Note: See my blog for 7/31/2024 to learn more about how dual eligibles receive their care in the Medicare and Medicaid programs. This would be a good primer before you read this blog on Special Needs Plans (SNPs).
In January of 2022, Medicare Advantage (MA) Special Needs Plan (SNP) enrollment was just short of 5 million. In July, SNP enrollment (including Medicare-Medicaid Plans (MMP) has grown to 7.15 million, nearly a 44% growth in just 2.5 years. This is about 21% of MA enrollment. The vast majority of the enrollment in SNPs is in the Dual Eligible type (D-SNPs or MMPs), which is about 87% of total SNP enrollment. In both cases, integration of benefits and care between the Medicare and Medicaid programs is the goal.
As growth in SNPs occurs, the Centers for Medicare and Medicaid Services (CMS) is upping its audit oversight as well as its strategy toward SNPs. In this vein, below I highlight the major changes for SNPs over the past few years and what the future holds.
Audit protocols and scrutiny
CMS has put a huge priority on firmly establishing its protocols for SNP Model of Care (MOC) oversight. Initially, CMS focused on the timely undertaking of initial and annual health risk assessments (HRAs). While these are still important, it has now gone further down the road to timely issuance of comprehensive care plans as well as how plans are intervening to improve overall health outcomes. CMS specifically wants to know how plans identify new risks and changes in health status and how they timely reassess members in these cases. Further, CMS wants to see how the interdisciplinary care team (ICT) engages with the member and the documentation of its engagement. CMS also wants to have ICT activities integrated with the plan’s overall care coordination.
We will continue to see these protocols enhanced, including how plans will use technology to identify risks, engage members, and close out goals and interventions within reasonable timeframes. The SNP MOC areas scrutinized by CMS are now a long list. I have come up with about fifty items that plans need to focus on for a successful SNP program audit. Ping me if you would like a copy.
An important note: a new requirement mandates all SNP plans must provide face-to-face encounters between each enrollee and a member of the enrollee’s ICT or the plan’s case management and coordination staff on at least an annual basis. Remember that a PCP can document this interaction and technology can be used to help fulfill this new and onerous requirement.
Migration to more integrated SNPs
In recent rules, CMS also is pushing down the road to more integrated SNPs or at least more integration with Medicaid. While there will remain the two buckets of coordinated and integrated SNPs for the foreseeable future, CMS is requiring tighter communication and linkages between the Medicare SNP plans and the state Medicaid FFS program or Medicaid managed care world. States will now be allowed to force coordinated plans to become integrated plans (Fully Integrated Dual Eligible (FIDE) or Highly Integrated Dual Eligible (HIDE) Plans), including all the way to what are known as Exclusively Aligned Enrollment (EAE) HIDEs and FIDEs. Over time, EAE will be pushed for all HIDEs and FIDEs. I have pasted at the end of the blog a description of what exactly are FIDEs and HIDEs.
Further, a new rule will allow states and CMS to work together to establish free-standing SNP contracts. SNPs will be split from regular contracts so as to better evaluate quality performance. Last, as we move toward more integration with Medicaid, states will have the right to include many Medicaid requirements, including enhancing HRAs. With integration, more and more states will seek to meld Medicaid chronic long-term care (LTC) with the Medicare and Medicaid acute care services. Note that all MMP plans must be sunset and will move to D-SNPs (likely as HIDEs or FIDEs).
Related changes impacting SNPs
There are a number of other significant changes that will impact SNPs.
- CMS will replace the Reward Factor in the 2027 Star rating with a Health Equity Index (HEI). Plans with major dual eligible penetration or with SNPs will undoubtedly be eligible for a bonus of between 0.2 and 0.4 in their contract Star score. The more plans integrate SNP compliance and quality efforts with the HEI strategy, the more potential Star bonus the plan will receive. By the way, while the HEI factor hits the 2027 Star year, the measurement years are CY 2024 and 2025. So it is already here.
- In 2025, plans will be required to enhance outreach related to supplemental benefits and send a mid-year accounting of what supplemental benefits a member has used and how to access the others. This includes the so-called special supplemental benefits for the chronically ill (SSBCI), which plans often target to dual eligibles and SNP enrollees. Plans will need to increase the utilization of supplemental benefits across the board, but especially for SNP enrollees and dual eligibles, who likely could benefit the most from such services and benefits.
- With regard to SSBCI supplemental benefits, plans also need to demonstrate, by the time they submit bids, that such items and services meet the legal threshold of having a reasonable expectation of improving the health or overall function of chronically ill enrollees and are supported by evidence-based research.
- CMS, too, has hated what are known as D-SNP “Look Alikes,” which are plan benefit packages (PBPs) created to have benefits similar to SNPs but not filed as such plans. The PBPs attract dual eligibles and related populations yet do not have the regulatory or clinical oversight of a SNP. CMS has been attempting over the years to rein in the ability to create and market such plans. A new rule further restricts look-alikes by lowering the D-SNP look-alike threshold from 80% to 70% in 2025 and to 60% in 2026. A new rule also limits the number of D-SNP plan benefit packages an MA organization, its parent organization, or entity that shares a parent organization with the MA organization, can offer in the same service area as an affiliated Medicaid managed care organization (MCO).
- CMS is also refining its special enrollment period (SEP) policies to restrict the movement of dual eligibles and other low-income subsidy (LIS) enrollees outside of the regular enrollment periods. In 2025, the current SEP for duals and LIS enrollees will change to a once-per-month SEP to enroll in a standalone prescription drug plan or an integrated SNP. Further, the rule limits enrollment in certain D-SNPs to those individuals who are also enrolled in an affiliated Medicaid managed care organization. CMS likes this change because it will increase the number of dual eligibles subject to integrated materials, unified appeal processes across Medicare and Medicaid, and continued Medicare services during an appeal.
Conclusion
As I noted yesterday, healthcare for dual eligibles is extremely fragmented. CMS is working very hard to bring greater integration between the Medicare and Medicaid programs, both to improve quality and reduce costs. As I also pointed out, there are several proposals in Congress that favor even tighter integration of the two programs, including having all dual eligibles enroll in a single plan or a brand new government program. Other proposals would increase funding to help duals navigate the systems.
Plans need to think now about how they will introduce the right products in their market areas and meet the compliance and clinical mandates of this very tight integration between the two government programs and the cost and quality accountability the regulators want to see.
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FIDEs and HIDEs described
FIDE — A Fully Integrated Dual Eligible (FIDE) SNP plan provides Medicare and essentially all Medicaid covered services through a single managed care organization. The same organization that offers the FIDE SNP must also offer any Medicaid benefits or services through a Medicaid managed care organization contract. Contracting remains separate for Medicare and Medicaid. Some services still may be provided by the Medicaid FFS program or by a different Medicaid managed care plan (e.g., behavioral health could be carved out by the state Medicaid agency). The FIDE SNP must also meet all the requirements of a coordinated SNP.
In 2025, FIDE SNPs may only enroll full-benefit dual-eligible individuals if they are enrolled in both the FIDE SNP and the Medicaid plan sponsored by the same organization. Further, long-term services and supports and all Medicaid benefits must be covered. FIDE-SNPs that have exclusively aligned enrollment (EAE) between Medicare and Medicaid are called “Applicable Integrated Plans” (AIPs). EAE is a requirement as of 2025 as well.
HIDE — A Highly Integrated Dual Eligible (HIDE) SNP plan provides Medicare and most Medicaid covered services through a single managed care organization or have Medicaid services provided by a Medicaid managed care plan operating in the same counties as the D-SNP (controlled by the same Medicare plan sponsor). HIDE SNPs include coverage of long-term services and supports or behavioral health or both. The HIDE SNP must also meet all the requirements of a coordinated SNP. HIDEs can also have EAE but are not required to be aligned.
#medicareadvantage #cms #specialneedsplans #snps
— Marc S. Ryan
