Tackling the D-SNP Complexities in 2023 with Modern, Interoperable Systems

Enrollment in dual-eligible special needs (D-SNPs) care management plans grew by 20% in 2022, increasing from 3.8 million in 2021 to 4.6 million beneficiaries in 2022. This population now represents just 20% of the Medicare beneficiaries, but they make up 34% of the Medicare spending. They also represent 15% of the Medicaid population and account for nearly 1/3 of the spending.

Dual-Eligible Special Needs Plans (D-SNP) are a special kind of Medicare Advantage Plan for dual-eligible individuals who qualify for both Medicare and Medicaid and Part D coverage.

With such growth in this population comes a growth in the number of health plans serving these complex beneficiaries, with hundreds of health plans now supporting one or more D-SNP populations.

However, the complexities of the dual-eligible experience, from a medical and social perspective, coupled with the highly fragmented nature of Medicare and Medicaid systems, often presents significant care coordination challenges that health plans must be prepared to address.

In addition to the high prevalence of issues such as high food insecurities, behavioral health issues, and cognitive impairment, most D-SNP members live in rural communities that can have limited access to proper healthcare professionals, as well as limited access to broadband services. Other challenges health plans must be prepared for include the ever-evolving regulatory environment that exists at both the federal and individual state levels.

With the modifications CMS made in its 2023 Final Rule, it’s now more important than ever for health plans to have a modern, flexible, and highly interoperable infrastructure, including:

• Robust care management platform
• Flexible and configurable CAPS
• Modern member engagement solutions

Track Record of Success

HealthEdge has supported health plans that service government-covered lives for decades, including those who cover D-SNP. For example, Eldercare, the only 5-star Medicaid Advantage Plus (MAP) plan in New York State, uses HealthEdge’s care management platform, GuidingCare^®.

According to Craig Azoff, Senior Vice President, Health Plan Information Services, “Elderplan specializes in intense, complex care management of our membership, and GuidingCare supports these care management goals as well as our compliance goals, as far as STARS ratings, HEDIS scores, and other initiatives.”

Here are a few additional samples of success stories health plans have experienced by turning to HealthEdge:

• Customer Spotlight 1: The midwestern state was looking to reduce the number of Medicated Managed Care Organizations by one third, and the health plan had to prepare to recompete for its Medicaid business, which represented a significant portion of its members. Its outdated legacy care management system could not accommodate the ever-increasing complexities of state requirements.
  • The solution: GuidingCare + Mobile Clinician + HealthEdge’s years of experience with safety net plans.
  • The results: The plan won the bid with advanced care management capabilities and mobile clinician in addition to HealthEdge’s years of experience with safety net plans.

• Customer Spotlight 2: This health plan needed to transform its operations to reduce operational inefficiencies and eliminate redundant manual tasks. The team was challenged with 30-40% of incoming claims being marked with a pricing inquiry or set up to require manual pricing.
  • The solution: Source payment integrity platform designed to manage both claims pricing and editing in one place using the latest regulatory data.
  • The results: Reduced repetitive building, reduced dollars spent on maintenance, generated six-figure range in annual savings, reduced the number of claims requiring rekeying by 40%, generated 25% savings over previous processes by eliminating hundreds of manual tasks.
  • “The biggest benefit we have seen from Source is the capability it has to do one-stop pricing and editing. When it comes to building and managing claims, I never want to go back to anything else.” – Director of Policy and Editing
• Customer Spotlight 3: This independent, non-profit health plan serving more than 2 million customers, was seeking to deliver more human-centric experiences for members, providers and staff. Other goals for the team included: identify and act on operational inefficiencies; gain a more comprehensive view of member services; and bring new solutions to the market faster.
  • The solution: HealthRules ® Payer + GuidingCare® + Source
  • The Results: Average auto-adjudication rates increased from 50% to 80%, ease of configurability improved speed-to-market and ability to identify sustainable savings, integration between HealthEdge systems delivered new opportunities for automation of manual processes, and greater access to authorization data across systems is reducing gaps in care.
  • “HealthEdge understands the everyday challenges we face, like manual processes, workflow inefficiencies, and data disparity. They are bringing solutions to the table that address those challenges and facilitate greater integration across our claims, care management, and payment platforms because they are now all under one roof. HealthEdge is the source that is fueling our digital strategy.” Staff VP of the Advancement Office

• Customer Spotlight 4: This Pittsburg-based managed care plan servicing more than 534,000 Medicaid and Medicare beneficiaries across Pennsylvania and Delaware was looking for a better way to effectively and affordably deliver government member services while maintaining high levels of quality care. The team knew they needed to become more agile to keep pace with complex and rapidly changing federal regulations and state issued mandates, reduce the overhead costs associated with financial reconciliation for provider payments, as well as correct issues related to managing maximum out-of-pocket, claims tied to duplicate providers, and mismatches between old and new contacts
  • The solution: HealthRules Payer + GuidingCare + Source
  • The results: Improved auto-adjudication rates 50%-93% through better authorization matching capabilities and more accurate pricing, increased the volume of electronic claims submissions, and improved business agility through the use of advanced benefit, and improved payment accuracy through the seamless integration of HealthRules Payer and GuidingCare
  • “As a user of multiple HealthEdge products, we see tremendous value in the tight integration between the platforms. Things like being able to match on authorizations can not only help streamline care management, but also improve payment accuracy to facilitate better relationships with our providers.” — Director of Strategy & Operations

Health plans serving D-SNP members need a comprehensive, highly interoperable platform for end-to-end care management and population health that is effective at simultaneously reducing overall costs and improving care, while ensuring the plan is compliant with state and federal regulations.

To learn more about how HealthEdge solutions can help your organization address the unique challenges of D-SNP, visit the Dual Eligibles page on the HealthEdge website.