Persevering with our collection discussing the CY 2023 Medicare Benefit and Half D Ultimate Rule (Ultimate Rule), this publish focuses on the D-SNP associated provisions beneath the Ultimate Rule. As we mentioned, the Facilities for Medicare & Medicaid Providers (CMS) proposed important modifications to its laws governing Twin Eligible Particular Wants Plans (D-SNPs). CMS finalized nearly all of its proposals with restricted modifications. This weblog summarizes among the key D-SNP provisions, specializing in the modifications from the proposed rule and CMS’ commentary that gives perception into CMS’ priorities and focus areas. Please consult with our prior publish on D-SNPs for a extra in-depth overview of the proposals.
Enrollee Participation in Plan Governance
CMS finalized proposed laws requiring D-SNPs to ascertain an enrollee advisory committee. CMS is requiring that D-SNPs create a number of enrollee advisory committees that encompass “a fairly consultant pattern of enrollees” in every state that the D-SNP operates. That means, if a D-SNP covers a number of states, it should set up a number of advisory committees so that every state has its personal. In opposition to the request of commenters to delay or a minimum of phase-in this necessities, CMS is requiring all D-SNPs (fairly than only a subset of D-SNPs) to implement these advisory committees efficient January 1, 2023.
CMS didn’t set up particular necessities with respect to frequency, location, format, and participant recruiting and coaching strategies for the committees. By way of its responses to feedback, CMS clarified that sure D-SNPs, and notably Absolutely Built-in D-SNPs (FIDE SNPs) and D-SNPs with aligned membership that have already got enrollee committees to fulfill state necessities, might depend on the identical committee to fulfill the brand new federal necessities. CMS additionally clarified that D-SNPs could compensate plan members for participation on the enrollee advisory committee, as long as compensation shouldn’t be money, presents, prizes, or different financial rebates and doesn’t in any other case violates fraud and abuse legal guidelines.
Housing, Meals Insecurity, and Transportation Questions on the Well being Danger Assessments
CMS finalized its proposal that each one forms of particular wants plans (SNPs) should embrace questions relating to housing, meals insecurity, and transportation on their well being threat evaluation (HRA) varieties. In a change from the proposed rule, CMS shouldn’t be requiring all SNPs to implement the identical customary questions. Primarily based on suggestions from commenters, the Ultimate Rule requires that SNPs embrace a minimum of one query from an inventory of screening devices specified by CMS on every of those three domains. CMS states that it will likely be issuing sub-regulatory steering with the screening devices by the tip of 2022 to permit SNPs time to include these questions into their HRA by the start of 2024.
Redefining Definitions for Absolutely Built-in and Extremely Built-in D-SNPs
CMS acknowledged its present terminology and the nuances between FIDE SNPs and Extremely Built-in D-SNPs (HIDE SNPs) are too sophisticated. In taking steps to make clear and higher differentiate a majority of these D-SNPs, CMS finalized the next updates:
- Solely Aligned Enrollment. CMS finalized its proposal that each one FIDE SNPs will need to have “solely aligned enrollment” by 2025 with out modification. Underneath this requirement, solely enrollees who’re receiving Medicaid advantages from an affiliated Medicaid MCO of the identical authorized entity could enroll within the FIDE SNP. A subset of commenters beneficial that CMS additionally prolong “solely aligned enrollment” to HIDE SNPs. CMS declined to take action, noting that is outdoors the scope of the rule.
- Scope of Providers supplied by FIDE and HIDE SNPs. CMS finalized its definitions of FIDE and HIDE SNPs to make clear the scope of providers every sort of plan should present and to higher differentiate the plans. FIDE SNPs should cowl Medicaid main and acute care providers, residence well being, sturdy medical gear, and behavioral well being providers by a capitated contract with the State Medicaid company. The adjustments to the definition of a HIDE SNP make clear that HIDE SNPs are required to cowl, at a minimal, the total scope of the Medicaid profit for Medicaid long-term providers and helps or Medicaid behavioral well being providers (topic to restricted carve outs).
- Aligned Service Areas for HIDE- and FIDE-SNPs. CMS additionally finalized its proposals to amend the definitions of FIDE and HIDE SNP in order that, beginning in 2025, all FIDE SNPs and HIDE SNPs should maintain capitated contracts with the state Medicaid company that cowl the identical service space for the D-SNP plan.
Stand-Alone D-SNP Contracts
CMS finalized its proposal to create a pathway for states to require D-SNPs with solely aligned enrollment to carry a “D-SNP solely” contract. Medicare Benefit contracts are held on the authorized entity stage, with a number of plan profit packages (PBPs) beneath one contract. As such, SNPs and non-SNPs could also be PBPs in the identical contract, with sure information solely reported on the contract stage (e.g., Star Rankings). This transformation permits the D-SNP PBPs to be beneath separate and stand-alone agreements in order that this information reporting might be reported just for the D-SNP.
Commenters raised concern about this proposal, together with (i) information integrity points as D-SNPs could battle to have enough pattern sizes and (ii) equity considerations, as D-SNPs will probably be in contrast in opposition to MA plans with restricted dual-eligible enrollees. CMS responded by saying that it doesn’t assume the information will probably be unreliable primarily based on its expertise beneath the Monetary Alignment Initiative. As to the priority that dual-eligible people typically have decrease Star Rankings given the inhabitants, CMS pointed to the Categorical Adjustment Index (CAI) at the moment used within the Star Rankings system to appropriate for this problem (although it acknowledged that there’s concern with the CAI) and stated it could monitor the method.
Along with the provisions mentioned above, CMS additionally finalized adjustments to the calculations of the utmost out-of-pocket (MOOP) prices, requiring Medicare Benefit plans to rely secondary protection in calculating MOOP. We mentioned this requirement in depth within the first weblog of this collection. We will probably be rounding out our collection of the Ultimate Rule with a ultimate publish on the non-D-SNP provisions.