Medicare Advantage dual eligible special needs plans aligned with Medicaid managed long-term services and supports

Dually Eligible Beneficiaries

Medicaid managed long-term services and supports (MLTSS) programs have become more prevalent. In 2017, 24 states operated MLTSS programs, up from 8 in 2004 (Lewis et al. 2018).

States may integrate care for dually eligible beneficiaries enrolled in their MLTSS programs with Medicare Advantage’s dual eligible special needs plans (D-SNPs). Originally authorized as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, P.L. 108-173), D-SNPs began operating in 2006. Legal authority was extended several times and made permanent in the Bipartisan Budget Act of 2018 (P.L. 115-123). As of March 2018, D-SNPs were operating in 42 states and the District of Columbia with about 2 million dually eligible beneficiaries enrolled (CMS 2018).

A state that aligns its MLTSS program with a D-SNP typically requires either the D-SNP to operate a companion MLTSS plan or the MLTSS plan to offer a D-SNP. D-SNPs are required to contract with states but states are not required to contract with D-SNPs (Verdier et al. 2016). The contracts must cover eight minimum MIPPA requirements, including:

  • the Medicare Advantage organization’s responsibilities—including financial obligations—to provide or arrange for Medicaid benefits;
  • categories of eligibility for dually eligible beneficiaries to be enrolled under the D-SNP, including the targeting of specific subsets;
  • Medicaid benefits covered under the D-SNP;
  • cost-sharing protections covered under the D-SNP;
  • information about Medicaid provider participation and how that information is to be shared;
  • verification process of an enrollee’s eligibility for both Medicare and Medicaid;
  • service area covered under the SNP; and
  • period of the contract.

Fully integrated dual eligible special needs plan (FIDE-SNP).  FIDE-SNPs fully integrate care for dually eligible beneficiaries under a single managed care organization. FIDE-SNPs were enacted by the Patient Protection and Affordable Care Act (P.L. 111-148, as amended) and permanently authorized, along with regular D-SNPs, in the Bipartisan Budget Act of 2018 (P.L. 115-123). They must have a contract with the state Medicaid agency that complies with the MIPPA requirements above and includes coverage of primary, acute, and long-term services and supports benefits. FIDE-SNPs may be eligible for a payment adjustment to account for the cost of serving a high concentration of frail individuals, depending on their enrollees’ risk scores.