Authors: Brie Ensslin Janoski, Amy Abdnor, and Arielle Mir 

Enacted in March 2021, the American Rescue Plan Act (ARPA) is expected to infuse upwards of $11 billion in additional federal spending to states to bolster Home and Community Based Services (HCBS) in Medicaid with more money potentially on the way depending on the outcome of reconciliation negotiations. State Medicaid agencies have been feverishly working to determine how they can best use these new funds.

Despite the new attention on the various ways states can make HCBS systems improvements including through workforce development strategies, quality initiatives, and service and benefit offerings, relatively few states are connecting the dots on how integrated Medicare-Medicaid models for dual-eligible individuals can also support these efforts. As we highlighted last month, integrated models can help support person-centered care by coordinating and maximizing HCBS.

One model and tool with real potential to advance this coordination is the Medicare Advantage (MA) Dual Eligible Special Needs Plan (D-SNP). D-SNPs are an MA plan limited to dual eligible individuals, required to have an approved Model of Care that details their approach to serving dual eligible individuals. Because D-SNPs serve individuals who have Medicaid coverage, in addition to Medicare, the D-SNP is required to have a contract with the state Medicaid agency to operate in the state (commonly referred to as the “SMAC”). This allows states to place requirements on these plans to not only coordinate Medicare and Medicaid but strategically offer certain benefits, design person-centered Models of Care, and improve quality management programs that directly address ARPA HCBS spending plan goals.

Despite the promise of the SMAC, currently only a fraction of the 42 states with D-SNP programs have tapped the potential of this authority to improve the delivery of supports at home and in the community. This blog outlines the opportunity that D-SNPs present to states and strategies they can employ immediately under the SMAC to better serve the dual eligible population with long-term services and supports (LTSS) needs.

D-SNPs and the Untapped Potential of SMACs

Enrollment in D-SNPs has grown 80% over the past five years, bringing current enrollment to upwards of 3.6 million enrollees (Figure 1). During this same time, the number of dual-eligible individuals in Medicare and Medicaid grew from 10.6 million[i] to 12.3 million[ii], or about 14%.

The federal policy environment impacting D-SNPs has evolved considerably since 2017 (read more here about different integrated care models). Most notably and most recently, beginning in 2021, D-SNPs are required to meet enhanced Medicaid integration requirements that include data sharing with states and in some instances, risk-bearing for Medicaid services. The year prior, CMS implemented improved appeals and grievances experiences for D-SNP enrollees and clarified that D-SNPs must coordinate Medicaid benefits for all D-SNP enrollees, even those for which they don’t provide Medicaid benefits. From 2018 – 2019, CMS and Congress began allowing MA plans to offer non-medical benefits that are like LTSS and social services – services that typically were prohibited in Medicare.

There are core requirements that all SMACs must include for CMS to approve the contract. However, CMS gives states incredible latitude to build in additional program requirements in their SMACs to advance integration and provide that state with insight into the needs and costs of their dually eligible populations. While states work with CMS in the coming months to refine and implement HCBS spending plans, they should consider how to leverage their D-SNP program to accomplish state rebalancing and other HCBS systems improvement goals.

The following outlines several common HCBS spending plan goals and describes how states can leverage D-SNP SMAC provisions to advance these same goals.

1. HCBS Goal #1: Expand Access to Social Support Benefits. States can leverage SMACs to require D-SNPs to coordinate with the state Medicaid agency in the development of their supplemental benefits such as offering transportation for non-medical needs or expanding access to healthy meals. States can also require that D-SNPs include certain benefits to complement the state’s Medicaid goals or fill a gap in the current Medicaid benefit package; however, this approach should be carefully considered given the potential for unintended consequences. See Figure 2 for a snapshot of benefits that MA plans offer which promote community living and common HCBS spending plan goals. Example states with related provisions include: Arizona and Pennsylvania

2. HCBS Goal #2: Improve Quality. States can affect quality for their dually eligible populations in D-SNPs by requiring plans to i) report Medicare data to the state on metrics that can inform state program planning and quality improvement activities; and ii) implement quality improvement activities that address certain state priorities. States can review data submitted by D-SNPs to inform future requirements and program refinements to improve quality of care and services. Through SMACs, states can require D-SNPs to submit to the state Medicare D-SNP encounter and performance data such as Medicare Health Outcomes Survey data; HEDIS measures; Medicare grievances and appeals reports; Medicare Advantage Star Quality Ratings; and Quality Improvement projects. Example states with related provisions include: Pennsylvania and Wisconsin

3. HCBS Goal #3: Understand Consumers’ Perspectives about their Coverage. While states often require their Medicaid managed care organizations to share data on beneficiary satisfaction, few require D-SNPs to do the same. Through SMACs, states can require D-SNPs to implement CAHPS and report results to the state Medicaid agency. These data can inform future implementation of provisions to improve quality and experience of care, such as requiring D-SNPs provide an integrated provider directory or a single identification card for beneficiaries in an aligned D-SNP and Medicaid MCO to minimize confusion.

4. HCBS Goal #4: Strengthen Assessment and Person-Centered Planning Practices. States can require certain care management design considerations that put the beneficiary at the center of the D-SNP Model of Care, much in the same way they often implement these requirements in their Medicaid managed care programs. Through SMACs, states can require D-SNPs to bring Medicaid goals into the design of Models of Care including specific considerations around how D-SNPs should implement interdisciplinary care teams with the person at the center, training on person-centered care and motivational interviewing, identification of natural supports, and engagement of beneficiary caregivers or other designees. Example states with related provisions include: Minnesota and Wisconsin

5. HCBS Goal #5: Understand and Address Social Determinants of Health (SDOH) Needs. For dually eligible individuals, states often have limited insight into their social needs, inhibiting state ability to appropriately design programs and benefits. Through SMACs, states can require D-SNPs to engage with the state, or other designated entities, to advance projects that address social determinant of health needs of its membership. States can require broad engagement of its D-SNPs in state efforts to address SDOH that advance state goals, such as improving health disparities or supporting community living. Example state with related provisions include: Tennessee

6. HCBS Goal #6: Strengthen Institutional Diversion and Community Transition Activities. All states must require D-SNPs that are not FIDE-SNPs[iii] or HIDE-SNPs[iv] to share inpatient and skilled nursing facility (SNF) admissions data with the state, and any state may require this of all D-SNPs. The extent to which these data are shared in a meaningful and useable way to support diversion and transition activities is limited. States should consider program improvements that better connect D-SNPs and unaffiliated Medicaid managed care organizations or case managers, such as using the state’s Health Information Exchange to share timely (as quickly as possible) data on shared members’ admissions and discharges. States also can require D-SNPs to train designated staff and providers regarding nursing facility diversion and HCBS benefits that can support diversion or transition activities. Taking it a step further, D-SNPs can be required to participate in transitions of care and continually monitor opportunities to transition members to the community as their capabilities and preferences evolve. Example states with related provisions include: Pennsylvania, Tennessee, and Virginia

7. HCBS Goal #7: Better Support the Direct Care Workforce. As states grapple with the incredible stress the COVID-19 pandemic has placed on an already taxed direct care workforce, they should consider leveraging the connections D-SNPs have with this group of providers. Through SMACs, states can require D-SNPs to implement plan-led initiatives via their Model of Care to address direct care workforce issues such as requiring plans to train workers on COVID-19 protocols. Plans can also be required to work with community partners to develop an innovative solution to address a local workforce issue.

8. HCBS Goal #8: Provide Support for Informal and Family Caregivers. Informal and family caregivers provide an undeniably valuable service to our communities. Ensuring caregivers are receiving the supports they need to continue to care for their loved ones at home is critical to maintaining and improving HCBS balance across LTSS systems of care. Through SMACs, states can require D-SNPs to involve caregivers in care planning and assessment activities to ensure appropriate considerations are given to their capabilities in developing person-centered plans. SMACs can also be used to require D-SNPs to undertake certain activities to support caregivers directly such as assessing the caregiver’s needs and responding with supports such as training and connections to available services or respite benefits.

Next Steps for State Implementation

With the current focus on refinement and implementation of HCBS spending plans, states should use this time to evaluate opportunities to leverage D-SNPs and further integrate care for dually eligible beneficiaries to help achieve state goals and support community living. Even though it can be challenging as a state official to think about 2023 while we’re still in 2021, the last few months of 2021 and early 2022 are the ideal time for a state to draft new SMAC requirements to include in CY2023 D-SNP SMACs as outlined in Figure 3.

Focusing on Medicare when you’re a Medicaid agency official is challenging but doing so is an incredible opportunity for the state to expand its positive impact on beneficiaries in need. Many of the SMAC provisions highlighted here require a minimal effort on the state agency to implement. Depending on the requirement, ensuring compliance is all that’s needed.

States are missing an incredible and unprecedented opportunity to promote integration, and to leverage their D-SNPs to address HCBS spending plan goals. So why not consider adding a few new requirements to contracts for 2023?

This insight was developed with support from Arnold Ventures.

[i] https://www.kff.org/medicaid/state-indicator/duals-as-a-of-medicare-beneficiaries/?currentTimeframe=2&selectedDistributions=dual-eligible-enrollees&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

[ii] https://www.macpac.gov/publication/improving-integration-for-dually-eligible-beneficiaries-strategies-for-state-contracts-with-dual-eligible-special-needs-plans/

[iii] FIDE-SNPs stands for Fully Integrated Dual Eligible Special Needs Plans. These are D-SNPs with a parent organization that offers Medicaid managed care that includes LTSS and may or may not include behavioral health in accordance with the state Medicaid model design. All FIDE-SNPs have exclusively aligned enrollment. FIDE-SNPs are not required to participate in the D-SNP requirement to share inpatient and SNF data that was required in the BBA of 2018.

[iv] HIDE-SNPs stands for Highly Integrated Dual Eligible Special Needs Plans. These are D-SNPs with a parent organization that offers Medicaid managed care that includes at least LTSS or behavioral health benefits in the benefit package. Some HIDE-SNPs have exclusively aligned enrollment if the state only allows individuals to enroll in an aligned plan. HIDE-SNPs with exclusively aligned enrollment are not required to participate in the D-SNP requirement to share inpatient and SNF data that was required in the BBA of 2018.

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