Month: May 2022

COVID-19 has highlighted weaknesses in our healthcare system and shone a spotlight on fault lines, especially for the most clinically and socially vulnerable like the dual-eligible special needs populations (D-SNPs). Those who are dually eligible for Medicare and Medicaid are amongst the sickest and most clinically complex with more than half of this population having significant medical, behavioral health, and long-term care needs. These health issues along with social risk factors like poverty, food insecurity, housing instability, and lack of transportation have been disproportionately magnified for this cohort during the pandemic.

Some of the most challenging aspects of healthcare including gaps in care, a highly fragmented system, and lack of coordination between Medicare and Medicaid have worsened as a result of COVID-19. According to the Center for Health Care Strategies, data examined across every demographic category finds that dually eligible individuals are more likely to contract or be hospitalized for COVID-19 than Medicare-only beneficiaries. In the dually eligible beneficiary cohort, hospitalizations with COVID-19 related complications were tracked at a rate more than four times higher than Medicare-only beneficiaries according to the data.

For those health plans serving D-SNP programs, a technology platform for end-to-end care management and population health is critical. Platforms like HealthEdge’s GuidingCare enable plans to deliver a customized model of care that not only meets the needs of a D-SNP population but also enables the plan to be compliant with state and federal regulations. The right D-SNP managed care platform can:

• Create automated and customized care plans
• Manage compliance reporting accurately and efficiently for all required activities
• Schedule and perform interdisciplinary care team meetings
• Leverage social determinants of health (SDOH) connections
• Improve member engagement
• Enable easy updates for changing state and federal regulation requirements

GuidingCare is a next-generation care management platform that meets all these needs and more.  For health plans serving D-SNP populations, GuidingCare has a proven track record for meeting the needs of this challenging population. HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations. The GuidingCare platform integrates with both findhelp and Healthify to seamlessly connect members with services they need to address SDOH challenges. Plans that rely on GuidingCare can maximize coordination and member engagement for improved STAR ratings, better health outcomes, and increased member satisfaction.

Now more than ever, the challenges and demands on health plans serving the D-SNP populations is even more emphasized and urgent – at both the state and federal level. These health plans must adopt an efficient and effective care management platform, not only to meet the needs of its population, but also to remain competitive.

Hear from Jennie Giuliany, RN, HealthEdge’s Lead Clinician, Client Management and GuidingCare client Commonwealth Care Association in the April ACAP webinar.

As the dual eligible population grows, Dual Eligible Special Needs Plans (D-SNPs) are also experiencing tremendous growth across the country. CMS reports that as of February 2022, D-SNPs are operating in 45 states and have upwards of 3.8 million beneficiaries. The growth is primarily driven by these factors:

• Choice of Medicare Advantage over traditional Medicare due to benefits and population health flexibilities
• Provider understanding of these plan benefits, a common thread of some of the fastest growing new entrants
• Recent increased acceptance of managed care for this population
• State and federal attention on ways to better manage care for vulnerable Medicare beneficiaries
• State and federal policies that embrace well-run managed care, highlighting an opportunity for health plans with existing Medicaid lines of business that are considering expanding into Medicare offerings, including D-SNPs

While growth in D-SNPs is rapid, the offerings across states and health plans vary tremendously due to different requirements at the state level. For example, the differences between a non-fully integrated D-SNP and a fully integrated D-SNP (FIDE-SNP) determine whether Medicaid benefits are going to be fully intertwined and managed by the same managed care entity as the Medicare D-SNP covered services. Depending on which state(s) a plan is operating in, there could be a different paradigm to their approach such as Medicare-Medicare Plan (MMP) in states that opt in to running a three-way contract with CMS as part of the Financial Alignment initiative.

From a plan perspective, understanding what’s essential to the care model and adapting it to resource availability in each state requires having technology in place that enables flexibility. Depending on the state where a plan operates, there will be significant fluctuations in diversity which makes personalization and customization necessary to work in lockstep with state regulators. And regardless of the state, there’s also a certain amount of coordination as specified in state Medicaid agency contracts, such as specific protocols and population health interventions that are part of the CMS model of care proof.

Within the context of modern technology, care management technology is key to improving population health especially as it relates to the D-SNP population. HealthEdge’s GuidingCare is a next-generation technology platform that supports a health plan’s patient-centric model of care and is currently used in 29 states to help manage this complex population. These plans use GuidingCare service plans and script forms to meet the varying requirements in the different markets.

HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations. The GuidingCare platform integrates with both findhelp and Healthify to seamlessly connect members with services they need to address social determinants of health (SDOH) challenges. Plans that rely on GuidingCare can maximize coordination and member engagement for improved STAR ratings, better health outcomes, and increased member satisfaction.

Learn more about GuidingCare for Dual Eligible Special Needs Plans (D-SNP) here.

Within Medicare Advantage (MA), there are Special Needs Plans (SNP) with specialty cohorts that provide coverage for members who qualify for both Medicare and Medicaid. The membership for these Dually Eligible Special Needs Plans (D-SNP) include some of the most vulnerable populations in the United States who have medically complex needs and social risk factors. As a result, this beneficiary group has a higher spend profile due to their end-to-end care management requirements and population health strategies necessary to meet their complicated healthcare needs.

When D-SNPs were introduced in 2006, they were available in just seven states. In 2022, D-SNPs are offered in 43 states and Washington D.C. This year, two new states have joined those offering D-SNPs – Wyoming and South Dakota. As of 2021, the SNP Alliance reported 627 Dual-Eligible SNPs serving 3,133,448 beneficiaries. The growth trajectory for Medicare Advantage will continue more than ever before at any point in history. Combine this with increasing Medicaid enrollment and eligibility growth, and enrollment in dual eligible specialty plans will continue to surge.

While the D-SNP market grows, health plans need a way to help members navigate their complex population health needs. GuidingCare® supports care management and population health services with a 360-degree view of the member that incorporates social determinants of health data. Recent data from the Centers for Medicaid and Medicare (CMS) show that for the D-SNP eligible population:

• 41% have at least one mental health diagnosis
• 49% receive long-term care services and supports (LTSS)
• 60% have multiple chronic conditions

Health plans with Dual-Eligible members must stay compliant with changing regulations while serving this population with complex health needs. GuidingCare provides 280 evidence-based clinical and health status assessments available out-of-the-box or customizable. One in five Medicaid members are managed through GuidingCare, 29 states employ GuidingCare to help manage D-SNP populations, and 14 states use GuidingCare for LTSS.

This solution automatically delivers up-to-date Medicare and Medicaid policies and fee schedules, resulting in lower administrative costs, increased operational efficiency, and improved compliance. Not only does care management lower costs and improve health outcomes, but those plans that execute it well set themselves apart from the competition with improved Star ratings.

Learn more about GuidingCare for Dual Eligible Special Needs Plans (D-SNP) here.