Important News CMS Rule Impacts [Dual Eligible Plans]

 

The Centers for Medicare & Medicaid Services (CMS) recently finalized a new rule impacting Dual Eligible Special Needs Plans (D-SNPs) for 2025 and beyond. This is significant news for the estimated 13 million Americans who qualify for both Medicare and Medicaid (dually eligible) and are considering a D-SNP for their healthcare needs. But what exactly does this rule change, and how will it affect you? Let's unpack the details and explore the potential implications

In the past, some Medicare Advantage plans attracted a high number of dually eligible individuals without meeting the specific requirements of a D-SNP. These "look-alike" plans could create confusion for beneficiaries and potentially lower the quality of care

The new rule addresses this by lowering the threshold for what qualifies as a look-alike plan. Previously, a non-D-SNP plan with 80% or more of its members being dually eligible was considered a look-alike. This threshold drops to 70% in 2025 and 60% in 2026. This change aims to incentivize these plans to formally become D-SNPs, ensuring they comply with stricter quality and integration standards specifically designed to benefit dually eligible individuals. .

D-SNPs offer several advantages over traditional Medicare Advantage plans for dually eligible beneficiaries. Here's a breakdown:

• Focus on Integration: D-SNPs work closely with both Medicare and Medicaid programs to ensure your care plan considers benefits from both sides and avoids duplication of services.
• Enhanced Care Coordination: D-SNPs often have dedicated care teams who coordinate your care across different providers, potentially leading to smoother transitions and better overall health outcomes.
• Additional Benefits: D-SNPs might offer benefits beyond traditional Medicare, such as vision, dental, and hearing coverage, transportation assistance to appointments, or even meal programs.
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Another key element of the new rule focuses on improving care coordination for dually eligible individuals enrolled in both a D-SNP and a Medicaid Managed Care Organization (MCO). Here's a breakdown of the phased approach Starting in 2027, only dually eligible individuals who are already enrolled, or enrolling, in the affiliated Medicaid plan will be eligible to join the D-SNP. This aims to simplify care coordination and ensure a more integrated experience for these individuals. While the enrollment limitations might seem restrictive, there's a solution. The new rule creates a new monthly special enrollment period (SEP) specifically for D-SNPs with affiliated Medicaid plans. This allows dually eligible individuals already enrolled (or enrolling) in the affiliated Medicaid plan to join the D-SNP any month throughout the year. This provides flexibility and ensures access to the D-SNP even with the enrollment changes.

The final rule also proposes, but hasn't yet been finalized, limitations on out-of-network cost-sharing for certain services offered by D-SNP Preferred Provider Organizations (PPOs). This aims to reduce the financial burden on enrollees who might accidentally use an out-of-network provider and face higher costs. Additionally, it could incentivize D-SNP PPOs to expand their in-network provider options, making it easier for enrollees to access care

If you're a dually eligible individual considering a D-SNP, it's important to understand these changes. The new rules aim to improve the quality of care you receive by Ensuring D-SNPs meet stricter standards, potentially leading to better coordinated care. Streamlining care coordination with your Medicaid plan (if applicable)

Here are some steps you can take to navigate these changes:

• Talk to your doctor: Discuss your healthcare needs and see if a D-SNP is still the right option for you.
• Contact your current plan: Ask them about any changes to your D-SNP due to the new rule, particularly regarding enrollment or network providers.
• Explore your options: Depending on your situation, you might want to compare D-SNPs with affiliated Medicaid plans to traditional D-SNPs or even other Medicare Advantage plans

The CMS final rule on D-SNPs signifies a shift towards a more standardized and potentially higher-quality D-SNP experience for dually eligible beneficiaries