselves duals have many choices to select from, and we listing a few of these choices right here on this slide. To allow them to stick to the standard Medicare fee-for-service program and decide up a standalone Half D plan, or they’ll determine to enroll in a non-D-SNP Medicare Benefit plan, or they’ll select PACE. So even when the state decides to robotically enroll dually eligible folks in D-SNPs, duals nonetheless have the appropriate to disenroll or decide out, and that’s vital to recollect. Subsequent slide please.
So folks can enroll in D-SNPs in a number of methods. So insurance coverage brokers and brokers can market D-SNPs, however there are limits to how insurance coverage brokers and brokers instantly work together with people. And CMS does present guidelines on advertising steering, the dos and don’ts of what brokers and brokers can do, how they’ll talk with Medicare enrollees. So folks may also affirmatively select to enroll throughout one of many Medicare enrollment intervals.
People can also be enrolled in a D-SNP by means of a course of referred to as default enrollment. In default enrollment, an individual is robotically enrolled right into a D-SNP once they first turn out to be Medicare eligible. And that may very well be both by turning age 65, or by means of the receipt of their social safety incapacity advantages, for instance, once they meet that 24 month interval. However to make use of this course of, D-SNPs should meet sure standards, high quality requirements, and have approval from the state and federal authorities. Default enrollment will not be utilized by each plan or in each state. So there are limits to who’s enrolled through default enrollment. And the plan should ship a minimum of one discover previous to default enrollment, so people at all times have the appropriate to say no and might select one other path.
There’s additionally room for advocacy on this house and in states the place default enrollment is being contemplated or is already in follow. So advocates can request a further discover to be mailed earlier than default enrollment takes place so that folks have extra time to grasp what’s taking place. Advocates may also ask for stronger continuity of care protections in order that newly enrolled people don’t expertise a disruption in care if their earlier medical supplier, for instance, will not be in community with their new D-SNP.
I additionally need to uplift the significance of the State Well being Insurance coverage Help Packages, the SHIPs, or additionally they’re referred to as HIICAPs in some states. So the SHIPs are a terrific useful resource. They’re additionally free, they supply free providers and so they present goal counseling on Medicare advantages and plan choices and might actually assist folks navigate. Subsequent slide please.
So right here we now have the totally different intervals when dually eligible people can enroll and disenroll from a D-SNP. So that you all have heard in regards to the Medicare Benefit open enrollment interval and the annual election interval or fall open enrollment interval, so I cannot go into extra element there. I wish to carry to your consideration that the ultimate Half C and D rule from final yr consists of two new particular enrollment intervals that went into impact in January of this yr, and these embrace the month-to-month SEP for dually eligible people and for people which can be enrolled in additional assist and a brand new month-to-month built-in care SEP.
So beginning January 1 of this yr, CMS changed the quarterly SEP with a brand new month-to-month SEP particularly for dually eligible people and individuals who solely have additional assist. So this new month-to-month SEP permits dually eligible people and additional assist recipients the power to modify to a special standalone prescription drug plan or disenroll from a Medicare Benefit plan into authentic Medicare, and once more, decide up a standalone prescription drug plan. You will need to be aware that whereas people can use this SEP to return to authentic Medicare and enroll in a Half D standalone prescription drug plan on a month-to-month foundation, the SEP can’t be used to enroll into one other Medicare Benefit plan.
So when it comes to the brand new built-in SEP, this additionally began in January of this yr, and it’s meant for full profit dually eligible people in order that they’ll select to enroll into or change between built-in D-SNPs on a month-to-month foundation. So this SEP additionally got here out of the Half C and D rule from final yr. It’s vital to notice right here that this new SEP is proscribed and might solely be used once more, by full profit twin eligible people to enroll into built-in merchandise that aligned enrollment between the Medicare and Medicaid plans.
So on the backside of this slide, we included hyperlinks to sources. So for a complete listing of SEPs and the eventualities that apply, Medicare.gov offers an excellent listing with explanations. Moreover, we included a hyperlink to the Justice in Getting old situation temporary overlaying the SEP modifications that affect low-income older adults in 2025. Subsequent slide please.
On this part, we’ll take a deep dive into the totally different integration ranges of the varied D-SNPs fashions. Subsequent slide please.
So once we focus on the degrees of integration for D-SNPs, it’s crucial to debate alignment. So right here we evaluate vital definitions of what constitutes aligned enrollment versus different sorts of enrollment. So aligned enrollment implies that a dually eligible particular person is enrolled in a D-SNPs and an affiliated Medicaid Managed Care plan or MMCO. As we state within the first bullet, this alignment between the D-SNPs and the MMCO creates a monetary incentive to scale back spending, duplicative providers and might even foster extra communication between either side, each entities offering protection. And completely aligned implies that enrollment within the D-SNPs is proscribed to enrollees in aligned enrollment described above, so people who’re in a D-SNPs with an identical MMCO. When it comes to unaligned enrollment right here, this implies the exact opposite of what we simply mentioned. The person is enrolled in a D-SNPs with no matching MMCO, or the particular person can also be in payment for service Medicaid.
So lastly, I wish to uplift the advocacy tip right here. So for states which have Medicaid Managed Care, advocates ought to contemplate discussing with the state Medicaid company a SMAC requirement to align or completely align enrollment as it will foster the situations for a way more streamlined built-in medical insurance expertise for dually eligible people. Subsequent slide please.
So to drive residence the purpose on aligned versus unaligned enrollment conditions, we now have this visible from the Built-in Care Useful resource Middle, ICRC, and the picture on the left depicts each the aligned with inexperienced arrows and the unaligned conditions with crimson arrows. You possibly can see that alignment is achieved when the D-SNP from firm A is matched with the MMCO from firm A. So the picture on the appropriate depicts full alignment, the place all D-SNP firms on the left are matched with the MMCOs which can be beneath the identical mother or father firm on the appropriate. Subsequent slide please.
So right here we now have the totally different D-SNP classes and we’ll focus on how every has various ranges of integration. So the absolutely built-in or FIDE-SNP presents dually eligible people the very best degree of integration between the Medicare and Medicaid sides. As a result of as we listing within the slide, FIDE-SNPs should present nearly all Medicaid providers to enrollees. Now the extremely built-in or HIDE-SNP presents rather less integration than the FIDE in that this D-SNP or its matching MMCO should present most Medicaid providers, however not all.
Now, the Coordination-Solely or CO-D-SNPs supply the least integration between the Medicare and Medicaid sides. Now, CO-D-SNPs present the Medicare providers and the Medicaid providers are offered by one other entity. Now that may very well be the MMCO that will not be affiliated with the D-SNP, or it may very well be payment for service Medicaid. Subsequent slide please.
So right here, we delve into extra element with the FIDE-SNPs. So FIDE-SNPs supply enrollees protection of all their Medicare providers and nearly the entire Medicaid providers. FIDEs supply the very best degree of integration. So that features communication supplies, appeals and grievances data, and all should be offered in an built-in format on the plan degree for the primary ranges of the appeals processes. So at the moment, FIDE-SNP enrollments constitutes solely 7.8% of all D-SNP enrollments. Which means that FIDEs should not the norm throughout the nation.
So beginning this yr, there are vital necessities for FIDE-SNPs. They should be completely aligned, that means they solely enable enrollment to dually eligible people who’re aligned in an identical MMCO. So they need to cowl extra Medicaid providers reminiscent of behavioral well being providers, residence well being providers, medical gear, provides and home equipment, and so they should cowl Medicare value sharing.
So for people who wish to evaluate what the D-SNP panorama seems like in your state, we included a hyperlink to the CMS SNP knowledge, so you possibly can filter the Excel desk to your particular state to see what D-SNPs are provided per county. Subsequent slide please.
In order we mentioned beforehand, HIDE-SNPs supply much less integration than FIDE-SNPs in that they supply protection for many Medicaid providers, however not as comprehensively as FIDE. So a couple of issues to uplift in regards to the HIDE-SNPs on this slide. They will carve out behavioral well being or long-term providers and helps. They will supply Medicaid advantages through the D-SNP or the affiliated MMCO. They aren’t required to be completely aligned until the state mandates this. They provide a pathway for states to realize larger ranges of integration with the FIDE-SNPs later, for instance. So that they actually construct on larger integration ranges.
The final be aware on the slide is vital to emphasise. At present, the vast majority of D-SNPs are Coordination-Solely D-SNPs and don’t supply the excessive degree of integration that the FIDEs and HIDE-SNPs supply. Subsequent slide please.
So right here, we now have Coordination-Solely D-SNPs, these plans that provide, once more, essentially the most minimal ranges of integration. They’ve fewer necessities than FIDE and HIDE-SNPs and haven’t any scientific or monetary involvement on the Medicaid facet. Coordination-Solely D-SNPs should nevertheless present care coordination of Medicaid providers. And this implies helping enrollees to entry Medicaid advantages that they’re eligible for, it additionally means serving to enrollees with Medicare and Medicaid appeals and grievances for instance. These plans should additionally notify the state Medicaid company when sure enrollees who’re high-risk are hospitalized or admitted in a nursing facility. Subsequent slide please.
So right here we now have a visible of the present D-SNP panorama. So this knowledge comes from the ATI Advisory State Knowledge Dashboard. You possibly can see that almost all of D-SNPs obtainable for dually eligible people are Coordination-Solely D-SNPs. So in accordance with the ATI knowledge, Coordination-Solely D-SNPs are about 59% of the D-SNP market in comparison with FIDE-SNPs which make up about 8%, and HIDE-SNPs which make up an estimated 33% of the market. In order we’ll focus on with extra element, Coordination D-SNPs supply essentially the most minimal ranges of integration. And it is very important be aware that some states solely have Coordination D-SNPs obtainable. Subsequent slide please.
So it is a graph from the Built-in Care Useful resource Middle that depicts the totally different ranges of integration, and actually what meaning when it comes to healthcare protection for dually eligible people. So if we focus our consideration in the midst of the graph right here, we see that D-SNPs and Medicaid have some interplay in comparison with the fee-for-service Medicare and different non-D-SNP Medicare Benefit plans.
All D-SNPs are required to supply some coordination of Medicaid providers. The FIDE-SNPs and HIDE-SNPs supply the very best ranges of integration, and from the graph you possibly can see what meaning. They supply all of the Medicare protection and the vast majority of Medicaid providers within the case of the FIDE-SNPs. And within the case of the HIDE-SNPs, as we mentioned, these plans should present the vast majority of Medicaid providers with the potential for some carve-out advantages such, because the Medicaid long-term care providers and helps or the behavioral well being advantages. Subsequent slide please.
So there’s another designation, another acronym I’m going to cowl. It’s referred to as Relevant Built-in Plans or AIPs. And it at the moment applies to FIDE-SNPs and it will probably apply to HIDE-SNPs or Coordination-Solely D-SNPs. Relevant Built-in Plans or AIPs should implement built-in appeals, which Hannah will focus on later. So AIPs are D-SNPs that function with completely aligned enrollment and canopy it least some Medicaid advantages, both by means of the D-SNP or by means of an affiliated Medicaid Managed Care plan operated by the identical mother or father firm because the D-SNP.
So beginning this yr, FIDE-SNPs should function with completely aligned enrollment, which implies they’re AIPs. And so as to be an AIP for HIDE-SNPs, they will need to have completely aligned enrollment, that means that they’ll solely settle for enrollment from people additionally enrolled in a Medicaid Managed Care group owned and operated by the identical mother or father firm because the HIDE-SNP.
Now for Coordination-Solely D-SNPs, so as to be Relevant Built-in Plans, AIPs, they need to even have completely aligned enrollment and canopy by means of the D-SNP or an affiliated Medicaid Managed Care plan, Medicaid major and acute care advantages, Medicare value sharing, and a minimum of one of many following Medicaid advantages: residence well being providers, medical provides, gear and home equipment or nursing facility providers.
So our D-SNP Fundamentals Transient, the Appendix B part, goes by means of every of those classes of FIDE, HIDE-SNPs and Coordination-Solely D-SNPs, and likewise present a dialogue of the AIP standing. So for now, I’ll now flip it over to Hannah, who will start the dialogue on D-SNP necessities.
Hannah Diamond: Thanks a lot, Sam. And I do know that we simply mentioned numerous acronyms, a few of which I’ll repeat in my part, however don’t fear, you’ve entry to this recording after right this moment’s presentation so you possibly can evaluate at your personal tempo.
So now we’re going to debate the federal necessities for all D-SNPs. These necessities lengthen past the fundamental necessities for Medicare Benefit organizations. And as beforehand famous by Sam, the varied classes of D-SNPs that we simply mentioned, a few of these have extra necessities above and past these baseline necessities that I’m going to discover on the following few slides.
So all D-SNPs should implement one thing that’s referred to as an evidence-based mannequin of care. This doc demonstrates how the D-SNP goes to tailor its providers to the inhabitants that it serves. So the mannequin of care outlines how the plan will present the well being providers after which coordinate and enroll these Medicare and Medicaid advantages. D-SNPs are required to submit their mannequin of care paperwork to CMS, the Facilities for Medicare and Medicaid Providers, in addition to the Nationwide Committee for High quality Assurance, NCQA, for analysis and approval.
D-SNPS should additionally coordinate, not essentially cowl, however coordinate all Medicaid advantages, together with Medicaid fee-for-service advantages, to assist guarantee enrollees can entry the healthcare and tackle their desires and desires. D-SNPs are also anticipated to help with grievances and appeals, and we’re going to debate an built-in appeals course of that’s particular to some classes of D-SNPs later on this presentation. D-SNPS additionally should display for housing stability, meals safety, and transportation wants of members. The outcomes of this evaluation are then addressed in every member’s individualized care plan.
And up to date rulemaking established that Medicare Benefit organizations providing a number of D-SNPs should set up and preserve a number of Enrollee Advisory Committees, or EACs, to solicit suggestions and enter from members within the design and supply of plan choices. These committees should mirror the plan enrollee inhabitants, and plans should solicit member enter on a sequence of issues, together with enhancing entry to providers, coordination of providers and well being fairness for underserved populations.
Communications. So there aren’t any extra communication necessities past the Medicare Benefit necessities particular to D-SNPs. That stated, many states require D-SNPs to satisfy extra necessities to guarantee that supplies are accessible and acceptable for the populations that they’re serving. When communications should not built-in, for instance, an enrollee’s Medicaid plan may not reference their Medicare choices and vice versa. This results in confusion and probably conflicting data for the enrollee.
So coverage levers reminiscent of aligned enrollment, what we’re speaking about right this moment, can allow streamlined communication, making communication appear to be “one plan” versus two separate Medicare and Medicaid choices. This could seem like one listing of suppliers for that particular person, or a single drug listing that features each their Half D prescription choices and likewise the over-the-counter medicines which can be lined by the state’s Medicaid plan. So mainly integration offers a software to simplify and streamline communications for the members.
Some suggestions that we now have right here to enhance communication between plans and members. Generally states could have extra beneficiant translation necessities for his or her Medicaid plans than the federal commonplace for Medicare, that means {that a} Medicaid plan should translate supplies into extra languages than the federal authorities requires. If so, advocates ought to use their SMAC, that State Medicaid Company Contract that Sam talked about earlier, to require D-SNPs to translate their supplies into the usual that’s most beneficiant. That means the member isn’t receiving communications for his or her Medicaid advantages of their most popular language, however then when it pertains to their Medicare advantages in English. Ideally, they’ll obtain data of their most popular language in an built-in format.
States additionally ought to require D-SNPs to check their communications on a subset of members. An awesome use for that is the Enrollee Advisory Committee, previous to launch to their total member inhabitants to make sure meant affect. States may also require plans to submit sure supplies particular to advertising and communications to that state for his or her evaluate and approval previous to member distribution, which provides states better oversight of plan supplies. Moreover, advocates can encourage plans to supply customer support traces to assist with answering Medicare and Medicaid questions and enhance communication general.
Okay, the following part, Care Coordination. That is sort of the meat and potatoes of built-in choices. In order we’ve famous all through the presentation, D-SNPs are required to coordinate Medicaid providers. So all D-SNPs, no matter kind, should develop a complete person-centered care plan often known as an individualized care plan for every member, that outlines that particular person’s objectives and targets for his or her care and consists of measurable outcomes and particular providers and advantages that shall be offered.
The D-SNP should make the most of an interdisciplinary care group. So this care group has to have demonstrated experience and coaching on methods to present care and assist to that particular person to handle the member’s care and actualize their care plan that we simply mentioned. D-SNPs additionally should describe of their mannequin of care paperwork, so we referenced that earlier, they need to describe their transition protocols. So for instance, how they’re going to deal with nursing facility transitions to coordinate with Medicaid lined providers and likewise preserve continuity of look after enrollees.
Steering additionally states that D-SNPs are supposed to assist members with sustaining their Medicaid eligibility. That is particularly vital now within the context of H.R.1 given considerations about lack of advantages. And eventually, plans are anticipated to take care of good knowledge trade to assist care coordination efforts and make sure that members are accessing the care that they want. As beforehand famous, aligned enrollment can allow extra streamlined sharing of knowledge and details about a member’s providers, as both one plan or two affiliated entities are administering providers. And since they share knowledge methods, that coordination and sharing of knowledge is simpler.
Supplemental Advantages. This can be a huge space, I’ve seen some questions already are available through supplemental advantages. D-SNPs can supply supplemental advantages past the advantages which can be provided in Medicare Components A, B and D, additionally above and past Medicaid choices. So in an try to deal with considerations about entry and the utility of supplemental advantages, latest rulemaking has tried to reinforce oversight of supplemental advantages. Particularly, plans should now notify their members mid-year about the advantages they’re probably eligible for however should not utilizing. Plans should doc approvals and denials for supplemental advantages. That is actually vital in order that we will perceive and establish fairness points. Plans should stabilize supplemental profit eligibility standards, that means that they can’t change the eligibility standards mid-year. And there are additionally now new restrictions and the way these advantages may be marketed in hopes of enhancing knowledgeable choice making round D-SNP enrollment.
So some suggestions to enhance advocacy on this house. We advise that states and D-SNPs are publicly posting eligibility standards for supplemental advantages to be sure that people know. It’s additionally vital to advocate for clear details about these advantages, particularly within the context of current Medicare and Medicaid choices. Now we have seen at occasions supplemental advantages duplicating current advantages which can be obtainable to members. They need to be including on high of each Medicare and Medicaid choices. So it’s actually vital to be sure that there isn’t a duplication. As an alternative, they need to complement current Medicare and Medicaid advantages. And moreover, it’s actually vital to be gathering knowledge and conducting oversight to see whether or not or not the plans are abiding by the latest regulatory necessities on this house.
So D-SNPs should conduct one thing referred to as a well being danger evaluation, that means that they need to assess every enrollee’s medical, purposeful, cognitive, psychosocial, psychological well being wants and social determinants of well being wants, together with screening for housing, transportation and meals wants. And importantly, latest rulemaking requires sure D-SNPs, particularly AIP D-SNPs, to conduct an built-in evaluation for each Medicare and Medicaid relatively than separate assessments for every program. So the outcomes of this screening shall be included into every member’s individualized care plan, after which that plan is anticipated to make use of Medicare, Medicaid, supplemental advantages, referrals to group sources and different collaborations and partnerships to satisfy that member’s holistic well being wants.
Appeals Processes. In order we talked about, plans are anticipated to assist with submitting grievances and appeals, and there are some extra necessities for D-SNPs which can be AIPs or Relevant Built-in Plans. So simply as a reminder, these are FIDE-SNPs, these are HIDE-SNPs working with completely aligned enrollments, after which these are Coordination-Solely D-SNPs which can be working with completely aligned enrollment and overlaying some Medicaid choices.
So on the preliminary choice {that a} plan makes and on the first degree of attraction, the plan will contemplate each Medicare and Medicaid standards of their determinations, and they’ll ship a single discover willpower to the member. If the member desires to attraction, then they solely should handle one attraction course of versus two separate Medicare and Medicaid processes. Importantly, after this primary degree, this primary degree of attraction, the upper ranges are now not required to be built-in, and subsequently they’ll break up off into their separate Medicare and Medicaid attraction pathways. Moreover, if a D-SNP will not be an AIP, so for instance, a Coordination-Solely D-SNP that’s not working with completely aligned enrollment and never overlaying Medicaid providers, they don’t have to supply this built-in appeals course of.
And as a tip general, we’d encourage advocates to push for accessible details about plan attraction processes to make sure that members perceive the method that’s obtainable and might entry their rights to attraction choices.
So now we’re going to debate the affect of H.R.1 on folks dually eligible. So H.R.1, or the One Large Lovely Invoice Act as some individuals are referring to it or OB3A, this was signed into legislation on July 4th. It accommodates almost a trillion {dollars} value of Medicaid cuts which can be stemming from modifications to Medicaid financing which can be actually going to shift the burden of prices from the federal authorities to states. And since states should steadiness their budgets, there are considerations about optionally available advantages, particularly residence and community-based providers, imaginative and prescient, dental and listening to advantages. The legislation accommodates in depth administrative necessities that states should implement, which can cut back their capability general to give attention to integration.
The legislation additionally accommodates vital modifications that can affect the Medicaid enlargement inhabitants, reminiscent of work necessities, reminiscent of extra eligibility determinations and cost-sharing necessities. And we consider although folks dually eligible should not within the Medicaid enlargement inhabitants, that folks dually eligible may very well be impacted by these modifications. For instance, there’s numerous confusion about what’s on this legislation, there’s numerous misinformation, and likewise as a result of this legislation is so burdensome to implement, it may value system pressure which can affect different populations. Moreover, folks dually eligible might use a caregiver or depend on a caregiver that’s within the Medicaid enlargement inhabitants. So if there are unfavorable penalties for them, it may negatively affect folks dually eligible.
So we’re uplifting D-SNPs as a chance to consider them as a mitigation technique in relation to H.R.1. And the rationale that we’re uplifting them that means is we now have such a strong coverage lever through the SMACs on the state degree. That stated, earlier than I get into some examples, it’s actually vital for us to state that D-SNPs can not fill the void that’s attributable to these Medicaid cuts. It’s actually vital that in your collective advocacy that sure, you’re contemplating uplifting D-SNPs as a coverage lever, as a mitigation software, however that you simply’re additionally forming coalitions to guard current Medicaid advantages and develop Medicaid choices to deal with gaps in protection as there isn’t a substitute for funding in HCBS and Medicaid general.
So some concepts right here that we’ve brainstormed and simply need to spotlight. We’ve talked about, through supplemental advantages, how these plans can supply advantages above and past Medicare and Medicaid. So that’s one thing to flag for you as you’re contemplating mitigation methods. And in addition through the SMAC, you may get fairly detailed and strong care coordination necessities that may assist to make sure that a person doesn’t lose their Medicaid advantages, or prevents it to the very best extent potential, which is very vital given the modifications in H.R.1.
So some advocacy alternatives that we need to flag for you all. First, we simply need to acknowledge, like I alluded to within the final slide, the surroundings that we’re in. We all know so lots of you had been concerned in opposing H.R.1 or defending Medicaid in your state, and now are very concerned in mitigation methods on the state degree. So first, it’s vital to notice that state capability on behalf of the Medicaid company goes to be centered on H.R.1, and subsequently there could be much less give attention to integration. Moreover, we simply need to state that it is a difficult space of coverage, probably the most difficult in well being coverage arguably, and that it’s vital that we’re all studying collectively, particularly within the context of implementing H.R.1. And we additionally need to acknowledge that relying upon the state, generally advocates don’t have an efficient technique of speaking with their Medicaid company on integration.
So listed here are some issues that you are able to do to deal with a few of these considerations that I simply said. First, it’s actually vital to stand up to hurry. It’s actually vital to be taught your state’s native D-SNP environments. Every state could be very totally different, numerous components of the state differ from each other, so actually encourage you to start out with studying about what your state’s integration panorama seems like.
It’s additionally actually vital to have interaction your state early and infrequently. So these contracts, these State Medicaid Company Contracts, they’re finalized in the summertime, however really planning for these contracts begins within the fall. So the autumn is a superb time to be partaking along with your Medicaid company about SMACs. We additionally actually encourage you to demand to be on the desk. When advocates are concerned in these conversations and when members are concerned in these conversations, it improves the supply of those plans and their choices. And we additionally encourage you to evaluate your state’s SMAC. If it’s not public, that’s your first precedence with the Medicaid company, is to get entry to your SMAC.
Now we have some sources for you right here that we wished to stipulate and spotlight. So the primary useful resource, D-SNPs: What Advocates Have to Know, that is our situation temporary that covers a lot of the identical content material that was included in right this moment’s webinar. We even have an accompanying doc that’s a regularly requested questions doc. This displays the questions that we mostly obtain, a few of which I’m certain we’ll cowl on right this moment’s webinar through the Q&A bit, however encourage you to look there. We even have a rules doc that outlines the core values and objectives of integration care from Justice in Getting old’s perspective.
We even have an built-in care schooling undertaking, so we run a listserv of advocates nationally which can be engaged on integration. In case you are not already a member of that listserv, I encourage you to enroll. We host coalition calls on a quarterly foundation. We ship out supplies particular to integration by means of that listserv, so encourage you to hitch. We even have state factsheets that reveal the D-SNP panorama in 10 states. And so we’d encourage you simply to have a look there in hopes that your state is a type of 10 states.
Additionally, as Sam talked about, we now have a SMAC toolkit. The SMAC toolkit is analyzing publicly obtainable SMACs and uplifting finest practices so that you simply all can take that language to policymakers and attempt to get that language into your state’s SMAC. So we’ve achieved toolkits particular to supplemental advantages, advertising and communications, care coordination, and our subsequent toolkit goes to be centered on client protections.
After which we now have two sources, and I’ve seen some questions in regards to the modifications to the particular enrollment interval. Now we have some very detailed sources about that as nicely, so would encourage you to evaluate these two sources which can be listed on the backside of the slide.
And there are another nice sources from companion organizations that we work with. So ICRC, the Built-in Care Useful resource Middle, has numerous fantastic supplies. CMS, the regulatory company, they launch month-to-month knowledge. It’s very well timed about plan choices in property and how much plan it’s, so would encourage you to look there for extra data. After which KFF as nicely has some nice sources about folks dually eligible and likewise about D-SNP choices.
And with that, Sam and I’ll begin to reply some questions. And our e-mail is included on this slide, so please be at liberty to succeed in out to us, however we’ll attempt to get to as many questions as we will right this moment.
I’ll begin us off with the primary one. Sam, whilst you had been presenting, somebody was asking for a evaluate of a full profit twin versus a partial profit twin. Are you able to go over these definitions once more to assist us perceive?
Samantha Morales: Positive, thanks. So full profit duals refers to individuals who each have, once more, we’re talking in regards to the inhabitants that’s enrolled in Medicare, which is their major medical insurance protection in fact, after which Medicaid. For full profit duals, meaning people who’ve Medicare and full Medicaid advantages. Meaning the medical, all features of the Medicaid program that they’re eligible for of their state, the medical portion, the whole lot. So long-term care providers, in the event that they meet the factors for protection. And that’s in contrast to Partial Duals who’re people who’ve Medicare and who could also be enrolled in a Medicare Financial savings Program, however they’re not eligible for the medical portion of the Medicaid program of their state. In order that’s what makes them totally different.
Hannah Diamond: Thanks.
Samantha Morales: Hannah, I do have a query right here within the Q&A about D-SNP members who fall out of this system. And the query actually is, is there a means for them to proceed with the identical Medicare Benefit plan? So primarily the identical D-SNP. And I’m completely happy to take a stab at it, however when you have extra that you simply wished to develop, I’m additionally completely happy to supply that to you as nicely.
Hannah Diamond: Okay, I’ll begin and let’s tag group. So I believe that it is a actually good query. Initially, let’s discuss possibly why somebody is wanting to go away their Medicare Benefit plan or their D-SNP providing. Doubtless it’s as a result of they’ll’t entry the providers that they want. So I believe first, I’d actually emphasize the significance of knowledgeable decision-making. So contacting the plan, for instance, to seek out out what degree of integration it’s providing. Contacting the plan, not solely to have a look at their supplier community, however ask, like I’ve this actually vital supplier, is that this supplier lined beneath this plan? Simply ensuring you could entry the providers and the suppliers that you simply want. So doing that vetting on the entrance finish is absolutely vital.
And once more, the SHIP counselors or the HIICAP counselors that Sam famous earlier are actually essential for that course of, as a result of they don’t have a bias of eager to enroll you in a selected plan like a dealer. A dealer receives an incentive to enroll a person right into a plan. The SHIPs are volunteers, they need what’s finest for you. To allow them to undergo these numerous choices with you, so we’d actually encourage you to do this. Additionally, Medicare Plan Finder can assist you make this choice. For instance, you possibly can put in what prescribed drugs you’ve and it will probably make it easier to decide whether or not or not a plan goes to satisfy your wants. In order that’s one factor that I’d say.
If the query, and I’m undecided if the query was going on this line of considering, however I’m going to reply it as a result of it makes me suppose that means, however for instance, what if somebody loses their Medicaid protection after which they’re now not a twin eligible? What can we do there? And there are some protections that we will advocate for. There’s one thing referred to as deeming. Deeming may be as much as six months, for instance, with the understanding and the rationale why deeming exists. Somebody can preserve their enrollment in a D-SNP and proceed to obtain D-SNP choices. And it’s with the understanding that oftentimes individuals are shedding entry to their Medicaid advantages, not as a result of they’re not eligible, however due to procedural causes.
So deeming intervals, in the event that they’re written into SMACs, present that safety to permit people to remain enrolled whereas they’re determining any considerations concerning their Medicaid protection, for instance.
Sam, are there different belongings you would add there?
Samantha Morales: No, precisely the deeming half was what I used to be going to construct on. However I believe you lined it, Hannah. Thanks.
Hannah Diamond: We had a extremely fascinating query that I noticed earlier concerning the advantages, or asking for touch upon limiting enrollment to specific populations. For instance, limiting enrollment of partial dual-eligibles into D-SNPs. I believe that from Justice in Getting old’s perspective, we’re nonetheless watching this house. Relating to Partial Duals, they don’t have Medicaid advantages to coordinate. However on the similar time, people can entry supplemental advantages through these plans, and so these supplemental advantages would possibly profit a partial twin.
So that is an space the place we actually need to hear from you all about the way you’re seeing D-SNPs present care and sort of the utility of D-SNPs for Partial Duals.
Samantha Morales: Yeah, and might I add one thing there, Hannah? I believe that could be a very fascinating query and it will get to numerous what we now have been discussing throughout this presentation. And it’s once more, a reminder that dually eligible people like all Medicare enrollees have a alternative in the best way they obtain their Medicare advantages. So all Medicare enrollees, particularly throughout follow-up and enrollment, have to contemplate their healthcare wants and their prescription remedy wants. So if these supplemental advantages are value getting right into a plan that has restrictive supplier networks and likewise networks for pharmacies for instance, it’s vital for folks to contemplate that. In order Hannah stated, it’s a really particular person alternative and that’s why there are SHIP counselors and different sources which can be obtainable to assist folks navigate these choices.
Hannah Diamond: Sam, one other query that I noticed once you had been speaking about default enrollments, are you able to remind us of the truth that in terms of Medicare choices, people at all times have alternative? So even when somebody is default enrolled, what their choices are concerning default enrollments, possibly when it occurs, after which only a reminder of a person’s choices for Medicare choices.
Samantha Morales: Thanks a lot for elevating that. One other, I believe, vital query. So sure, although a state can impose default enrollment, although they write it of their SMAC for instance, once more, dually eligible people have a alternative, identical to all Medicare enrollees, to determine that they don’t need to be enrolled within the D-SNP plan. And so the plans should, they’re required, by federal laws they’re required to supply notices to people who’re going to be default enrolled so that folks have adequate time to decide and to determine what kind of Medicare protection to enter.
So a part of the patron protections that advocates can actually ask for with their state Medicaid company is to be sure that they’ll transcend, states can transcend that required minimal discover of only one discover and ask for extra notices to exit to eligible people for instance, earlier than they’re default enrolled. So folks have extra data, extra time to decide. And when it comes to the alternatives that folks have, they’ll positively return, they’ll go to authentic Medicare and stick to their Medicaid protection individually and decide up a standalone Half D plan. They will go into PACE of their state, or they’ll go into a special kind of non-D-SNP Medicare Benefit plan.
So all of it relies upon once more on the particular person’s particular person wants. They need to contemplate their suppliers, whether or not their suppliers are going to be in-network or not, and their prescription remedy wants as nicely.
Hannah Diamond: And we’re over time, however there’s one query that I noticed that I simply should reply. The place can SMACs be discovered? So not all SMACs are publicly obtainable. In order that’s the very first thing. In our sources slide, we linked to a useful resource that’s the equal of this webinar, so it’s D-SNPs: What Advocates Have to Know. Inside that situation temporary, we now have offered hyperlinks to the entire publicly obtainable SMACs. So try that doc as a place to begin. And for those who can’t discover your state there, you go and also you ask your state Medicaid company and that’s a terrific first alternative to start out engaged on integration in your state and to get engaged.
So with that, thanks all a lot for becoming a member of us this afternoon. We so recognize it. Recording shall be posted on Vimeo and Sam and I’ll reply any questions that we didn’t get to right this moment. Thanks a lot.
