Imagine being at the doctor’s office when you’re asked for your insurance card. You begin rummaging through your wallet and remember you have multiple insurance cards, one from Medicare, one from another program with a vague-sounding name, and another that might be for your prescription drugs, but, “Who can tell?.” You have no idea which is right so you hand them all over and hope that one of programs that sent you those cards will cover the visit and you won’t be saddled with a large co-pay. Not having a visit covered might mean not seeing the doctor today. Not seeing the doctor today might mean foregoing necessary care for a chronic condition or addressing an emerging symptom that could worsen and result in a trip to the emergency room.
This hypothetical is often the reality for the 12 million people that have simultaneous Medicare and Medicaid coverage, the so-called “dual eligible” population. These individuals have worse health and greater health needs than their Medicare-only counterparts, and yet they are forced to navigate a confusing and fragmented system to obtain care.
One model that has the potential to make navigating Medicare and Medicaid together simpler is the Dual Eligible Special Needs Plan (D-SNP). Today, this model serves 1 in 4 dual eligible individuals.[i] D-SNPs were created through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to provide tailored coverage to the dual eligible population. State and federal policymakers came to recognize that these specialized plans could be leveraged to align the Medicare and Medicaid programs and address some of the issues that come from having multiple forms of insurance coverage, including multiple insurance cards, coverage policies, and provider directories. Congress opted to permanently authorize the D-SNP model in the Bipartisan Budget Act (BBA) of 2018 and directed the Centers for Medicare & Medicaid Services (CMS) to establish a higher minimum standard of Medicare-Medicaid integration under these plans. In response, CMS identified three D-SNP model designations: Coordination Only D-SNPs (CO-D-SNPs), Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNPs), and Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) (Figure 1).
Figure 1: Dual Eligible Special Needs Plan (D-SNP) Models
The D-SNP models outlined above are supposed to reflect a spectrum of integrating Medicare and Medicaid from least integrated (i.e., CO-D-SNP) to most integrated (i.e., FIDE-SNP). As a result, many of us find comfort in knowing a dual eligible individual is enrolled in a FIDE-SNP, because we presume the experience is, well, fully integrated. However, the current FIDE-SNP definition isn’t clear for states, and while it may mean fully integrated in some parts of the country, that isn’t always the case. Additionally, confusion around the FIDE-SNP model definition has hindered growth of this model across states. For example, state Medicaid Directors and their staff play an important role in determining which, if any, D-SNP models can operate in their state. The Medicaid agency must have a contract with each D-SNP. Medicaid staff typically are not Medicare experts and struggle to know how to use this contracting authority. The confusion around the definition has led many states to opt for the less integrated HIDE-SNP model simply because the requirements are clearer.
Ultimately, we want to ensure that all dual eligible individuals have access to an integrated model that solves for the fragmentation challenges that people experience. The FIDE-SNP model is a strong catalyst for reaching this goal, but changes to the FIDE-SNP definition are necessary to make it both more meaningful and clearer than it is today.
Improving and Clarifying the FIDE-SNP Definition
The FIDE-SNP definition is in statute. However, the statutory definition is broad, leaving considerable leeway for CMS to define the model. Overtime, CMS has refined the definition through regulation, rulemaking comments, and guidance (Figure 2).
Figure 2: Where is the FIDE-SNP Defined?
Given the broad definition of FIDE-SNP in statute, CMS has considerable latitude and flexibility to make it a more meaningful program for dual eligible individuals. CMS should clarify and improve key FIDE-SNP requirements so that people enrolled in this model experience their Medicaid and Medicare coverage as a single program, and also remove inconsequential barriers to entry. Table 1 outlines the existing FIDE-SNP requirements and recommended improvements, followed by some additional requirements we believe should be added to the FIDE-SNP definition.
Table 1: FIDE-SNP Requirements and Recommended Improvements
Leveraging State Medicaid Agency Contracts (SMACs) to Improve FIDE-SNP Integration Now
In upcoming rulemaking cycles, CMS has the opportunity to make changes to the FIDE-SNP definitions to improve beneficiary experience, as suggested above. However, to the extent that CMS does not adopt these recommendations, states can pursue many attributes of a fully integrated model themselves. The contracts states must sign with D-SNPs, state Medicaid agency contracts (SMACs), provide significant authority for states to require higher standards of integration of D-SNP, including and in particular in FIDE-SNPs.
While some states stick close to the minimum requirements mandated by CMS , others add significant additional requirements to their SMACs to strengthen integration within FIDE-SNPs (Table 2). In addition to requiring all their D-SNPs to be FIDE-SNPs, New Jersey, for example, added special provisions to its contracts that created a unified process for reviewing plan materials that go above minimum FIDE-SNP requirements defined by CMS.[ix] Minnesota requires FIDE-SNPs to keep their premiums at zero dollars, create integrated enrollment materials, and conduct one integrated CAHPS survey annually. The state even makes integration impactful for providers–plans must allow integrated claims, so providers do not have to bill separately for Medicare and Medicaid services.
Table 2: Opportunities for States to Improve FIDE-SNP Integration
We do a disservice to dual eligible individuals enrolled in FIDE-SNPs when we assume their experience is fully integrated, simply because of the name of the plan. FIDE-SNPs are intended to represent the North Star of current D-SNP integration models. While some states and plans collaborate to create meaningfully integrated FIDE-SNPs, the Biden Administration has the opportunity to ensure that all FIDE-SNPs provide a high-quality integrated enrollee experience and to help increase the number of these programs available nationwide. Table 3 below summarizes the key opportunities identified to improve the current FIDE-SNP definition. If adopted, these changes would be tremendously helpful in moving the dial on Medicare and Medicaid integration.
Table 3: Opportunities for CMS to Improve the FIDE-SNP Definition
[ii] Donovan, Sharon. Additional Guidance on CY 2021 Medicare-Medicaid Integration Requirements for Dual Eligible Special Needs Plans (D-SNPs). CMS. 2019.
[iii] Section (1859)(f)(8)(D)(i) of the Social Security Act
[v] 42 Code of Federal Regulations § 422.2
[vi] Section (1859)(f)(8)(D)(i) of the Social Security Act
[vii] Donovan, Sharon. Additional Guidance on CY 2021 Medicare-Medicaid Integration Requirements for Dual Eligible Special Needs Plans (D-SNPs). CMS. 2019.
[ix] Office of Health Insurance Program. Providing Integrated Care for New York’s Dual Eligible Members Stakeholder Discussion. December 2018. New York State Department of Health. December 2018.