Medicare Advantage DSNP Plans for 2025

Understanding the Possible Changes to DSNP Plans

DSNPs will likely be tailored to enhance coverage and coordinate care for individuals enrolled in both Medicare and Medicaid, commonly referred to as dual-eligibles. This population may be recognized for having high costs and special care needs.

Embracing this challenge, CMS may propose potential policy updates that might aim to:

• Streamline processes

• Align benefits

• Lower enrollment thresholds

• Enhance appeal rights for DSNP members

This proactive strategy might lead to substantial improvements in the quality of care and service delivery.

Some of these proposed changes may also be timely, considering the growing interest in D-SNPs. Over the past few years, D-SNP enrollment has witnessed about a 60% growth rate, outpacing the 38% growth in non-SNP plans.

Given this trend, these potential policy updates might have a broader impact, possibly reshaping the healthcare experience for a large number of dual-eligible beneficiaries.

Some of these proposed policy updates may also span across several areas – from potentially increased integration with Medicaid services and adjustments to enrollment thresholds to enhanced appeal rights for DSNP members. Each of these areas will likely bring unique advantages and opportunities, as well as improved care outcomes for dual-eligible individuals.

Possible Integration with Medicaid Services

To potentially provide dual-eligible individuals with more integrated care, CMS may propose measures that might increase the percentage of dual-eligible Medicare Advantage enrollees who could receive integrated Medicare and Medicaid services. This could potentially streamline the processes and possibly provide more opportunities for enrollment in integrated plans.

One such measure may be the potential revision of the current quarterly special enrollment period to a monthly opportunity. This might allow those receiving low-income subsidies, including the dual-eligible members, to elect an integrated Dual Eligible Special Needs Plan.

Additionally, some D-SNPs may be required to have contracts with state Medicaid agencies that meet the integration requirements and may even establish unified appeals and grievance processes.

By potentially simplifying the coordination of coverage for individuals eligible for both Medicaid and Medicare, CMS will likely aim to overcome challenges posed by separate financing and administrative structures.

Adjustments to DSNP Enrollment Thresholds

Another area of focus for these potential policy updates may be the adjustment to DSNP enrollment thresholds. By potentially lowering these thresholds for D-SNP look-alikes, the CMS could aim to enhance the quality of care and service delivery for dual-eligible individuals.

The CMS might propose a phased approach, which may reduce the enrollment threshold from 80 percent to 70 percent in 2025, with a further reduction from 70 percent to 60 percent in 2026. This possible progressive lowering of thresholds may be designed to ensure that dual-eligible individuals could choose the most integrated product type available, possibly maximizing the potential benefits of their coverage.

Enhanced Appeal Rights for DSNP Members

Recognizing the importance of fair and effective appeal processes, CMS may also propose to align certain Medicare Advantage plan regulations with those of Traditional Medicare, which may ensure that traditional Medicare beneficiaries could experience enhanced enrollees’ appeal rights for non-hospital service coverage terminations.

Under the proposed ruling, Quality Improvement Organizations may also be allowed to review untimely fast-track appeals regarding the termination of services in home health agencies, comprehensive outpatient rehabilitation facilities, and skilled nursing facilities for MA enrollees.

Additionally, MA enrollees may also no longer forfeit their right to appeal the decision to terminate services if they leave the facility before the initially planned termination date. This potential extension of appeal rights stems from policy developments that will likely be initiated by the Bipartisan Budget Act of 2018, which directed unifying Medicare and Medicaid appeals processes for D-SNPs.

Streamlining DSNP Operations

Efficiency and accuracy in operations may be paramount in healthcare delivery. To this end, CMS might want to standardize the Risk Adjustment Data Validation (RADV) appeals process for Medicare Advantage (MA) plans.

The goal will likely be to enhance payment accuracy and performance measurements, possibly streamlining DSNP operations.

Additionally, CMS may also implement new contracting standards for D-SNP look-alikes. This may ensure that they could meet similar requirements to D-SNPs, which may further reinforce the integrity of these plans.

By taking on the responsibility for coordinating care and bearing risk for Medicare and, in some cases, Medicaid spending, D-SNPs will likely play a crucial role in managing the care for the dual-eligible population.

Risk Adjustment and Data Validation Reforms

To enhance payment accuracy and performance measurements, CMS might propose the standardization of the RADV appeals process for MA plans. This standardization may be a key component of the potential reforms that may be initiated to improve the operational efficiency of DSNPs.

Under some of these proposed rules, Medicare Advantage organizations will likely need to follow a sequential approach when appealing medical record review determinations and payment error calculations

This could potentially ensure a transparent and thorough review process, possibly enhancing the accuracy of payments and the overall performance of DSNPs.

Contracting Standards for DSNP Look-Alikes

To maintain the standard of care provided to dual-eligible individuals, CMS may propose to implement new contracting standards for D-SNP look-alike plans. Some of these standards may ensure that look-alike plans meet requirements similar to those of D-SNPs, possibly guaranteeing a consistent level of service provision.

Some of these potential standards may include a phased reduction in the D-SNP look-alike threshold from 80% to 70% in 2025 and then further to 60% by 2026. This gradual lowering of the threshold will likely ensure that the quality of care provided by these look-alike plans might be maintained while also allowing for the possible integration of more dual-eligible individuals into the most suitable product type.

Enhancing Health Equity in DSNPs

In the pursuit of healthcare excellence, equity will likely be key. Recognizing this, CMS may also propose measures that could enhance health equity in DSNPs. This may include an annual health equity analysis of certain utilization management policies and procedures for DSNPs.

The proposed health equity analysis would likely need to incorporate specified metrics. These metrics may include denial rates, appeal overturn rates, and determination turn-around times. The CMS may also want input on which enrollee groups, items, or services should be further analyzed for health equity, particularly in terms of utilization management policies.

The performance of D-SNPs may also have significant implications for health equity; given that a significant proportion of D-SNP enrollees may be Black, Hispanic, or other people of color, the interaction between utilization management policies and social risk factors might become particularly salient. Therefore, these proposed measures could play a crucial role in addressing disparities and promoting health equity.

Annual Health Equity Analysis Mandate

To better serve traditionally underserved individuals, which may form a significant number of D-SNP enrollees, CMS might mandate an annual health equity analysis. This potential mandate could be an important step towards understanding and addressing the disparities that might exist within the healthcare system.

Through this potential analysis, D-SNPs could gain valuable insights into how their services may be utilized by different populations. This information may then be used to tailor interventions and policies that could better meet the needs of these groups, possibly improving health outcomes and promoting equity.

Addressing Social Risk Factors

In addition to the annual health equity analysis, CMS may also aim to address social risk factors and possibly enhance care coordination for dual-eligible individuals, particularly those of color.

To address some of these potential social risk factors, CMS may also authorize payments for services like Community Health Integration and Principal Illness Navigation which will likely be provided by community health workers and peer support specialists.

These services may be particularly beneficial in instances when social needs might pose challenges to healthcare provision. By addressing these potential factors, CMS could potentially ensure that heightened coverage and management strategies may result in fair and equitable care for all dual-eligible individuals.

Fostering Transparency and Beneficiary Protection

Some of CMS’s proposed changes for 2025 may focus on measures that could:

• Bolster beneficiary protections

• Improve access to behavioral health care

• Enhance equity in coverage

• Expand supplemental benefits

These potential measures may include implementing enhanced ‘guardrails’ for agent and broker compensation and possibly ensuring transparency through the notification of unused supplemental benefits.

CMS may also propose to implement enhanced ‘guardrails’ for agent and broker compensation that might set upper compensation limits, possibly reinforcing protections for beneficiaries. Some of these potential restrictions may ensure that the various incentives of agents and brokers may not negatively impact Medicare beneficiaries.

Furthermore, CMS may also try to foster transparency by proposing that some Medicare Advantage plans should issue a ‘Mid-Year Enrollee Notification of Unused Supplemental Benefits’ annually. This potential notification will likely serve to encourage better utilization of supplemental benefits, possibly maximizing the benefits for beneficiaries.

Notification of Unused Supplemental Benefits

To potentially promote transparency and encourage the utilization of special supplemental benefits, CMS might propose that some Medicare Advantage plans should issue an annual ‘Mid-Year Enrollee Notification of Unused Supplemental Benefits.’ This notification, which will likely be personalized to each enrollee, may list supplemental benefits that might not be accessed during the first six months of the year.

The notification may include:

• A detailed description of each benefit

• Cost-sharing details

• Instructions on accessing the benefit

• Any network application information for each available benefit

• A customer service number for additional assistance

By providing a comprehensive list of unused benefits with relevant details, the mid-year notification has been intended to encourage better utilization of the DSNP supplemental benefits that may be underutilized.

Regulation of Agent and Broker Compensation

To potentially enhance beneficiary protections, CMS may also propose to redefine ‘compensation’ for agents and brokers. The proposal might aim to set a uniform rate across Medicare Advantage enrollments.

The proposal may also aim to generally prohibit certain contract terms that might result in volume-based bonuses or incentives for agent and broker enrollment into specific Medicare Advantage plans. This could potentially ensure that financial incentives may not lead to anti-competitive steering.

Additionally, some of these potential rules may lead to administrative payments that were previously considered separate from compensation to be classified under the same regulatory limits as commissions. This might prevent circumventing established caps and possibly ensure fair compensation practices.

Summary

As this article has explored some of the proposed changes for DSNP plans in 2025, it may be evident that CMS may try to make concerted efforts to improve care coordination and access for dual-eligible enrollees. From potentially increasing integration with Medicaid services and possibly adjusting DSNP enrollment thresholds, to enhancing appeal rights for DSNP members, some of CMS’s proposed changes may provide significant transformation for dual-eligible beneficiaries.

Furthermore, the proposed measures that may be aimed at streamlining DSNP operations, enhancing health equity, and fostering transparency and beneficiary protections could serve to create a more efficient and equitable healthcare system.