Medicare Advantage DSNP Plans for 2025

For those eligible for both Medicare and Medicaid, some of the potential Medicare Advantage DSNP plans for 2025 may be for you. This article breaks down what you’ll need to navigate these potential plans and their possible changes.  From enrollment thresholds and streamlined coordination of care to appeal rights, this guide will provide a more efficient system for dual-eligible individuals.

Key Takeaways

• CMS may introduce some potential policy updates to certain Dual Eligible Special Needs Plans (DSNPs) for 2025, which could be aimed at enhancing care coordination and expanding enrollment for Medicare and Medicaid dual-eligible individuals.

• To help streamline DSNP operations and payment accuracy, CMS may standardize the Risk Adjustment Data Validation (RADV) appeals process for certain Medicare Advantage plans and may even implement new contracting standards for DSNP look-alikes.

• CMS may also propose measures that could potentially improve health equity in DSNPs, which may include an annual health equity analysis of utilization management policies, addressing social risk factors, and possibly including more provider specialties and outpatient services.

DSNPs have been tailored to enhance coverage and coordinate care for individuals enrolled in both Medicare and Medicaid, commonly referred to as dual-eligible. These programs may be recognized for having high costs and special care needs. CMS may also propose policy updates for 2025 that could aim to:

• Streamline processes

• Align benefits

• Lower enrollment thresholds

• Enhance appeal rights for DSNP members

This potential strategy could lead to improvements in the quality of care and service delivery.

These potential changes will likely be timely, considering the growing interest in D-SNPs. Over the past few years, D-SNP enrollment has had at least a 60% growth rate, outpacing the approximate 38% growth in non-SNP plans. Given this trend, the potential 2025 policy updates could have a broader impact, potentially reshaping the healthcare experience for a large number of dual-eligible beneficiaries.

The proposed policy updates may also span across several areas – from integration with Medicaid services and adjustments, enrollment thresholds, and to appeal rights for DSNP members.

Each of these areas could bring unique advantages and opportunities, possibly providing seamless service delivery and improved care outcomes for dual-eligible individuals.

Possible Integration with Medicaid Services

To potentially provide dual-eligible individuals with more integrated care, CMS may implement measures that could increase the percentage of dual-eligible Medicare Advantage enrollees who receive integrated Medicare and Medicaid services. This could streamline processes and may even provide more opportunities for enrollment in certain integrated plans.

One of the potential measures may be the revision of the current quarterly special enrollment period to a monthly opportunity.

This could allow those receiving low-income subsidies, including the dual-eligible members, to elect an integrated Dual Eligible Special Needs Plan. Additionally, D-SNPs may be required to have contracts with state Medicaid agencies meeting integration requirements and possibly establish unified appeals and grievance processes.

By potentially simplifying the coordination of coverage for individuals eligible for both Medicaid and Medicare, CMS will likely aim to overcome challenges that might be posed by separate financing and administrative structures.

Potential Adjustments to DSNP Enrollment Thresholds

Another potential area of focus for the policy updates may be the adjustment to DSNP enrollment thresholds. The possibility of lowering these thresholds for D-SNP look-alikes could potentially enhance the quality of care and service delivery for dual-eligible individuals.

The CMS might propose a phased approach, which will likely gradually reduce the enrollment threshold from 80 percent to 70 percent for 2025, with a further reduction from 70 percent to 60 percent for 2026. This progressive lowering of thresholds will likely be designed to allow dual-eligible individuals to choose some of the more integrated product types available, possibly maximizing the potential benefits of their coverage.

Enhanced Appeal Rights for DSNP Members

Recognizing the importance of fair and effective appeal processes, CMS may also propose to align certain Medicare Advantage plan regulations with those of Traditional Medicare, possibly ensuring that traditional Medicare beneficiaries could experience enhanced enrollees’ appeal rights for certain services.

Under this proposed ruling, Quality Improvement Organizations may be allowed to review fast-track appeals regarding the termination of various services in home health agencies, comprehensive outpatient rehabilitation facilities, and skilled nursing facilities for MA enrollees.

Additionally, MA enrollees may also no longer be able to forfeit their right to appeal the decision to terminate services if they leave the facility before the initially planned termination date. This possible extension of appeal rights may stem from policy developments that might have been initiated by the Bipartisan Budget Act of 2018, which directed unified Medicare and Medicaid appeals processes for D-SNPs.

Streamlining DSNP Operations

Efficiency and accuracy in operations will likely be paramount in healthcare delivery. To this end, CMS may propose to standardize the Risk Adjustment Data Validation (RADV) appeals process for certain Medicare Advantage (MA) plans. By doing so, CMS could potentially enhance payment accuracy and performance measurements, which could streamline DSNP operations.

Additionally, CMS may also add new contracting standards for D-SNP look-alikes. This potential change may ensure they meet similar requirements to D-SNPs, possibly reinforcing the integrity of these plans. By taking on the responsibility for coordinating care and potentially bearing risk for Medicare D-SNPs could play a crucial role in managing the care for the dual-eligible members.

Some of these proposed changes could mark a significant step towards potentially enhancing the operational efficiency of D-SNPs, which might improve service delivery and may even provide a better healthcare experience for dual-eligible enrollees.

Risk Adjustment and Data Validation Reforms

To potentially improve the payment accuracy and performance measurements, CMS may propose the standardization of the RADV appeals process for various MA plans. This possible standardization could be a key component for the potential reforms that may be initiated to improve the operational efficiency of DSNPs.

Under some of the potential rules, Medicare Advantage organizations may need to follow a sequential approach when appealing medical record review determinations and payment error calculations. The process may include:

• Appeal the medical record review determination.

• Once the medical record review determination appeal has concluded, CMS may provide a revised audit report with a recalculated payment error calculation.

• Appeal the payment error calculation.

This sequential approach could ensure that the relevant factors have been considered before any adjustments were made.

This could potentially ensure a transparent and thorough review process, possibly enhancing the accuracy of payments and the overall performance of DSNPs.

Contracting Standards for DSNP Look-Alikes

To maintain the standard of care provided to dual-eligible individuals, CMS may also propose new contracting standards for D-SNP look-alike plans. Some of these potential standards could ensure that look-alike plans may meet requirements similar to those of D-SNPs, possibly providing a consistent level of service provision.

Some of these new standards may include a phased reduction in the D-SNP look-alike threshold.  This gradual lowering of the threshold may ensure that the quality of care provided by these look-alike plans could be maintained while possibly allowing for the integration of more dual-eligible individuals into the most suitable product type.

Enhancing Health Equity in DSNPs

Among the many potential changes that may come in 2025, CMS might propose measures that could enhance health equity in DSNPs. This may include requiring an annual health equity analysis of utilization management policies and procedures for DSNPs.

Such an analysis could potentially offer insights into some of the systemic factors that might influence health outcomes and potentially offer strategies that could improve care for dual-eligible individuals.

The proposed health equity analysis will likely need to incorporate eight specified metrics. Some of these metrics may include denial rates, appeal overturn rates, and determination turn-around times. The CMS may also seep input from enrollee groups, items, or services, which could be further analyzed for health equity, particularly in terms of utilization management policies.

The performance of D-SNPs will likely have significant implications for health equity; given that a significant proportion of D-SNP enrollees are Black, Hispanic, or other people of color, the interaction between utilization management policies and the potential social risk factors could become a pressing issue. Therefore, some of these proposed measures could play a crucial role in addressing disparities and promoting health equity.

Annual Health Equity Analysis Mandate

To potentially help underserved populations, which will likely form a significant portion of D-SNP enrollees, CMS might mandate an annual health equity analysis. This mandate could be an important step towards understanding and addressing the disparities that may exist within the healthcare system.

Through this analysis, D-SNPs could gain valuable insights into how their services may be utilized by different subpopulations. This information could then be used to tailor interventions and policies that might better meet the needs of these groups, possibly improving health outcomes and promoting equity.

Addressing Social Risk Factors

In addition to the annual health equity analysis, CMS may also aim to address social risk factors and potentially enhance care coordination for dual-eligible individuals, particularly those of color. Some of the dual-eligible individuals may have a greater prevalence of chronic and disabling health conditions when compared to Medicare-only beneficiaries.

To address some of these social risk factors, CMS may authorize payments for services like Community Health Integration and Principal Illness Navigation, which could be provided by community health workers and peer support specialists.

Certain services may be particularly beneficial where the potential social needs might pose a challenge to healthcare provision. By addressing these potential factors, CMS will likely aim to ensure that heightened coverage and management strategies could result in fair and equitable care for all dual-eligible individuals.