By Will Dede, MPP, Associate Director Health Policy, SNP Alliance

January 2022 – Let me introduce you to Gladys. She is an 82-year-old female with poorly controlled diabetes, chronic lung problems, and early kidney disease. Add in “low income” and qualification for Medicaid and you have 70% of the population dually eligible for Medicare and Medicaid. Now it’s time for our 82-year-old beneficiary with three chronic conditions to manage her Medicare and Medicaid benefits and services.

Beneficiaries dually eligible for Medicare and Medicaid have more chronic conditions, increased social determinant of health (SDOH) risks, and the need to manage benefits and services from two independent, misaligned programs. Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage organizations (MAOs) that integrate Medicare and Medicaid benefits and services to varying degrees under one health plan.

While not all D-SNPs furnish Medicaid benefits and services, all D-SNPs are required to assist beneficiaries with navigating and coordinating their Medicaid services, even when beneficiaries have a different health plan for some or all of their Medicaid services—also known as unaligned enrollment. D-SNPs that have beneficiaries with unaligned enrollment are still required to assist enrollees in their navigation of the delivery system. In short, if a beneficiary with unaligned enrollment comes to a D-SNP for assistance with their Medicaid, the D-SNP is required and obligated to assist that beneficiary toward resolution of their issue.

Full integration, when Medicare and Medicaid services are under one health plan, provides the most value and care coordination to enrollees. Under such full integration the medical, support services, and even behavioral health services can be coordinated, based on the person’s unique needs.

Whether a fully aligned D SNP, or an “unaligned” plan, beneficiaries still obtain substantial care management and assistance by simply being enrolled in a D-SNP.

In addition to integrating Medicare and Medicaid services, D-SNPs have a requirement to include a Model of Care (MOC) for meeting the needs of their enrollees. MOCs are submitted to the National Committee for Quality Assurance (NCQA) to assess four clinical and non-clinical standards: 1) a description of the SNP population; 2) care coordination; 3) the provider network; and 4) MOC quality measurement and performance improvement. To meet these four standards, there are 15 elements (listed below) that SNP MOCs must have and address to ensure health status is monitored, chronic diseases are managed, inappropriate hospitalizations are avoided, and beneficiaries’ health status is maintained or improved.

Elements of the Model of Care

Due to D-SNPs being the primary platform and model for integrating Medicare and Medicaid, and as the only Medicare Advantage organization with an MOC requirement, D-SNPs are indeed special. The combination of integration and MOCs makes D-SNPs the proper enrollment option for a population that has more complex care and SDOH needs than other populations. As noted earlier, 70% of the population dually eligible for Medicare and Medicaid have three or more chronic conditions, in addition to low-income status and therefore qualification for Medicaid. Clearly our 82-year-old beneficiary with poorly controlled diabetes, chronic lung problems, early kidney disease, and qualification for Medicaid would benefit from Medicare-Medicaid integration and a person-centered approach to care.

About the Author

Will Dede is the Associate Director of Health Policy at the SNP Alliance, a national leadership association for special needs and Medicare-Medicaid plans serving vulnerable adults. As Associate Director of Health Policy, Will where oversees administrative and operational activities, provides strategic advice on regulatory and policy matters to SNP Alliance members, and works with the SNP Alliance government relations team to advance SNP Alliance legislative and regulatory priorities.

Will joined the SNP Alliance from Duty First Consulting, where he supported the Center for Medicare and Medicaid Services (CMS) in its administration and oversight of the Affordable Care Act. During his time there, Will supported the state technical assistance team’s oversight of the 39 state Exchanges using the federal platform HealthCare.Gov by working directly with those state governments. Will provided these 39 states policy and operational guidance with matters related to the certification of Qualified Health Plans intended to be sold on HealthCare.Gov.

Will holds a Bachelor of Arts with a double-major in Political Science and History from Randolph College and a Master of Public Policy from American University.