Table 1.
Integration Options for Medicaid with Special Needs Plans for Dual-Eligible Medicare Beneficiaries
| Type of alignment (from least to most integrated) | Description and requirements | Payment model | States and statistics |
|---|---|---|---|
| Dual-Eligible Special Needs Plans (D-SNPs) |
- Must contract with state Medicaid agencies. - Subject to 8 minimum requirements to provide or arrange for Medicaid benefits, but integration not required.7 |
- Separate payments to Medicare and Medicaid.6 - No shared savings with Medicaid state programs.6 |
- 2.6 million enrollees. - 480 plans. - 42 states, PR and DC.4 |
| D-SNPs with additional state-mandated covered services |
States can require D-SNPs to:3 - Cover Medicare premiums and cost-sharing (typically paid by Medicaid). - Provide Medicaid acute care services not covered by Medicare (vision, dental, hearing, transportation, etc.). - Provide or arrange for Medicaid MLTSS or behavioral health services. |
- If the D-SNP covers Medicaid benefits, and no companion Medicaid plan exists, Medicaid capitated payments may go directly to the D-SNP.7 | - Varies by state. |
| D-SNPs with Medicaid Managed Long-Term Services and Supports (MLTSS) plans |
- State Medicaid MLTSS plans either offer a companion D-SNP plan or states can require D-SNPs to operate MLTSS plans in the same geographic area.7 - Includes both Medicare and Medicaid benefits (LTSS and/or behavioral health services).5 - Allows for administrative alignment of these benefits when the plans are highly integrated.5 |
- If there is a companion Medicaid MLTSS plan, Medicaid capitated payments go directly to the Medicaid plan.7 | -14 of 22 states with MLTSS programs have enhanced contracting between D-SNP and MLTSS.3 |
| Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs) |
- Aligned Medicare and Medicaid benefits through a single managed care organization.2 - Integrated enrollment process and administrative alignment of Medicare and Medicaid.3 - Must cover Medicaid benefits with LTSS, and nursing facility services for at least 180 days per plan year.9 |
- Plan receives separate capitation payments from Medicare and Medicaid and integrates services.5, 6 - Savings from reduced Medicare service go to Medicare, no mechanism for shared savings with state.6 |
- 201,765 enrollees. - 45 plans. - 10 states.4 |