Major Changes in D-SNP Policies for 2025

The Centers for Medicare & Medicaid Services (CMS) plans to increase the average Medicare Advantage (MA) payments for 2025. This increment aims at maintaining stable premiums and benefits for D-SNP enrollees.

The move is part of a larger strategy to ensure the financial stability of these programs, including the Medicare Cost Plan Program, for the benefit of dual-eligible individuals, who are enrolled in both Medicare and Medicaid.

At the same time, we expect D-SNPs to undergo operational changes. These include enrollment restrictions that limit membership to individuals who are enrolled in both Medicare and Medicaid. These changes, which are part of a broader shift taking effect from 2023 to 2025, aim to ensure that the dual-eligible population is adequately catered for.

While the increase in MA payments and operational changes form the cornerstone of the 2025 D-SNP policies, there may be other significant changes on the horizon. Some of these may include the expansion of fast-track appeals rights and the integration of Medicare and Medicaid services.

Expanding Fast-Track Appeals Rights

To bolster patient rights, CMS intends to broaden the fast-track appeals process. The goal is to bring these processes more in line with those of traditional medicare. This alignment extends to appeal rights for ending coverage of services provided by home health agencies, skilled nursing facilities, and comprehensive outpatient rehabilitation facilities.

Under the proposed rule, a Quality Improvement Organization (QIO) rather than the MA plan would review untimely appeals for terminated services in specific non-hospital settings. This shift aims to mirror the procedures of Traditional Medicare.

The proposed rule also seeks to eliminate the existing forfeiture rule. The intention is to ensure that MA beneficiaries do not forfeit their right to appeal, regardless of whether they remain in or exit the healthcare facility. These changes represent a significant step towards ensuring that MA beneficiaries have the same access to appeals as Traditional Medicare beneficiaries.

Integration of Medicare and Medicaid Services

The integration of Medicare and Medicaid services in D-SNPs represents a significant policy shift. This integration aims to address challenges like:

• fragmented care

• poorer health outcomes

• higher health spending

• incentives for shifting costs to the Medicare program

By offering a unified set of benefits and a single contact point for care, the integration simplifies the healthcare experience for dual-eligible individuals.

Another major advantage of this integration is improved data sharing between Medicare and Medicaid. This enhanced data sharing can facilitate informed decision-making in patient care and better allocation of resources.

Indeed, the integration of Medicare and Medicaid services in D-SNPs is poised to bring about sweeping changes to the healthcare landscape, with beneficiaries standing to reap significant benefits from these reforms.

Lowering the D-SNP Look-Alike Threshold

Addressing the proliferation of plans that serve a high percentage of dual-eligible individuals without meeting D-SNP requirements, CMS plans to decrease the D-SNP look-alike threshold.

To accommodate smaller or newer plans, those active for less than a year or those with 200 or fewer enrollees would be exempt from the proposed D-SNP look-alike threshold.

The lowering of the D-SNP look-alike threshold represents a meaningful step towards ensuring that plans adhere to D-SNP requirements. This move is expected to bring about greater consistency and fairness in the provision of benefits to dually eligible individuals.

Enhancing Behavioral Health Access in D-SNPs

Recognizing that access to behavioral health services is a vital part of comprehensive healthcare, CMS plans to establish a new category, ‘Outpatient Behavioral Health.’ This new category, designated as a facility-specialty type, is designed to improve Medicare Advantage enrollees’ access to a wide range of behavioral health providers.

The proposal includes updates to network adequacy standards to incorporate ‘Outpatient Behavioral Health.’ This change will expand the network to include clinical psychology, clinical social work, and marriage and family therapists, aligning with the need to provide comprehensive behavioral health care.

Additionally, CMS is incentivizing the inclusion of telehealth providers in Medicare Advantage networks. A 10% credit will be offered for services provided by contracted telehealth providers specializing in outpatient behavioral health.

These behavioral health care providers can include clinical psychologists, licensed clinical social workers, mental health counselors, and community mental health centers.

These proposed changes stand to significantly enhance access to behavioral health services for Medicare Advantage enrollees. The inclusion of a broader range of providers, coupled with the incentivization of telehealth services, represents a significant step towards improving behavioral health outcomes for beneficiaries.

Standardizing the MA Plan Risk Adjustment Data Validation Appeals Process

CMS has been focusing on standardizing and simplifying the Medicare Advantage Plan Risk Adjustment Data Validation (RADV) appeals process. The goal is to simplify the resolution of disputes related to risk adjustment data.

Under the new process, MA organizations will be required to go through all levels of appeal for medical record review determinations before they can appeal payment error calculations. This change aims to organize the process and reduce back-and-forth appeals.

The Secretary will issue revised audit reports with recalculated payment error calculations when a medical record review determination appeal or a payment error calculation appeal is final. This process will provide a more accurate assessment of the payment errors. This move enhances transparency for the MA organizations.

The standardization of the RADV appeals process ensures:

• Fair and consistent application of rules and procedures to all MA plans, including D-SNPs

• Elimination of variability in outcomes across different plans

• A more equitable system for all

Health Equity Analysis of Utilization Management Policies

To promote equitable treatment of all beneficiaries, CMS plans to conduct an annual health equity analysis of Utilization Management policies. This analysis aims to identify disproportionate impacts on underserved populations.

The results of the annual health equity analysis of Medicare Advantage plan organizations must be publicly available on their websites, promoting transparency. The health equity analysis is specifically designed to flag any disparities in the effect of Utilization Management policies on certain enrollees, such as those eligible for the Part D low-income subsidy, dually eligible beneficiaries, or those with disabilities.

To facilitate this analysis, Medicare Advantage plan organizations are required to conduct an annual health equity analysis through their Utilization Management committee. This analysis must include scrutiny of prior authorization policies and actions.

This proposed rule represents a significant step towards ensuring health equity across Medicare Advantage plans.

Contracting Strategies for Coordinating Medicare and Medicaid Benefits

States are currently employing strategies to enhance care coordination for dual-eligible individuals. These strategies involve Medicaid-managed care contracts that require Medicare coordination and various integration incentives.

For instance, the Financial Alignment Initiative (FAI) represents an integration effort across nine states and CMS.

To enhance the integration of Medicare and Medicaid benefits, 29 states have specific requirements for D-SNPs. These include offering supplemental benefits that align with Medicaid and coverage of long-term services. D-SNPs are advised to understand the complex socio-economic factors that influence service utilization among dual-eligible beneficiaries to better tailor outreach and retention strategies, while also considering the potential impact of unused supplemental benefits.

Future Outlook: Increasing Coordination between Medicare and Medicaid

The future promises beneficial changes as CMS and policymakers strive to improve care for dual-eligible individuals. These changes aim to:

• Improve coordination between Medicare and Medicaid

• Enhance integration requirements among existing D-SNPs

• Pursue new strategies to facilitate compliance with recent Medicare program changes.

However, incorporating state flexibility into these integrations remains a challenge. Solutions must balance the need for universal access across all states with the desire to maintain state-specific approaches to care coordination.

Bipartisan policymakers, including Senators Bill Cassidy, Tom Carper, John Cornyn, Bob Menendez, Tim Scott, and Mark Warner, are actively involved in dialogues to enhance the integration requirements for D-SNPs. Their efforts are driven by feedback from healthcare providers and patient communities, which has highlighted problems with fragmented care and poorer health outcomes for dual-eligible individuals.

Summary

In summary, the proposed changes to D-SNP policies for 2025 represent a significant step towards improving healthcare outcomes for dually eligible individuals. These changes are expected to bring about meaningful improvements for beneficiaries.

As we look to the future, the continued efforts of policymakers offer a promising outlook for increased coordination between Medicare and Medicaid, ensuring an even better healthcare experience for dual-eligible individuals.