The Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2023 Medicare Advantage and Part D Final Rule. The ruling places a spotlight on the vulnerable D-SNP population, and places health plans in a challenging yet opportunistic position to engage these notoriously difficult-to-reach members.
2023 Ruling’s Impact on D-SNP at a Glance
Enrollee Participation in Plan Governance
MA organizations offering a D-SNP must establish at least one enrollee advisory committee in each state to solicit input from member experiences. The sample must include those enrolled in D-SNP and garner input from members regarding access to services, coordination of services and health equity.
Opportunity: Feedback will help identify and address barriers to care, which will allow plans to further assess their series and processes to ensure a better member experience, while also collecting valuable data regarding their unique member population.
Standardizing Housing, Food Insecurity, and Transportation Questions of Health Risk Assessments (HRAs)
Initial and Annual assessments will be conducted to evaluate each member’s physical, psychosocial, and functional needs. HRAs must include one or more questions on housing stability, food security, and access to transportation.
Opportunity: Visibility of member needs will enable plans to address the unique needs of each member, allowing better access and resource allocation of plan offerings and services.
Refining Definitions for Fully Integrated and Highly Integrated D-SNPS
Beginning in 2025 and in years following, FIDE SNPs will have aligned enrollment and cover Medicare cost-sharing and Medicaid benefits for home health services, medical supplies, and behavioral health services between the state and the MCO, with the same legal entity as the FIDE SNP. Additionally, HIDE SNPs have service that overlaps the plan’s Medicaid managed care plan with the state. This rule will organize Medicaid long-term services while supporting Medicaid behavioral health services affiliated with FIDE SNPs and HIDE SNPs.
Opportunity: Create better integration between FIDE SNPs and HIDE SNPs, whose definition and intricacies have previously lacked consistency.
Additional Opportunities for Integration Through State Medicaid Agency Contract
D-SNP contracts will be required through the state agency to provide benefits/ arrange a provision of benefits. New pathways will require aligned enrollment and establish contracts that only include one or more D-SNPs within a state and use integrated materials and notices for members.
Opportunity: Members have clarity of their coverage and benefits. Star Ratings are assigned at the contract level, which means this rule provides greater transparency on D-SNP quality ratings and will allow CMS to identify disparities between beneficiaries and interventions. This will improve federal and state oversight and scale information sharing.
Attainment of the Maximum Out-Of-Pocket (MOOP) Limit
Plans must establish a limit on beneficiary cost-saving for Medicare Part A and B services after the plan pays 100% of the costs. Current guidance allows MA plans, including D-SNPs to not count Medicaid-paid amounts or unpaid amounts towards the MOOP limit, which results in increased state payments of Medicare cost-sharing and disadvantages providers serving D-SNP members. The MOOP limit within the plan will be calculated based on total cost sharing, regardless of whether it was paid by the beneficiary, Medicaid, secondary insurance, or left unpaid.
Opportunity: More equitable payments for providers serving D-SNPs. This will result in increased bid costs, and increased Medicare spending, which will be offset by lower federal Medicaid spending. The net federal 10-year cost is estimated at $614.8 million.
As plans heighten their attention and focus on D-SNP members with the new ruling in mind, several opportunities surface and a more robust engagement model that provides an exceptional experience becomes critical. Look out for Part 2, D-SNP Spotlight: Engagement Opportunities within the 2023 Ruling, to learn how plans can upgrade their engagement strategy to drive proven outcomes with D-SNP members.