In the CY 2023 Final Rule, CMS made several changes that directly impact plans offering Dual Eligible Special Needs Plan (D-SNP) programs, which are a type of Medicare Advantage (MA) plan that are designed specifically for individuals who are eligible for both Medicare and Medicaid.
In general, the 2023 changes are intended to make the D-SNP population more attractive for providers, and therefore increase access to care for these beneficiaries. For payers, these changes are intended to increase clarification regarding different D-SNP programs and reduce the administrative burden of offering separate MA and D-SNP programs. However, many payers are concerned about the impact these changes will have on their bottom lines.
Here are four changes from the 2023 Final Rule that we believe deserve additional consideration.
- Capturing Social Determinants of Health (SDOH) Data
The Final Rule requires D-SNPs to incorporate one or more questions in their standard health risk assessments (HRA) addressing beneficiary housing, food insecurities, and transportation. Acknowledging that many factors other than physical health go into a person’s ability to maintain their health, many physicians have already started collecting this type of information, which is commonly referred to as social determinants of health (SDoH). The goal of taking a more holistic view of a patient’s life, including psychological, functional, and environmental factors, is to increase the likelihood of better health outcomes and lower the total cost of care. Care management teams within many health plans are also on board with collecting SDoH data and are already using this data to tailor services beyond medical benefits to achieve optimal health outcomes. Some care management platforms, like GuidingCare®, have already released capabilities within their platform that help health plans more systematically integrate SDOH into their care management programs.
- Recalculation of the Maximum Out of Pocket (MOOP)
CMS also finalized changes to the way Medicare Advantage plans calculate MOOP, requiring plans to include all cost-sharing, including those paid by secondary payers, in the calculation of the beneficiary’s MOOP. Previously, MOOP was calculated only by the amount the enrollee had to contribute. The result? Beneficiaries are likely to reach MOOP faster, and health plans will have to pay 100% of the service costs sooner. Some industry experts believe this change will result in an additional $4B in costs to health plans, but the improvement in health outcomes and improved access to medical and non-medical care is projected to save $3B. Despite the pushback from health plans on this change, CMS proceeded with the implementation of this and made it effective June 1, 2023. The complexities and urgency of the implementation of this change is a perfect example of why health plans need a modern, highly flexible core administrative processing system (CAPS) like HealthRules® Payer.
- Enrollee Participation in Plan Governance
Medicare Advantage organizations offering a D-SNP must establish one or more enrollee advisory committees in each state to solicit direct input from beneficiaries on their experiences with the plan. Plans that operate D-SNPs in multiple states had to establish multiple committees, one for each state. Although these committees must have a representative sample of the population enrolled in this plan, very little direction was given about the committee meeting frequency, location, format and training.
- Bringing Greater Definition to multiple Types of D-SNPs
Historically, the fully integrated dual eligible (FIDE) and highly integrated dual eligible (HIDE) SNP definitions have been confusing and inconsistent. Through this final rule, CMS is making changes to the definitions, which will support a greater understanding of the different types of D-SNPs, clarify beneficiary options, and improve integration. According to a National Law Review article, this means all FIDE SNPs, with the same legal entity holding the MA and Medicaid contract: 1) be capitated (with certain exceptions) for all Medicaid services, and 2) operate unified grievance and appeal processes. CMS also clarified the definition of HIDE SNPs requiring the plan to cover long-term services and supports, including i) community-based long-term services and supports and some days of coverage of nursing facility services during the plan year; or (ii) behavioral health services. For plan year 2025 and subsequent years, the FIDE and HIDE SNP must cover the entire service area for the dual eligible special needs plan. By helping health plans enroll the appropriate beneficiaries into the right categories and having the ability to create tiered or dual networks, HealthRules Payer enables health plans to quickly spin up whichever type of D-SNP program they believe would be most valuable for the communities they serve.
Turning Mandates into Advantages
While the only constant in government health plans, including D-SNP programs, is change, health plans with a highly configurable CAPS can turn mandates into competitive advantages. For example, health plans using HealthRules Payer now have the opportunity to pursue D-SNP populations with less IT and administrative burdens because the system can be configured to address the unique D-SNP requirements. Health plans don’t have to implement an entirely new system. Things like dual networks and tiered networks are completely configurable in HealthRules Payer. The business flexibility HealthRules Payer gives health plans is unmatched and dramatically lowers the cost of entry into new lines of business.
In addition, the requirement to capture additional data, such as SDoH, is another opportunity for health plans to convert mandates into competitive advantages. With modern data analytics and reporting solutions from HealthEdge, plans can easily turn data into actionable insights that can help drive improved member outcomes, higher HEDIS scores, and better Star ratings. For example, SDoH insights can help care management teams configure new non-medical services, like transportation or meal support, for certain populations. Utilization management data collected can be folded into benefit plan development, and even fed into payment integrity initiatives to minimize provider and member abrasion with more accurate payments.
Looking at the Whole Picture
When regulatory changes such as those mentioned above are put in place, health plans often make the mistake of just looking at the one part of their business that is directly impacted instead of taking an end-to-end approach to implementing the changes across their enterprise. That’s where the professional services team at HealthEdge can be a health plan’s biggest asset. With years of experience in helping government-related health plans properly configure their systems to support regulatory changes, the team knows how to guide health plans through all aspects of the business that may be impacted so that everything from enrollment to claims coming in and payment going out are aligned.
To learn more about how HealthEdge solutions help health plans turn mandates into advantages, visit www.healthedge.com or email [email protected].