The recently-passed Bipartisan Budget Act of 2018 (BBA of 2018) makes a number of changes to Medicare, including permanently authorizing Dual Special Needs plans (D-SNPs), which are Medicare Advantage (MA) plans for people who are dually eligible for Medicare and Medicaid.
To help inform implementation of these changes, earlier this month the Centers for Medicare & Medicaid Services (CMS) issued a request for stakeholder input on (1) The design of an integrated Medicare-Medicaid appeals approach for D-SNPs; and (2) The establishment of minimum state contract requirements for D-SNPs.
The Medicare Rights Center’s comments, submitted today, are informed by our experience assisting Medicare beneficiaries, their family members, and health care professionals in general, and by our work with dually eligible New Yorkers and the programs that serve them in particular—including New York State Medicare-Medicaid Fully Integrated Duals Advantage (FIDA) Plans and D-SNPs.
Currently, nearly one-third of the over 700,000 full dual eligible New Yorkers are enrolled in some type of managed care product. However, most of these plans do not fully coordinate and integrate Medicare and Medicaid services. Through our helpline and casework, we know that many dually eligible New Yorkers experience fragmented care, often struggle to navigate their multiple plans or sources of coverage, and face challenges in trying to obtain needed services. Without access to care and effective coordination, beneficiaries may experience otherwise avoidable hospitalizations, duplication of services, and poorer health outcomes overall.
Often, it is only when there is a problem in access or payment that the fractured nature of their coverage becomes apparent. Therefore, integration of the appeals and grievance systems—where patients and providers turn when there is an issue—is of utmost importance. In developing a truly unified process, we recommend that CMS:
- Take into account the “administrative” burden of directing and organizing the appeal that largely falls on beneficiary shoulders, in part by retaining the more protective rule when applicable rules conflict;
- Consider the ways in which different appeals rules currently exist within Medicare, in addition to the differences between Medicare and Medicaid;
- Prohibit harmful plan marketing practices;
- Include assisting and re-directing any appeal or grievance received among a D-SNP’s case management obligations; and
- Ensure there is aid-to-continue or aid paid pending review for all claims.
As CMS seeks to develop new requirements for integration, we encourage the agency to:
- Assign a care manager or point person at the D-SNP who can assist with coordinating care by locating in-network providers, helping with appeals and troubleshooting, and smoothing interactions between programs;
- Require robust and meaningful care management that prioritizes integrated, comprehensive, person-centered decision making;
- Allow comprehensive data sharing, including making Medicare and Medicaid claim information accessible to the plan, the care manager, and the beneficiary; and
- Ensure oversight by both CMS and the state. This oversight should be transparent and accessible to beneficiaries, advocates, and researchers.