Care management for D-SNP populations: The key to compliance and member satisfaction

Dual Eligible Special Needs Plans (D-SNP) are a special kind of Medicare Advantage Plan for people who qualify for both Medicare and Medicaid. This program takes members’ Medicare, Medicaid, and Part D needs and puts them all together into one package to provide an overall healthcare experience.  D-SNP plans are unique in that they provide extra benefits. In addition to Medicare, Medicaid, and Part D coverage, they also help with additional healthcare coverage, including transportation (to doctor visits), dental or vision coverage, and credits to purchase OTC products.

Support for Highest-Need Populations

D-SNP members represent some of the most vulnerable populations in the United States. Health plans serving D-SNP programs need a holistic platform for end-to-end care management and population health that enables their unique Model of Care and keeps them compliant with state and federal regulations.

Best-in-class D-SNP care management platforms hinge on two critical factors: compliance and member satisfaction.


  • Federal & state compliance
  • Compliance reporting
    • ODAG and CDAG Reporting
    • User-friendly documentation management
  • Complex Assessments
  • STARS ratings
  • HEDIS scores

Member Satisfaction

  • Coordination of care and collaboration
  • Coordination of activities of daily living (ADL) needs identified via responses to assessment questionnaire which will generate service plan needs that can automatically feed authorization of such required services.
  • Ongoing communication and engagement
  • Member care plans with intelligent automation and evidence-based goals and opportunities
  • Leverage social determinants of health (SDOH) connections to address nontraditional challenges for improved member outcomes

The right D-SNP managed care platform means better health outcomes and compliance with federal and state regulations.

HealthEdge’s GuidingCare: Next-gen care management platform for health plans with D-SNP

With strong expertise and experience in providing care management and population health services for government-funded payers and plans, HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations.

Nationally, 1 in 5 Medicaid members are managed on GuidingCare. GuidingCare is currently live in 35 states for Medicaid, 29 states for D-SNP, and 14 states for LTSS. Learn more about how GuidingCare supports D-SNP populations here.

Collaboration, Innovation and Reducing Provider Abrasion

We’re two ears, one mouth when listening to customer issues. We are fortunate to work with a variety of health plans ranging from large nationals to small regional plans.

Reducing provider abrasion is top of mind for all plans, particularly for the regional health plans that require cooperation with the providers in their communities to survive.

GuidingCare has made a lot of improvements in provider satisfaction for our regional plans. A big complaint from providers is the time it takes to receive an authorization from a payer. Our prior authorization portal helped solve this issue. With most of our plans using this technology, more than half of the authorizations get auto-approved without human intervention. Providers spend less time waiting for answers with the prior authorization portal; they quickly receive the information they need.

One of our customers is a small regional plan in a state where national plans have a significant presence. Provider satisfaction is critical to ensure our customer can remain competitive. The regional plan came to us with ideas for how to improve the authorization portal. They wanted to bring together their organization, their local health system, and the GuidingCare team to create the best authorization portal in the industry.

As a technology vendor that values our customers, we knew it was an incredible opportunity to hear directly from the health plan and health system to find out what’s important to them then work together to see how our technology can meet their needs.

While this collaboration was not part of the scope of work or implementation plan, we were all in.

We spent three months with a tiger team and built an entirely new best-in-class product. We’ve sold six so far this year, and our customers are finding tremendous success.

For the customer who influenced this innovation, 80% of their authorizations come through the portal, and the majority are automatically approved. They have saved more than 5% of their overall care management budget.

These savings were made possible by listening to our customer’s feedback and innovative ideas, then working together to build them. Collaborating with our customers is a formula for success.

Supporting our Customers from Implementation and Beyond

Difficult implementations have led to the demise of many care management solution vendors. Sometimes success can be a vendor’s worst enemy. If they pick up too many customers and can’t implement them properly, word of that spreads quickly.

We’ve invested a lot in having a successful implementation team. We wanted to make sure that if we win new business, we implement the customers properly so they can stay focused on improving care for their members.

Every customer is assigned an executive sponsor for their implementation, someone on our senior leadership team responsible for the customer relationship and ensuring that we’re meeting their needs.

Each implementation also has a core team that includes a project manager, a business analyst, a clinical subject matter expert, and, most importantly, a solutions architect. The solutions architect looks at the health plan’s overall ecosystem and configures it in the best way for GuidingCare.

The role of the solutions architect is important because health plans today want to seamlessly connect their care management system to other entities in the ecosystem.

Take social determinants of health (SDOH), for example. Care managers need the ability to reach out to an SDOH vendor, such as Unite Us, Healthify or Aunt Bertha, make an appointment for the member on whatever it might be―housing, food, job― without leaving the care management system. Everything must be connected and documented so they can report against it. Or, during an appointment, a care manager may realize a member could benefit from receiving specific content related to their healthcare needs. Without leaving the system, the care manager should be able to reach out to a vendor like HealthWise through the care management platform, gather that information and send it to the member in their preferred format.

Our customers want more integrations, and we’re listening.

Today, we have a developer portal with hundreds of APIs and continue to make new ones every month.

Health plans want a care management platform that is brilliant at the basics and innovative for the future. From the beginning of the implementation, we want our customers to know we will always be there to run to any challenge, support their needs, and continually improve our product.

Enabling the Why

We speak early and often about why we do what we do. We want to help people live the best lives they can, no matter their circumstances. We help care management teams achieve this “why” by offering the latest generation care management system.

It’s all about automation to allow clinical teams to work at the top of their license. For example, our prior authorization portal allows providers to enter a request, and if it passes the criteria, the service is automatically approved without human intervention. Provider satisfaction increases because they don’t need to wait for an answer, and as a result, the care clinicians can spend more time focusing on how they are going to help members live the best lives they can.

When you think about GuidingCare, the name, it should hopefully tell you that it is to guide the care journey—the platform offers evidenced-based next steps the provider should take to ensure the member receives the best care in their journey.

Compliance is another critical piece of care. The Affordable Care Act (ACA) caused the most significant shift in our business. After the ACA, health plans realized that the way to grow their business was through government programs. And, when it comes to government programs, regulations are complex, and compliance has a revenue implication. Take Medicare Advantage (MA), for example. As MA plans seek to grow their businesses, potential members are looking at which plans have the highest star ratings. If a health plan cannot achieve at least four stars in MA, it is very challenging to make it financially.

From the beginning of implementation, we’re focused on compliance. We help the customer avoid configuring their system in a way that would impact their ability to report on compliance, whether they’re NCQA, URAC or have CMS requirements for Medicare Advantage. We help our customers maximize their stars and make sure that they’re successful when they get audited by whatever governing body.

Our customers want to know they’re taking the best next step in the care model, that their people are efficient and working on the things that matter, and that they have the tools for regulatory compliance and reporting. GuidingCare enables all of that, and we’re always enhancing our capabilities.