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California Duals: Curating Competitive D-SNP Offerings with GuidingCare Care Management Software

The healthcare landscape in California is undergoing a significant transformation as part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative. A pivotal change involves the transition from Medicare-Medicaid Plans (MMPs) to Dual Eligible Special Needs Plans (D-SNPs). By 2026, health plans operating in California must make competitive D-SNP offerings available for those eligible for both Medicare and Medicaid coverage. The goal is to enhance integrated and coordinated care for dual-eligible member populations, who are among the highest-risk and have the most complex care needs.

These shifting regulations give health plans a huge opportunity to reach more members more effectively. In 2023 alone, 5.2 million individuals enrolled in a Medicare Advantage plan designed for dual-eligible individuals—a 13% increase from 2022. How is your organization preparing for these changes? And how can your vendors work with you to ease this transition?

What are the requirements of Dual Eligible Special Needs Plan (D-SNP) offerings?

D-SNPs are specialized Medicare Advantage plans designed to provide tailored health coverage for individuals eligible for both Medicare and Medicaid. Those who qualify for D-SNP plan coverage are among the most vulnerable member populations. Often, D-SNP members live in rural areas, are older than age 65, or have cognitive impairments.

As the administrative complexities surrounding D-SNPs increase, healthcare organizations must adapt to meet new requirements and ensure optimal care for this vulnerable population.

Use CalAIM Strategies to Inform D-SNP Offerings

Not sure where to start when it comes to competitive D-SNP offerings? For an example of effective strategies that support high-risk member populations, look at what payers are currently doing to support Medi-Cal members under CalAIM.

CalAIM initiatives fall into four categories: Shifting to Population Health Management, Standardized Managed Care Benefits, Mandatory Medi-Cal Managed Care Plan Enrollment for Dual-Eligibles, and Behavioral Health System Transformation. Understanding each of these areas can help your health plan get started on creating competitive D-SNP offerings that are effective and support members’ whole health.

As new requirements emerge, payers will have to stay flexible so they can adapt to new demands and shifting member needs.

Streamline D-SNP Care Management with GuidingCare®

Health plans that serve D-SNP members need an integrated solution for care management and population health. Holistic platforms like GuidingCare can streamline care delivery, improve clinical outcomes, and reduce costs—while ensuring state and federal regulatory compliance.

GuidingCare can also help improve member satisfaction and outcomes by providing coordinated care and ongoing encouragement from their care teams. Care managers can also uncover and leverage social determinants of health (SDOH) information to address barriers to healthcare access and other needs.

1. Enhanced Care Coordination

Effective care coordination is crucial for managing D-SNPs. GuidingCare facilitates seamless communication between healthcare providers, payers, and patients to advance care management. This integrated approach ensures that all stakeholders are on the same page, enhancing the overall quality of care and reducing the risk of errors or omissions.

2. Compliance Management

Navigating the regulatory landscape can be daunting. GuidingCare offers robust compliance management features and a regulatory support team with clinical expertise that help organizations stay ahead of new requirements and maintain compliance. The platform continuously updates to reflect the latest regulations, ensuring that healthcare payers and executives can focus on patient care instead of administrative tasks.

3. Data-Driven Insights

In an industry where data drives decisions, GuidingCare provides actionable insights through advanced analytics and business intelligence. These insights enable healthcare organizations to identify trends, track performance, and make informed decisions that enhance patient outcomes and operational efficiency.

4. Population Health

The GuidingCare solution features a stratification rule that helps health plans identify members with specific health conditions as well as provide risk scoring and offer patient management suggestions. In addition, GuidingCare users have access to advanced gaps-in-care analytics that flag high-risk members, making it easier for care teams to prioritize clinical interventions.

Comprehensive Reporting and Dashboards Deliver Key Clinical Insights

In addition to surfacing SDOH insights, GuidingCare offers near-real-time reporting and integrated dashboards with business intelligence capabilities that empower care teams to make more informed decisions, faster.

Access multi-layered analytics capabilities, including:

  • Interactive dashboards with custom views
  • Download and export capabilities
  • Access to more than 20 CMS reports covering ODAG, CDAG, and Part C/D needs
  • Audit and annual reporting support
  • Front end/database/source documentation

GuidingCare also offers ongoing training to make sure health plans are making the best use of the platform and taking full advantage of the tools available.

Preparing for the D-SNP transition: Strategic Steps

To effectively leverage GuidingCare® for managing D-SNP offerings under CalAIM, healthcare payers and executives should consider the following strategic steps:

  1. Evaluate Current Systems: Assess the existing care management systems and identify gaps that can be addressed by GuidingCare® solution suite.
  2. Training and Development: Invest in dynamic, self-paced training to ensure that staff understand GuidingCare benefits and are proficient in using available tools.
  3. Integration Planning: Develop a detailed integration plan that outlines how GuidingCare® will be incorporated into existing workflows and systems.
  4. Continuous Improvement: Establish a feedback loop to continuously monitor the platform’s performance and identify areas for improvement.

The transition from MMPs to D-SNPs under the Medi-Cal program is a significant step towards achieving a more integrated and coordinated healthcare system in California. By leveraging GuidingCare®, healthcare payers and executives can navigate this transition smoothly, ensuring compliance with new requirements while enhancing care quality and patient satisfaction. Embracing this change is not just about meeting regulatory demands; it’s about pioneering a future where healthcare is more inclusive, efficient, and patient-centered.

Is your health plan ready to build innovative and competitive D-SNP offerings for your dual-eligible members?

To learn more about how health plans are using GuidingCare to drive engagement and improve clinical outcomes, watch our on-demand ACAP webinar: Leveraging Clinical Expertise and Compliance Support to Serve Your Most Vulnerable Members.