State Resource Center

The State Resource Center Supports State Medicaid Agencies' Relationships with Dual Eligible SNPs

The purpose of the State Resource Center (SRC) is to assist State Medicaid Agencies who desire to contract with the Medicare Advantage (MA) Organizations operating in their state that offer Dual Eligible Special Needs Plans (D-SNP). Since only individuals who are dually eligible for Medicare and Medicaid can enroll in D-SNPs, the plans provide a more integrated experience for the dual eligible population. The SRC focuses on helping states understand the benefits of contracting with Medicare Advantage/Special Needs Plan organizations and providing technical assistance to states as they engage in the contracting process. It supports State Medicaid Agencies' efforts to improve Medicare-Medicaid benefit integration for their dual eligible populations by increasing coordination with MA organizations offering specialized plans for dual eligible individuals.

Statutory Background for D-SNPs and the State Resource Center

The Medicare Modernization Act of 2003 (MMA) created a new subset of MA coordinated care plans that focus on Medicare beneficiaries with special needs. These Special Needs Plans (SNP) serve beneficiaries who are 1) institutionalized (I-SNP) or meet the institutional level of care and live at home, 2) dually eligible for both Medicare and Medicaid (D-SNP), or 3) have severe or disabling chronic conditions (C-SNP). The MMA authority allowing MA organizations to offer SNPs expired in 2008; however, MIPPA reauthorized the program through 2010 and the Affordable Care Act reauthorized the program through December 31, 2013.

Section 164 of the Medicare Improvement for Patients and Providers Act (MIPPA) of 2008 required MA organizations offering a new D-SNP, or seeking to expand the service area of an existing D-SNP, to contract with their respective State Medicaid Agency(ies). MIPPA, as amended by the Affordable Care Act, allowed existing D-SNPs (that did not seek expansion and/or did not seek a change in its dual SNP type) to continue operating without state Medicaid agency contracts through 2012. Starting in 2013, all new and existing D-SNPs will be required to contract with the State Medicaid agency in which the MA organization wants to operate a D-SNP.

Following the passage of MIPPA, CMS promulgated regulations (42 CFR §422.107) that implemented the following eight contracting requirements:

1. The contract must document the MA organization's responsibility, including financial obligations, to provide or arrange for Medicaid benefits;
2. The contract must document the category(ies) of eligibility for dual eligible beneficiaries to be enrolled under the SNP;
3. The contract must document the Medicaid benefits covered under the SNP;
4. The contract must document the cost-sharing protections covered under the SNP;
5. The contract must document the identification and sharing of information on Medicaid provider participation;
6. The contract must document the verification of enrollee's eligibility for both Medicare and Medicaid;
7. The contract must document the service area covered by the SNP; and
8. The contract must document the contract period for the SNP.

For more information relating to the MIPPA contracting requirements, please find the MIPPA State Contracting Options paper in the “downloads” section below.

Dual SNP Types

Within the D-SNP program, there are five different types of D-SNPs that MA organizations, in accordance with their state contract, may offer. The five D-SNP types are:

1. All-Dual D-SNPs (Medicare and Medicaid dual eligibles can enroll);
2. Full-Benefit D-SNPs (Medicare beneficiaries and those eligible for full Medicaid benefits can enroll);
3. Medicare Zero-cost-sharing D-SNPs (Qualified Medicare beneficiaries (QMB) and QMBs' eligible for comprehensive Medicaid benefits (QMB+) can enroll);
4. Fully Integrated Dual Eligible (FIDE) SNPs (the plan meets CMS' definition for full integration of Medicare and Medicaid benefits); and
5. Dual Eligible Subset D-SNPs (a subset of Dual Eligibles as agreed to by the state and the Medicare Advantage Organization in the state-MAO contract can enroll).

For more information on the D-SNP types, please refer to section 20.2 and 20.2.6 of Chapter 16b of the Medicare Managed Care Manual in the “downloads” section below.

Overview of the CMS Medicare-Medicaid Coordination Office

The Medicare-Medicaid Coordination Office was established by Section 2602 of the Affordable Care Act. In general, the office is assisting states to develop initiatives to improve care coordination and reduce health care expenditures for the dual eligible population. The Medicare-Medicaid Coordination Office is helping states pilot innovative new models to provide care to this unique population. For more information relating to the Medicare-Medicaid Coordination Office, please refer to their website in the Internal Links section below.

Additional Resources

In addition, the State Resource Center provides a forum for states to make inquiries and share knowledge about the coordination of state and federal policies pertaining to SNPs. Please e-mail questions and information related to this topic to State_Resource_Center@cms.hhs.gov .