Medicaid experts Brie Janoski, Allison Rizer, and Tom Betlach hosted a webinar discussion, “D-SNP Design: Updating the State Medicaid Agency Contract (SMAC).” They explored considerations and opportunities for states interested in leveraging the SMAC to advance Medicare and Medicaid integration and improve care for dual eligibles.
Overview of the Dual Eligible and D-SNP Landscape
Currently, 12 million individuals are dually eligible for Medicare and Medicaid, with 5.1 million of these individuals enrolled in Dual Eligible Special Needs Plans (D-SNPs). D-SNPs play a crucial role in coordinating care across Medicare and Medicaid benefits. The number of individuals enrolled in D-SNPs is increasing, along with the number of D-SNP programs operating nationally. By 2025, 48 states and territories will offer some type of D-SNP program.
SMAC Authority and Development Timeline
The SMAC is a tool used by states to design their D-SNPs to meet their unique goals. States have the authority to decide which D-SNPs operate within their jurisdiction. CMS requires states to sign a SMAC with every D-SNP operating within their state annually, with plans submitting SMACs to CMS annually in July. States determine the content and extent of updates to the SMAC each year.
All SMACs must include ten minimum federal requirements:
- Coordination of Medicaid services by the Medicare Advantage Organization (MAO).
- Eligibility categories for dual eligible individuals.
- Medicaid benefits covered under the D-SNP.
- Cost-sharing protections.
- Information sharing on Medicaid provider participation.
- Verification of enrollee’s Medicaid eligibility.
- Service area covered by the D-SNP.
- Contract period.
- Unified appeals and grievances for applicable integrated plans.
- Minimum integration requirement for coordination-only D-SNPs.
Through the SMAC, states have the authority to mandate further requirements for D-SNPs to meet their goals, such as requirements around care management, quality measures, data sharing, and supplemental benefits.
Addressing the Needs of Dual Eligible Individuals
Dual eligible individuals are a heterogeneous population with complex needs. D-SNP programs can be tailored to support these diverse needs across states. States are increasingly leveraging D-SNPs to promote coordinated and integrated care, achieving meaningful incremental improvements with minimal investment.
States interested in advancing reforms for the calendar year 2026 can begin planning now.
The webinar closed with a discussion on where states should begin when thinking about program reforms for dual eligible individuals. Betlach recommended referencing language used in existing resources and SMACs, as well as getting deep into the data on the dual eligible population in the state to understand their unique needs. He also suggested prioritizing community feedback through conversations with dual eligible individuals, caregivers, and advocacy organizations to understand the pain points they identify in the care coordination experience. Rizer suggested collaborating with D-SNPs operating within the state to understand on-the-ground operational and cost considerations, as well as the market implications of new policies. Together, this work can help states develop an informed multi-year strategy for dual eligible program reform.
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