10 Things to Know About Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs)

About 12.9 million folks gained well being protection underneath each Medicare and Medicaid in 2021. Medicare-Medicaid enrollees, referred to as dual-eligible folks, are a diverse group, as just about part are folks of colour and just about 40% are underneath age 65. Alternatively, this team of folks proportion some commonplace traits, corresponding to restricted monetary method and well being care wishes which can be extra wide-ranging and complicated than the common Medicare enrollee.

Prior KFF study has described the complicated panorama of protection choices to be had to dual-eligible folks when enrolling in Medicare and Medicaid. Medicare, the main supply of medical insurance protection for dual-eligible folks, is also equipped underneath conventional Medicare or a Medicare Benefit plan. Medicaid, which in most cases wraps round Medicare, covers the price of Medicare premiums and in lots of circumstances, charge sharing help. Complete dual-eligible people are additionally eligible for advantages now not differently coated through Medicare, corresponding to long-term services and products and helps. Twin-eligible folks might obtain Medicaid advantages via fee-for-service or managed care, and protection and eligibility range through state. Separate eligibility necessities, advantages, and regulations for Medicare and Medicaid from time to time give a contribution to what has been described as a “fragmented and disjointed device of deal with twin eligibles” which might lead to difficulty in navigating care amongst dual-eligible folks.

In 2023, 5.2 million dual-eligible folks had been enrolled in a Medicare Benefit plan designed in particular for dual-eligible folks, referred to as Twin-Eligible Particular Wishes Plans (D-SNPs). D-SNPs are required to offer larger coordination of Medicare and Medicaid advantages than different Medicare Benefit plans to make stronger coordination throughout methods and affected person results. D-SNPs in most cases supply advantages now not differently to be had in conventional Medicare and in most cases don’t rate a top class.

This temporary highlights 10 issues to learn about D-SNPs, together with nationwide and state enrollment tendencies, plan availability, insurer participation, advantages, and prior authorization charges and denials, in keeping with knowledge from more than a few assets (see strategies for main points). Whilst D-SNPs can assist with coordination for dual-eligibles in Medicare and Medicaid and they’re rising impulsively, fewer than one in ten D-SNP enrollees had been in absolutely built-in twin eligible (FIDE) particular wishes plans (SNPs), elevating questions on how neatly protection and care is being coordinated between Medicare and Medicaid. As well as, gaps in knowledge make it tough to evaluate the standard of D-SNPs, prior authorization charges and denials through form of provider, and the level to which further advantages are used.

1. About 3 in 10 (29%) dual-eligible folks enrolled in D-SNPs in 2021.

In 2021, just about 3 in 10 (29%) dual-eligible folks had been enrolled in a D-SNP. Between 2010 and 2021, the percentage of dual-eligible folks enrolled in D-SNPs just about tripled from 11% to 29%.

As of 2023, maximum D-SNP enrollees (57%) had been in coordination-only (CO) plans which can be required to offer a minimal point of coordination between Medicare and Medicaid however aren’t absolutely built-in inside the similar plan. Every other 35% of D-SNP enrollees had been in what’s referred to as extremely built-in twin eligible (HIDE) SNPs that meet the necessities of CO plans and likewise require protection of long-term services and products and helps and behavioral well being. The remainder 8% had been in plans that had been absolutely built-in twin eligible (FIDE) particular wishes plans (SNPs), which coordinate deal with dual-eligible folks inside a unmarried controlled care group.

2. The proportion of dual-eligible folks enrolled in D-SNPs varies through state, starting from 5% (Nevada) to 58% (Hawaii) in 2021.

In 2021, D-SNP enrollment as a proportion of dual-eligible folks ranged from 5% in Nevada to 58% in Hawaii, as in comparison to 29% national. In seven states, 40% or extra of all dual-eligible folks had been enrolled in D-SNPs: Alabama (42%), New York (42%), Florida (46%), Tennessee (46%), Arizona (47%), and Hawaii (58%), in addition to in Puerto Rico (98%, now not proven). Conversely, not up to 10% of dual-eligible folks had been enrolled in D-SNPs in Nevada (5%), the place D-SNPs had been first to be had in 2021, and Montana (8%).

The proportion of dual-eligible folks enrolled in D-SNPs greater than doubled in 19 states between 2018 and 2021. States with somewhat low D-SNP enrollment relative to the dual-eligible inhabitants in 2018, corresponding to Oklahoma, Iowa, and West Virginia, had the absolute best share expansion in proportion of dual-eligible folks enrolled in D-SNPs between 2018 and 2021. As an example, the percentage of dual-eligible folks enrolled in D-SNPs in Oklahoma greater from 1% in 2018 to twelve% in 2021. A number of states, corresponding to Arizona (45% vs. 47%), California (10% vs. 10%), Hawaii (57 vs. 58%), Massachusetts (16% vs. 19%), and Minnesota (30% vs. 34%), maintained identical stocks of dual-eligible folks enrolled in D-SNPs between 2018 and 2021. New Mexico, Oregon, and Utah had been the one states the place a smaller proportion of dual-eligible folks enrolled in D-SNPs in 2021 in comparison to 2018. Insurers in Alaska, Illinois, New Hampshire, Wyoming, Vermont, North Dakota, and South Dakota didn’t be offering D-SNPs in 2018 or 2021. Total, Medicare Benefit enrollment in those states has a tendency to be less than the nationwide reasonable, in part explaining the somewhat low enrollment amongst dual-eligible folks in D-SNPs.

Variations in D-SNP enrollment throughout states is also reflective of a number of components, together with variation in: state-level insurance policies referring to D-SNP enrollment, demographic traits of the dual-eligible inhabitants within the state, company technique, and the facility to ascertain care networks for dual-eligible folks.

3. Inside states, the percentage of dual-eligible folks enrolled in a D-SNP various throughout counties in 2021.

Inside states, D-SNP enrollment amongst dual-eligible folks ceaselessly varies through county. As an example, in Northern California, 20% of dual-eligible folks in San Francisco County had been enrolled in D-SNPs in 2021, in comparison to solely 5% in within reach Santa Clara County. Despite the fact that there was once more or less the similar choice of dual-eligible folks in Alameda and Sacramento Counties in 2021, solely 16% of dual-eligible folks in Alameda County had been enrolled in D-SNPs, whilst over one-third (34%) of dual-eligible folks in Sacramento County had been enrolled in D-SNPs. In Florida, the percentage of dual-eligible folks in Orlando was once 54% (Pasco County) in comparison to 64% in within reach Tampa (Osceola County). Alternatively, in counties within the Florida Panhandle, the percentage of dual-eligible folks enrolled in D-SNPs was once a lot decrease: 24% in Jackson County and 45% in adjoining Gadsden County. In Puerto Rico (now not proven), enrollment of dual-eligible folks in D-SNPs is just about common.

Permutations in D-SNP enrollment on the county point is also attributed to a number of components, corresponding to rurality and Medicare fee charges.

4. Greater than 9 in 10 dual-eligible folks (92%) lived in a county that presented a minimum of one D-SNP in 2022.

Greater than 9 in 10 (92%) dual-eligible folks may choose between a minimum of one D-SNP when settling on protection for 2022, up from 86% within the 2018 plan yr. Many of the last 8% of dual-eligible folks with out get entry to to a D-SNP lived within the 5 states the place D-SNPs weren’t to be had in 2022 (Illinois, New Hampshire, South Dakota, Vermont, and Alaska).

5. The typical dual-eligible particular person may choose between 10 D-SNPs in 2022.

The typical dual-eligible particular person may choose between 10 D-SNPs in 2022 – extra D-SNPs than in any earlier yr. The choice of D-SNPs to be had to the common dual-eligible particular person has greater than doubled since 2011. Whilst the common dual-eligible particular person may choose between 10 D-SNPs, plan availability various extensively through county in 2022. As an example, dual-eligible folks in maximum counties composing metropolitan New York Town had get entry to to as much as 40 D-SNP choices, whilst dual-eligible folks in neighboring Suffolk County may choose between 17 plans. Twin-eligible folks in states corresponding to Wyoming and Montana had been in a position to get entry to just one D-SNP. Twin-eligible folks in Illinois, North Dakota, New Hampshire, Vermont, and Alaska didn’t have get entry to to a D-SNP in 2022 (and also will now not have get entry to to a D-SNP in 2024).

6. About part (52%) of D-SNP enrollees had been in UnitedHealthcare or Humana plans in 2023.

UnitedHealthcare and Humana had been the dominant suppliers of D-SNPs in 2023, accounting for 52% of general D-SNP enrollment. Enrollment in UnitedHealthcare plans by myself accounted for just about two-fifths of general D-SNP enrollment (37%) and exceeded blended enrollment of BCBS, Centene, Elevance Non-Blue, CVS Well being, Kaiser Permanente, and Cigna (31%) in 2023.

Between 2018 and 2023, the percentage of enrollees in plans presented through smaller corporations has declined from 27% to 17%. Between 2018 and 2023, the percentage of D-SNP enrollees opting for plans presented through Kaiser Permanente, Cigna, Centene, BCBS, and Elevance Non-Blue declined, whilst the percentage of enrollees opting for UnitedHealthcare, CVS Well being, and Humana plans greater.

7. Each and every primary insurer greater the choice of D-SNP choices between 2018 and 2024.

In plan yr 2024, insurers are providing 851 plans, greater than double the quantity presented in plan yr 2018 (401). The expansion in choices between plan years 2018 and 2024 will also be attributed to insurers expanding choices in present counties and increasing the quantity counties during which D-SNPs are presented.

8 primary insurers are providing 75% (638) of plans in 2024, up from 68% in plan yr 2018. The remainder 25% (213) of plans are presented through smaller insurers. In plan yr 2024, CVS will be offering 105 plans, an building up of 98 plans because the 2018 plan yr. This represents the biggest expansion in plan choices some of the primary insurers. Kaiser Permanente will be offering 10 plans, an building up of five plans because the 2018 plan yr. This represents the smallest expansion in plan choices amongst primary insurers.

One company, Florida Whole Care, is getting into the D-SNP marketplace in 2024 (despite the fact that it has presented different sorts of SNPs in prior years), whilst 5 corporations that presented D-SNPs (Ascension, Well being Selection Generations Utah, AgeWell New York, Essence Healthcare, and Vantage Well being Plan) are exiting the D-SNP marketplace. This differs from prior KFF analysis which examines entries and exits for the total Medicare Benefit marketplace.

8. D-SNPs are much more likely than different Medicare Benefit plans to supply some further advantages corresponding to over-the-counter advantages and meal advantages.

The proportion of D-SNPs providing eye assessments and/or eyeglasses (96%), dental care (95%), health advantages (94%), or listening to assessments and/or aids (92%) was once just about common for enrollees in D-SNPs in addition to individual Medicare Advantage plans in 2024 (Determine 8). Alternatively, D-SNPs are much more likely than particular person Medicare Benefit plans to supply over-the-counter advantages (96% vs. 85%), meal advantages (86% vs. 72%), rest room protection gadgets (32% vs. 22%), and in-home enhance services and products (23% vs. 9%). D-SNPs also are much more likely to supply transportation services and products than different Medicare Benefit plans (88% vs. 36%). Most of the further advantages is also coated through Medicaid as “Medicaid wraparound services.” States are required to hide non-emergency scientific transportation (NEMT), all states supply some home-based care (together with foods, rest room protection, or in-home helps), and lots of states quilt some dental and imaginative and prescient services and products. D-SNPs might extend upon the services and products presented via Medicaid and it’s unknown to what extent the D-SNP choices complement the Medicaid services and products for particular states or plans.

9. In 2021, dual-eligible folks enrolled in a plan in a D-SNP-only contract had been topic to at least one prior authorization request, on reasonable.

CMS publishes prior authorization knowledge through contract and now not through plan kind, which makes it unattainable to report the whole choice of prior authorization requests or denials for D-SNP enrollees. This research, due to this fact, depends upon knowledge about contracts containing solely D-SNPs, which account for approximately 19% of general D-SNP enrollment. Maximum D-SNP enrollees (81%) are in plans which can be in a freelance with different Medicare plan varieties, which means that CMS does now not accumulate or post prior authorization knowledge for many D-SNP enrollees.

On reasonable, corporations with contracts containing solely D-SNPs gained one prior authorization request in line with beneficiary in 2021, as in comparison to earlier KFF analysis appearing 1.5 prior authorization requests in line with enrollee for all Medicare Benefit plans, even if that estimate integrated contracts that integrated each D-SNPs and different plans. That is moderately sudden, taking into consideration dual-eligible folks in most cases make the most of more well being care services and products than the common Medicare beneficiary.

In contrast to different insurers, CVS had extra prior authorization requests for enrollees in D-SNP-only contracts than for enrollees in all Medicare Benefit contracts. Prior authorizations ranged throughout corporations from not up to one in line with beneficiary (UnitedHealthcare) to two.2 in line with beneficiary (BCBS) for contracts containing solely D-SNPs.

10.Regardless of fewer prior authorizations in D-SNP-only plans in comparison to all Medicare Benefit plans, the speed of denials was once two times as top.

In 2021, corporations with contracts containing solely D-SNPs gained just about 670,000 prior authorization requests, 12% of that have been denied. That is double the denial fee for all Medicare Benefit plans (6%), in line with earlier KFF analysis. The velocity of prior authorization request denials ranged from 5% (Humana) to fifteen% (CVS Well being and Centene) amongst contracts containing solely D-SNPs. Just about 7% of simply over 80,000 denials had been appealed, in comparison to 11% of denials for all Medicare Benefit plans. Simply over two-thirds (68%) of the ones appeals had been resolved favorably, by contrast to prior KFF research that discovered over 82% of appeals for all Medicare Benefit contracts had been resolved favorably.

Previous KFF analysis of Medicare Benefit prior authorization knowledge printed an inverse courting between the insurer’s quantity of prior authorization requests and proportion of requests that had been denied. This courting amongst D-SNP-only contracts holds for some corporations, corresponding to UnitedHealthcare and Humana, however now not others. As an example, Centene D-SNP-only contracts gained on reasonable 1.7 requests in line with enrollee, upper than the total fee of 1 prior authorization request and denied 15% of the ones requests in comparison to 12% total. As with prior authorization knowledge, denial charges are accrued and reported on the contract point, which means that denial charges in D-SNP-only contracts constitute a fragment of people enrolled in D-SNPs.

Dialogue

In 2021, just about 3 in 10 (29%) dual-eligible folks enrolled in D-SNPs, an building up from 20% in 2018. Expansion in D-SNP enrollment is also pushed through a number of components. D-SNPs is also horny to dual-eligible folks because of the provision of additional advantages, together with advantages which can be presented extra continuously in D-SNPs than Medicare Benefit plans for common enrollment, corresponding to over-the-counter advantages and foods. There may be sturdy pastime in D-SNPs amongst insurers, given relatively high margins. Since 2018, extra insurers have presented D-SNPs and bigger insurers have presented extra plans. Expansion in enrollment is also because of some degree to the automatic enrollment of a few folks into D-SNPs. In 2022, greater than 9 in 10 dual-eligible folks (92%) lived in counties the place insurers presented a minimum of one D-SNP, with a mean of 10 D-SNPs presented in line with dual-eligible particular person, in comparison to 6 plans in 2018.

Whilst enrollment and plan availability keep growing, it is not clear how neatly D-SNPs coordinate with Medicaid to give you the complete vary of advantages to dual-eligible enrollees. Fewer than one in ten D-SNP enrollees are in absolutely built-in plans.

Relatedly, little is understood concerning the high quality of D-SNPs. As a result of high quality rankings are reported on the contract point, moderately than the plan point, it isn’t imaginable to evaluate the standard of D-SNPs which can be integrated in contracts with different plans, affecting maximum D-SNP enrollees. Maximum D-SNP enrollees (81%) are in plans which can be a part of a freelance with different plans, which means that the standard rankings are on the contract point, now not in their particular plan. Additional, MedPAC has raised considerations that the present high quality measures aren’t enough to adequately assess care supply in D-SNPs. Early attempts at high quality measurements have produced combined effects, with some reporting little variation in high quality measurements between plans and others reporting little difference in care high quality between D-SNPs and different strategies of deal with dual-eligible folks.

Lack of data transparency additionally contributes to restricted working out of the have an effect on of prior authorization necessities and denials for dual-eligible folks enrolled in D-SNPs. KFF’s research means that contracts containing D-SNPs (however no different plans) deny prior authorization requests at a miles upper fee than Medicare Benefit plans total, despite the fact that corporations with contracts containing solely D-SNPs gained few authorization requests in line with enrollee. Once more, as a result of prior authorization requests and denials are reported on the contract point, it isn’t imaginable to report the choice of prior authorization requests for D-SNP enrollees total or in line with particular person, or denial charges.

Additional, even if maximum plans be offering some further advantages to D-SNP enrollees, it isn’t transparent how ceaselessly D-SNP enrollees benefit from those further advantages, whether or not insurers be offering good enough networks to get entry to those services and products, and whether or not they’re of worth to a inhabitants with such various well being wishes. A up to date proposed rule through the Biden Management will require insurance coverage suppliers to periodically notify D-SNP enrollees if they aren’t using supplemental advantages presented through their plan, however there may be a lack of complete knowledge referring to using supplemental advantages amongst D-SNP and different Medicare Benefit enrollees, according to KFF. As well as, there may be some fear amongst advocates and policymakers about advertising advantages, corresponding to transportation, dental, and imaginative and prescient when dual-eligible folks may already be eligible for these services through Medicaid. Given the numerous wishes of the dual-eligible inhabitants, and incentives for fast expansion in D-SNP enrollment, together with proposed policy changes to institute Particular Enrollment Sessions to extend D-SNP participation, larger perception into the stories of D-SNP enrollees can be precious for beneficiaries and policymakers.

Puerto Rico is integrated on this research of dual-eligible folks in Medicare. Particularly, Puerto Rico’s Medicare and Medicaid methods range from the 50 states and the District of Columbia. In Puerto Rico, just about all Medicare beneficiaries are enrolled in a Medicare Benefit plan. Medicare Advantage penetration is upper throughout Puerto Rico than within the 50 states and District of Columbia. In 2023, a minimum of 90% of eligible Medicare beneficiaries are enrolled in a Medicare Benefit plan throughout nearly all Puerto Rican counties. Specifically, enrollment in D-SNPs accounts for a miles better proportion of Medicare Benefit enrollment than in any of the 50 states or the District of Columbia. Because of this, knowledge for Puerto Rico isn’t proven at the maps for Figures 2 and three. Puerto Rico’s Medicaid program eligibility rules, benefits, delivery system and financing range in many ways from the ones within the 50 states and the District of Columbia. As an example, Puerto Rico does now not quilt many of the advantages that full-benefit dual-eligible folks use corresponding to long-term services and products and helps, and in Puerto Rico, cost-sharing help is equipped to full-benefit dual-eligible folks, however to not partial-benefit dual-eligible folks, as a result of Medicare Financial savings Techniques aren’t to be had in Puerto Rico. Strategies for figuring out dual-eligible folks in Puerto Rico differed than in different states and DC. Please see methods within the following KFF research: How Do Twin-Eligible People Get Their Medicare Protection?

 

This research makes use of knowledge from the Facilities for Medicare & Medicaid Products and services (CMS) Medicare Benefit Receive advantages and Panorama information for the respective yr. Twin-eligible beneficiary enrollment is in keeping with research of the Facilities for Medicare & Medicaid Products and services (CMS) Power Stipulations Knowledge Warehouse (CCW) research-identifiable Grasp Beneficiary Abstract Report (MBSF) Base. The estimates are in keeping with knowledge from 5 % of beneficiaries, 2010-2016; CCW knowledge from 20 % of beneficiaries, 2017-2021. The newest snapshot of the dual-eligible inhabitants was once to be had in 2021. D-SNP enrollment knowledge are from the Particular Wishes Plan (SNP) knowledge revealed through CMS within the Medicare Benefit (MA)/Phase D Contract and Enrollment Knowledge phase in March of the respective yr. Enrollment knowledge are solely equipped for plan-county mixtures that experience a minimum of 11 beneficiaries; thus, we exclude any plans that don’t meet this enrollment threshold. We excluded D-SNPs that had been sanctioned through CMS, as those plans had no enrollment. The 2021 depend of dual-eligible folks comprises the 11.5 million people who had Portions A and B who had been dual-eligible in March 2021. Different KFF research additionally require folks to have Portions A and B, however let them be twin eligible at any level right through the yr, and thus have 12.9 million dual-eligible folks in 2021. Counts of dual-eligible folks and D-SNP enrollees come with each full-benefit and partial-benefit twin eligible folks. Partial-benefit twin eligibles are eligible to sign up for D-SNPs in all however 7 states (Arizona, Hawaii, Idaho, Massachusetts, Minnesota, New Jersey, and Oregon). A limitation of this research is partial-benefit twin eligible folks aren’t excluded from the ones 7 states when comparing get entry to to a D-SNP from 2010 to 2022. Supplemental advantages in Medicare Benefit and Twin Particular Wishes Plans had been recognized the use of the 2023 Quarter 4 Facilities for Medicare & Medicaid Products and services (CMS) Plan Receive advantages Package deal knowledge. KFF defines a plan as providing a advantage whether it is to be had to enrollees as both a compulsory or non-compulsory supplemental advantage. Not obligatory supplemental advantages require an extra top class, which KFF does now not read about on this research. KFF additionally does now not read about the entire further advantages that Medicare Benefit and D-SNPs be offering – as an example, particular supplemental advantages for the chronically in poor health. Prior authorization knowledge had been received from group determinations and reconsiderations – Phase C knowledge from the Facilities for Medicare and Medicaid Products and services (CMS) Phase C and D reporting necessities public use report for contract yr 2021. Medicare Benefit insurers publish the specified knowledge on the contract point to CMS and CMS plays an information validation test. For the 2021 plan yr, 114 contracts didn’t move the information validation procedure, together with all contracts for Elevance Blue Pass Blue Protect plans, and are excluded from this research. This research displays knowledge on provider determinations and does now not come with claims determinations (for fee for services and products already equipped). This research additionally does now not come with withdrawn or disregarded choice requests. KFF recognized D-SNP-Best contracts through merging the plan-county enrollment knowledge and plan kind knowledge. If all plans within the contract are a D-SNP, regardless of the coordination kind, this is regarded as a D-SNP-Best contract.