CMS 2023 Final Notice & Updates for D-SNPs — What Should Plans Do Now?

In May, CMS published the 2023 Final Rule in the Federal Register. The rule includes many changes related to different areas, including marketing and communications, past performance, Star Ratings, network adequacy, medical loss ratio reporting, special requirements during disasters or public emergencies, and pharmacy price concessions; however, there are a number of changes related to special needs plans (SNPs) and dual eligible SNPs (D-SNPs) in particular.

The changes below relate specifically to D-SNPs and their applicability dates:

  • Enrollee Participation in Plan Governance (42 CFR § 422.107)
    • Medicare Advantage (MA) organizations offering a D–SNP must establish one or more enrollee advisory committees in each State to solicit direct input on enrollee experiences.
    • The committee must include a reasonably representative sample of individuals enrolled in the D–SNP(s) and solicit input on, among other topics, ways to improve access to covered services, coordination of services, and health equity for underserved populations.
    • Applicable January 1, 2023
  • Standardizing Housing, Food Insecurity, and Transportation Questions on Health Risk Assessments (42 CFR § 422.101)
    • As part of their health risk assessments (HRAs) all SNPs must include one or more questions on housing stability, food security, and access to transportation.
    • All SNPs do not have to use the same specific standardized questions.
    • Applicable for initial and annual HRAs beginning in contract year 2024
  • Refining Definitions for Fully Integrated and Highly Integrated D–SNPs (42 CFR §§ 422.2 and 422.107)
    • All fully integrated dual eligible SNPs (FIDE SNPs) must have exclusively aligned enrollment and cover Medicare cost-sharing.
    • FIDE SNPs must have a capitated contract with the State Medicaid agency to cover Medicaid benefits for home health services, medical supplies, equipment, and appliances, and behavioral health services.
    • Each FIDE SNP and highly integrated dual eligible SNP (HIDE SNP) must have a service area that completely overlaps the service area of the affiliated Medicaid managed care plan with the capitated contract with the State.
    • The final rule also codifies specific, limited carve-outs of the Medicaid long-term services and supports (LTSS) and Medicaid behavioral health services covered under the Medicaid capitated contract affiliated with FIDE SNPs and HIDE SNPs.
    • Applicable for plan year 2025 and subsequent years
  • Additional Opportunities for Integration Through State Medicaid Agency Contracts (42 CFR § 422.107)
    • In efforts to increase transparency and improve efficiency of integrated care for Medicaid and Medicare service, the final rule codified provisions for:
      • New pathways through which States can use contracts to require that certain D–SNPs with exclusively aligned enrollment establish contracts that only include one or more D–SNPs within a State and use certain integrated materials and notices for enrollees; and
      • Mechanisms to better coordinate State and CMS monitoring and oversight of certain D–SNPs when a State has elected to require these additional levels of integration, including granting State access to certain CMS information systems such as the Health Plan Management System (HPMS).
      • Applicable January 1, 2023
  • Attainment of the Maximum Out-of-Pocket Limit (42 CFR §§ 422.100 and 422.101)
    • The rule specified that the Maximum Out-of-Pocket (MOOP), the limit in an MA plan after which the plan pays 100% of MA costs for Part A and Part B services, must be calculated based on the accrual of all cost-sharing in the plan benefit, regardless of whether that cost-sharing is paid by
      • The beneficiary,
      • Medicaid,
      • other secondary insurance, or
      • remains unpaid, including cost-sharing that remains unpaid because of State limits on the amounts paid for Medicare cost-sharing and dually eligible individuals’ exemption from Medicare cost-sharing.
      • Applicable January 1, 2023

What Should Plans Do Now?

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