Operational Strategies for Effective D-SNPs – Eligibility & Enrollment

This is the first of a three-part blog series about operational strategies for Dual Special Needs plans (D-SNPs), which has been an emphasis and expansion topic for both CMS and individual states. This segment focuses on the scope of D-SNPs, eligibility requirements and enrollment process.

Defining a D-SNP

To begin, we need to understand what encompasses a D-SNP. Medicare allows certain categories of covered individuals to enroll in Medicare Advantage “Special Needs Plans” (SNPs) that address their particular care situations. SNP plans offer more generous coverage than regular Medicare Advantage plans or “Traditional Medicare” fee-for-service (FFS). One type of SNP is designed for Medicare enrollees whose limited income and assets make them eligible for additional Medicaid benefits. These individuals are referred to as “dual eligibles” and can enroll in Dual Special Needs Plans (D-SNPs) that provide extensive medical and long-term care coverage.  

Dual eligibles receive both types of coverage because:

• Medicare generally pays for acute care, hospital and post-acute care, such as services provided in skilled nursing facilities to promote recovery from acute illness or surgery.
• Medicaid pays for long-term services and supports (LTSS) that help people stay at home, or for lengthy or permanent skilled nursing facilities, as well as Medicare copays and deductibles and other costs that Medicare doesn’t cover. These include dental and vision services, more extensive behavioral and substance abuse treatment, and those services with Medicare coverage limits.

Qualifying for enrollment by category

There are numerous categories of dual eligibles, but only some of them qualify to enroll in a D-SNP.

• Qualified Medicare Beneficiaries (QMBs) have income below 100% of poverty ($15,060) and resources/assets below $4,000, who qualify for Medicaid to cover all their Medicare premiums, deductibles, copays and coinsurance.
• QMB+ meets QMB income and resource standards and criteria for full Medicaid benefits covering LTSS and other services that Medicare doesn’t cover.
• Specified Low-Income Medicare Beneficiaries+ (SLMB) have income below 120% of poverty ($18,072) and resources below $4,000 and meet state Medically Needy standards by spending down their excess income on services that would otherwise be covered by Medicaid. SLMB+ beneficiaries receive Medicaid coverage of their premiums, deductibles copays and LTSS that Medicare doesn’t cover.

Other categories of dual eligibles are those with higher income who are ineligible for D-SNPs because they only receive Medicaid subsidies for their Medicare premiums, rather than benefits under both Medicare and Medicaid.

There are three types of D-SNP plans approved by CMS. Enrollment in these plans is dependent on the category of the individual and state guidelines.

It’s important to note special rights and options regarding enrollment that are exclusively available to dual eligibles. These factors amplify the pressure on D-SNPs to maintain high levels of customer service, member satisfaction and competitive provider networks.

• Unlike standard Medicare beneficiaries, who can only change their coverage to enroll in a new Medicare Advantage plan or revert to Traditional Medicare FFS during the annual October-November open enrollment period, dual eligibles residing in 23 states or Washington DC can change their Medicare coverage plan every quarter, by either enrolling in an integrated D-SNP or switching to Medicare FFS.^[1]
• Additionally, dual eligibles can switch plans if their Medicaid eligibility is modified due to a change in status (such as a change in income or assets).  

Attracting and retaining dual eligible members can be challenging for D-SNPs, but enrolling is easier in states where CMS grants authority for direct enrollment using a Default Enrollment or Exclusively Aligned Enrollment process.  

• Under Default Enrollment, states are given authority to auto-assign the dual eligible into FIDE or HIDE SNPs when the individual has dual status. For example, when an individual on Medicaid turns age 65 and they’re default enrolled into the D-SNP offered by the organization managing their current Medicaid managed care plan.
• Another state arrangement is Exclusively Aligned Enrollment, where an enrollee who chooses a D-SNP must also enroll in a Medicaid plan operated by the same parent company. This arrangement usually involves HIDE SNP plans. In these cases, some enrollees prefer the D-SNP offered by their prior Medicaid managed care plan, since they are already familiar with how it works.

Determining Enrollee Eligibility

D-SNPs and even standard Medicare Advantage plans have the responsibility to confirm and monitor both Medicare and Medicaid eligibility of dual eligibles.

• Acceptable proof of Medicaid can be a current Medicaid card, a letter from the state agency that confirms entitlement to Medical Assistance, or verification through a systems query to a state eligibility data system.  
• While most Medicare beneficiaries remain in the program for the rest of their lives, Medicaid eligibility can fluctuate based on a recipient’s income, assets and resources, living status and place of residence.
• All Medicaid enrollees have their eligibility re-determined at least annually, which can cause them to lose Medicaid assistance if their income or assets increase above allowed thresholds, they move out of a region or state, or if they don’t respond to re-determination questionnaires.
• CMS allows D-SNPs to continue coverage for individuals who lose their Medicaid eligibility if the individual can reasonably be expected to be re-eligible for Medicaid within six months.

Thus, it is important for D-SNPs to track their enrollees’ eligibility re-determination status, remind them of the due dates and assist with their completion of necessary documentation.

Enrollment information for D-SNPs is primarily received from two government enrollment channels, both of which require monitoring.

• Daily transactions from the CMS Medicare communication and enrollment system, called MARx, which relays new enrollments, terminations and status changes.  
• State Medicaid enrollment transactions, which typically are relayed via a HIPAA X12 834 daily transaction file, containing new enrollments, terminations and status changes. States can also send D-SNPs a monthly roster file, containing all Medicaid plan eligibles.

D-SNPs are responsible for reconciling transactions from these two government enrollment systems on a member-specific basis, with a core requirement that the enrollee’s name, date of birth, gender and member numbers match between the two files. D-SNPs must notify both levels of government of any discrepancies, as well as other lifestyle changes when they are first known. This includes a change of address, phone number or other status changes.  

Some states have active call centers and vendors that manage default plan auto-assignment and Medicaid beneficiary status and contact changes, while other states delegate enrollee status to health plans.

Because of these variables, customer service responsibilities for D-SNP plans exceed those of standard Medicare Advantage plans.

• D-SNP enrollees are typically more vulnerable, transitory and have more frequent inpatient admissions, including to hospital, skilled nursing, behavioral, substance abuse and critical access facilities than regular Medicare recipients.
• Many dual eligibles need LTSS care due to multiple co-morbidities, which is the basis for their receiving expanded Medicaid coverage.
• Some are homeless, or lack a permanent residence, and can have other social challenges.

To be successful, D-SNP enrollment and customer service staff must be significantly more proactive in engaging with enrollees and their caregivers than the typical reactive health plan service model.

Comparing D-SNP vs. a Traditional Program

A key competitor for D-SNPs is the traditional Medicare and Medicaid FFS program, where coverage is directly administered by CMS or the state, and not under a single plan.   Dual eligibles can be automatically enrolled in FFS. This option is preferred by many healthcare providers since it subjects clinicians to less management, care authorization, and less program coordination by the two levels of government.

However, this situation may not be in the best interest of the patient, who can experience frustrations in dealing with multiple sets of rules, benefits, ID cards and providers. Such enrollees also lack the support of a health plan that could coordinate coverage, care and requirements between the two programs.

Additionally, some states require that dual eligibles be enrolled in managed care plans for the Medicaid portion of their coverage, creating further complexity for the patient.

Download our "Integrated D-SNP vs Medicare Advantage Enrollment" comparison matrix now for a snapshot of standard Medicare Advantage enrollment vs. that for D-SNPs.

Embracing the Opportunity

Coverage of the dual-eligible population represents an expanding opportunity for managed care plans. However, meeting beneficiaries’ needs and managing the complexities of both the Medicare and Medicaid programs can be an operational challenge. Areas of consideration for developing a clear strategy and potential investment for success:

• Will system and administrative modifications need to be made?
• Will the use of technology need to be refined?
• Plans should look to outsource highly specialized services.
• Support should be obtained from reliable partners if needed.

SS&C Health offers solutions in all key functions of D-SNP and MMP operations through our expertise and technology strength. Contact us today to see how we can help your plan embrace the opportunity and succeed in serving dual eligibles.

In part 2 of our series, we’ll explore the process of claims and benefit adjudication—the importance of coordination between Medicare and Medicaid, customized benefit packages and the complexities associated with care management and integrated services for this unique population.

^[1] AZ, CA, DC, FL, HI, IA, ID, IN, KS, KY, MA, MN, NE, NJ, NM, NY, OR, PA, PR, TN, TX, VA, WA, WI