Many states provide services to those eligible for benefits from both Medicaid and Medicare through contracts with Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs). Individuals who are “dually eligible” often have complex physical, behavioral and/or long-term services and supports (LTSS) needs and coordinating services across Medicaid and Medicare benefits can be challenging. For example, providers of Medicaid behavioral health services and LTSS may not know of hospital or skilled nursing facility stays, which are covered by Medicare and could have an impact on the provision of their Medicaid services.
Based on the Bipartisan Budget Act of 2018, CMS is adding requirements to D-SNPs to ensure smoother transitions of care and timely care management, with the goal of better supporting beneficiaries and reducing avoidable readmissions.
Starting in 2021, the Centers for Medicare & Medicaid Services (CMS) will require D-SNPs to:
- Cover Medicaid behavioral health services and/or LTSS through a capitated Medicaid contract (typically same parent company) to be either:
- A Fully Integrated Dual Eligible SNP, or
- A Highly Integrated Dual Eligible SNP
- Lay out a process for sharing information with the state or its designee on hospital and skilled nursing facility (SNF) admissions of specified individuals, specifically for a group of high-risk enrollees to improve coordination during transitions of care
Some states already require D-SNPs to share data on hospital and SNF admissions. The Integrated Care Resource Center released a report detailing three examples of approaches to information sharing already being taken by Oregon, Tennessee, and Pennsylvania. These examples include event notification solutions, state portals, and plan/provider developed processes.
Oregon uses Collective Medical’s platform to share real-time information throughout the state. In 2020, D-SNP Coordination of Benefits Agreements (COBA) with Oregon Health Authority (OHA) align with Coordinated Care Organizations (CCOs) that cover Medicaid behavioral health and incorporate requirements for use of hospital and SNF event notifications. As part of CCO 2.0, all CCOs are required to have affiliated Medicare plans, which may be a D-SNP, to build more integrated care opportunities for individuals who are dual eligible. OHA contractual and reporting elements seek to improve information sharing to impact health outcomes for dual eligible individuals served by aligned companion plans. Timely notification of inpatient admissions, discharge-planning documents, and high-priority health concerns are critical components in real-time information sharing to support beneficiaries. As such, Oregon will require D-SNPs to share data about SNF admissions as part of their contracts.
Since implementing Collective, organizations in Oregon have seen a decrease in visits by patients with high utilization patterns and an increase in care coordination. One behavioral health provider was able to establish a workflow that ensured 99 percent of mental health patients were receiving follow-up within seven days of a hospital discharge. Oregon anticipates that continued use of Collective’s technology will address the new CMS requirements for D-SNPs.
CMS. “Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021.” Federal Register, April 16, 2019, pp.15710-15718 and 42 CFR 422.107(d)) p. 15828. Available at: https://www.govinfo.gov/content/pkg/FR-2019-04-16/pdf/2019-06822.pdf
Integrated Care Resource Center (ICRC): ICRC August Brief: Promoting Information Sharing by Dual Eligible Special Needs Plans to Improve Care Transitions: State Options and Considerations. Available at: https://www.integratedcareresourcecenter.com/sites/default/files/ICRC_InfoSharing_HospitalSNF%20082819.pdf
General Manager, Pacific Northwest
VP of Policy