D-SNPs: Integration & Unified Appeals & Grievance Requirements

SPOTLIGHT & RELEASES
07/02/2024: CMS released the D-SNP EAC Strategic Conversation Lessons Learned Memorandum (06/18/2024). More information is available below.
07/01/2024: CMS released the CY 2025 AIP D-SNPs English Marketing Model Materials & Memoranda for California, District of Columbia, Hawaii, Idaho, Minnesota, New Jersey, New York (MAP), Tennessee, Virginia, & Wisconsin. More information is available below.

Overview

The Bipartisan Budget Act (BBA) of 2018 permanently authorized Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs), strengthened Medicare-Medicaid integration requirements, and directed the establishment of procedures to unify Medicare and Medicaid appeals and grievance procedures to the extent feasible for D-SNPs beginning in 2021. On April 16, 2019, CMS finalized rules to implement these new statutory provisions.

All D-SNPs must have executed contracts with state Medicaid agencies, referred to as the "State Medicaid Agency Contract" (SMAC) or MIPPA contract, that meet a number of requirements, including Medicare-Medicaid integration requirements and, for some D-SNPs, unified appeals and grievance processes.

Additional Information for D-SNPs and States

State Medicaid Agency Contracts Submission Requirements for Contract Year 2024 (PDF) released on January 11, 2023, outlines the requirements for review of State Medicaid Agency Contracts (SMACs) for contract year 2024. This submission will be due in the summer of 2023.
The Integrated Care Resource Center (ICRC) provides technical assistance to states to help with implementation of these requirements through briefs, technical assistance tools, tip sheets, webinars, appeals and grievance technical assistance tools, and sample contract language

New! Model Materials

Each year CMS and states jointly develop state-specific marketing guidance and model member materials for use by Plans. Guidance and model member materials, beginning with the Contract Year (CY) 2025, issued by CMS through the Health Plan Management System (HPMS) for states with Applicable Integrated Plan (AIP) D-SNPs that have chosen to work with CMS on integrated models, appear below. Information is state-specific and alphabetized by state name.

California

District of Columbia

Hawaii

Idaho

Minnesota

New Jersey

New York (Medicaid Advantage Plus (MAP) Model)

Tennessee

Virginia

Wisconsin

Information about D-SNP Look-Alikes

Integration

Integration Status for Contract Year 2024 D-SNPs (09/2023) (XLSX)
Integration Status for Contract Year 2023 D-SNPs (01/09/2023) (XLSX)
Integration Status for Contract Year 2022 D-SNPs (01/05/2022) (XLSX)
Integration Status for Contract Year 2021 D-SNPs (last updated 02/22/2021) (XLSX)
Frequently Asked Questions on Coordinating Medicaid Benefits and Dual Eligible Special Needs Plans Supplemental Benefits (PDF)
DSNPs COVID-19 CY2021 State Medicaid Agency Contract Requirements (04/13/2020) (PDF) outlines updated CMS processes for review and approval of state Medicaid agency contracts for Contract Year 2021
Additional Guidance on CY2021 Medicare-Medicaid Integration Requirements for D-SNPs (01/17/2020) (PDF)

D-SNP Enrollee Advisory Committees

D-SNP EAC Strategic Conversation Lessons Learned (06/18/2024) (PDF)

Unified Appeals and Grievances

CMS released the Coverage Decision Letter (ZIP) in English and Spanish for Applicable Integrated Plans. Please refer to the accompanying OMB-Approved Applicable Integrated Plan Coverage Decision Letter Memorandum (PDF) that announced the release on November 17, 2023.
CMS released the updated Addendum to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (08/2022) (PDF) for Applicable Integrated Plans. For more information on the Guidance Addenda please see the December 3, 2020 Parts C & D Addendum Memorandum (PDF).
CMS released the Letter about Your Right to Make a Fast Complaint (ZIP) and Appeal Decision Letter (ZIP) in English and Spanish for Applicable Integrated Plans. For more information on these notices, please see the November 20, 2020 CY 2021 D-SNP Integrated Notices Memorandum (PDF).
CY 2021 Denial notices for Medicare Advantage Organizations (MAOs) Integrating Medicare and Medicaid Benefits (PDF) identifies which version of the denial notice a MAO should use depending on the type of plan offered.
CMS released the CY 2021 Part C Reporting Updates for Applicable Integrated Plans and the Unified Appeals and Grievance Procedures (PDF) which identifies Part C reporting updates for Applicable Integrated Plans.
Medicare-Medicaid Integration and Unified Appeals and Grievance Requirements for State Medicaid Agency Contracts with D-SNPs for Contract Year 2021, a CMCS Informational Bulletin that summarizes the requirements of the April 2019 final rule and highlights important information that states need to ensure that D-SNPs in their market meet the new integration and unified appeals and grievance requirements beginning in 2021.
CY 2021 Medicare-Medicaid Integration & Unified Appeals & Grievance Requirements for D-SNPs Memorandum (10/07/2019) (PDF) (PDF).

More information about D-SNPs can be found on the Medicare D-SNPs page.

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Page Last Modified:

07/16/2024 10:18 AM

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