Understanding Dual-Eligible Special Needs Plans (D-SNPs): Your essential guide to types of D-SNPs and the impact of MMPs Sunsetting

In May of 2022, CMS finalized the rule that will sunset Medicare-Medicaid Plans (MMPs).  This rule proposes that required states transition their MMP enrollees to integrated Medicare Advantage dual eligible special needs plans.  This left many sponsors asking themselves questions ranging from, “what does our organization need to build or change in order to transition these members?” to “what are the differences between a HIDE and a FIDE SNP?”  This article will provide a refresher on the fundamentals of a Dual Eligible Special Needs Plan (D-SNP), explain the differences between a Highly Integrated Dual-Eligible Special Needs Plan (HIDE-SNP) and a Fully Integrated Dual-Eligible Special Needs Plan (FIDE-SNP), and take a look at what it means to have Aligned Enrollment versus Exclusively Aligned Enrollment.  Lastly, we will provide key implementation areas of focus to consider when converting an existing MMP plan into a HIDE D-SNP or a FIDE D-SNP.

D-SNP Fundamentals

Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans that only enroll individuals who are entitled to both Medicare and Medicaid.  All D-SNPs, whether Coordination Only (CO), Highly Integrated Dual Eligible Special Needs Plan (HIDE S-SNP) or Fully Integrated Dual Eligible Special Needs Plan (FIDE D-SNP), must meet the following basic CMS requirements:

• At least coordinate Medicaid benefits for their members
• Operate within their approved Model of Care
• Have an Enrollee Advisory Committee
• Incorporate 3 key Social Determinants of Health screeners into their Health Risk Assessment
• Have a State Medicaid Agency Contract (SMAC) with each state in which they operate
• Satisfy the criteria for the integration of Medicare and Medicaid benefits as specified by their contract with the Medicaid agency

For each type of D-SNP, there are additional requirements discussed below that determine whether the plan is a CO, HIDE or FIDE D-SNP.

Coordination Only D-SNPs

Along with meeting the above basic CMS requirements, the Coordination Only D-SNP plan must also notify the state Medicaid agency, or its designee, of a hospital or Skilled Nursing Facility (SNF) admission for the high risk full-benefit dually eligible (FBDE) enrollees.  This is for the purpose of care coordination of Medicare and Medicaid covered services during a transition of care.  The state Medicaid agency is responsible for determining the timeframes and methods by which the notice is to be provided.

Highly Integrated Dual Eligible D-SNPs (HIDE D-SNP)

HIDE D-SNPs must also meet the basic CMS requirements listed above, and in addition must provide coverage of Medicaid Long Term Services and Support (LTSS) and / or behavioral health (BH) services.  These services must be consistent with the state policy and under a capitated contract between the state Medicaid agency and either the MA organization itself, the MA organization’s parent company or another entity owned by the MA organization / parent company.  The HIDE D-SNP must use the unified grievance and appeals procedure if the D-SNP meets the definition for exclusively aligned enrollment.

Fully Integrated Dual Eligible DSNPs (FIDE D-SNP)

FIDE D-SNPs provide coverage of Medicaid and Medicare under a single legal entity that holds both an MA contract with CMS and a capitated contract with the state Medicaid agency.

In addition to meeting the basic CMS requirements and having a unified appeals and grievances procedure, the FIDE D-SNP must also cover Medicaid primary and acute services, LTSS, and must include at least 180 days of nursing facility coverage.  FIDE D-SNPs must coordinate Medicare and Medicaid benefits using aligned care management and specialty network methods for high risk beneficiaries.  The use of integrated beneficiary communications are also required.  All FIDE D-SNPs must operate with exclusively aligned enrollment and therefore, by default, all FIDE D-SNPs are Applicable Integrated Plans (AIPs).

Aligned, Unaligned and Exclusively Aligned Enrollment

When a Medicaid Managed Care Organization (MMCO) plan has a particular relationship with a D-SNP, either through the D-SNP itself, a parent company or another entity owned and controlled by the D-SNP’s parent organization, that MMCO is considered “affiliated” with the D-SNP.  Aligned enrollment occurs when a beneficiary enrolls chooses to enroll in the affiliated MMCO that is offered.  When the beneficiary chooses the unaffiliated MMCO, they are considered to have unaligned enrollment.  Unaligned enrollment may occur in both CO and HIDE D-SNPs.  It cannot occur in a FIDE D-SNP because, as mentioned previously, all FIDE D-SNPs must have exclusively aligned enrollment.

Exclusively Aligned Enrollment

When state policy limits D-SNP membership to only individuals with aligned enrollment, this condition is referred to as exclusively aligned enrollment.  This means, in those states, a member must be aligned to the same Medicare and Medicaid company.  For example, if the enrollee has the D-SNP through Company A, they are automatically enrolled in a MMCO by company A.  There is no mixing and matching as we may see in CO or HIDE D-SNPs.  To take it a step further, with aligned enrollment, the enrollee would have the choice of enrolling in Company A (aligned with affiliated MMCO) or Company B (unaligned with unaffiliated MMCO) for their D-SNP.  In exclusively aligned enrollment, there is no choice.  The beneficiary is automatically enrolled in Company A’s MMCO.

Exclusively aligned D-SNPs may not enroll any members who are partial duals, since those members are not enrolled in any MMCO.  There are exclusively aligned D-SNPs in at least 12 states.  Some D-SNPs have chosen to have exclusively aligned enrollment although it is not required to by the state.  This is likely because those plans recognize the benefits of an exclusively aligned, fully integrated D-SNP model.  Aligned enrollment has been promoted as a way to improve the experience of dually eligible individuals by facilitating coordination of benefits, integrated appeals, and less confusing enrollee communication.  Aligned enrollment has also been shown to improve provider experience and result in better patient outcomes.  The bottom line is the more integrated and less confusing the plan is for the enrollee, the better.

Applicable Integrated Plans are defined as D-SNPs that operate with exclusively aligned enrollment.  All three types of D-SNPs can be an AIP.  However, only FIDE D-SNPs are required to be AIPs.

Should you implement a FIDE or HIDE D-SNP?

The following questions can help your organization decide whether you are best suited to operate a HIDE D-SNP or a FIDE D-SNP:

1. Who will hold the Medicaid contract? Will it be the same legal entity?
2. Which Medicaid benefits will the plan provide? LTSS?  BH?  Both?
3. What is the available Medicaid coverage area? Is there coverage in the applicable counties?
4. What be offered as it pertains to Medicaid enrollment? Will the plan offer enrollment in both affiliated and unaffiliated MMCOs, or will the plan limit membership to only individuals with aligned enrollment?

Once the plan decides on a FIDE or HIDE D-SNP, they can submit their RFP and begin their operational build.

Transitioning an MMP

Plans with existing MMP should complete a gap analysis of the current plan and determine what would need to be bought versus built.  Key areas to consider when transitioning an existing MMP plan are:

1. Model of Care (MOC) – Existing MMPs will move from adherence to a 3 way contract to a MOC
2. Health Risk Assessment- MMP plans will need to move away from state required assessment instruments to a comprehensive assessment tool
3. Interdisciplinary Care Plan- evaluation of EMR capabilities are huge here. Does the HRA “speak” to the ICP and capture all positives on the HRA in the ICP?  Is the ICP compliant, does it contain SMART goals?
4. Creation of an Enrollee Advisory Committee
5. Staff Organization- possible reorganization of the staff structure to fit the higher level of integration and align with MOC
6. Quality Improvement metrics- reviewed / renamed specific to HIDE / FIDE product
7. Vendor notification- HEDIS, CAHPS vendors may have different tools and metrics
8. EMR evaluation- does it support Part C reporting requirements?
9. Unified appeals and grievances for AIP plans
10. Integrated Member Materials