D-SNPs: Integration & Unified Appeals & Grievance Requirements

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

Resource for New Special Enrollment Periods for Dually Eligible and Low-Income Subsidy Eligible Individuals

New! Effective January 1, 2025, the quarterly Dual/LIS SEP will sunset. It will be replaced by a new Dual/LIS SEP that will allow dually eligible and LIS-only eligible individuals to elect a standalone prescription drug plan (PDP) in any month. In addition, effective January 1, 2025, a new Integrated Care SEP will allow full-benefit dually eligible individuals to elect an integrated dual eligible special needs plan (D-SNP) in any month to align coverage with a Medicaid managed care organization. CMS designed this resource [New SEPs for Dually Eligible and LIS Individuals (PDF)] to provide an overview of the new SEPs and help anyone who assists dually eligible and LIS-only eligible individuals with their Medicare coverage choices to better understand eligibility for and availability of both SEPs. 

NEW! 2025 Integrated D-SNPs

The CY 2025 Integrated D-SNPs List (XLSX) provides a sortable list of 2025 Integrated D-SNPs.  These D-SNPs are able to enroll full-benefit dually eligible individuals in any month using the Integrated Care Special Enrollment Period (SEP).  Note: non-AIP D-SNPs can only use this SEP to align enrollment to an affiliated Medicaid Managed Care Organization.

New! Model Materials

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

Model Material Updates

• CY 2025 AIP D-SNP Model Material Updates Memorandum (08/29/2024) (PDF)

California

• CY 2025 California AIP D-SNP Model Materials Memo (ZIP)
• CY 2025 California AIP D-SNP Model Materials (ZIP)

District of Columbia

• CY 2025 District of Columbia AIP D-SNP Model Materials Memo (ZIP)
• CY 2025 District of Columbia AIP D-SNP Model Materials (ZIP)

Hawaii

• CY 2025 Hawaii AIP D-SNP Model Materials Memo (PDF)
• CY 2025 Hawaii AIP D-SNP Model Materials (ZIP)

Idaho

• CY 2025 Idaho AIP D-SNP Model Materials Memo (ZIP)
• CY 2025 Idaho AIP D-SNP Model Materials (ZIP)

Minnesota

• CY 2025 Minnesota AIP D-SNP Model Materials Memo (PDF)
• CY 2025 Minnesota AIP D-SNP Model Materials (ZIP)

New Jersey

• CY 2025 New Jersey AIP D-SNP Model Materials Memo (ZIP)
• CY 2025 New Jersey AIP D-SNP Model Materials (ZIP)

New York (Medicaid Advantage Plus (MAP) Model)

• CY 2025 New York MAP D-SNP Model Materials Memo (ZIP)
• CY 2025 New York MAP AIP D-SNP Model Materials (ZIP)

Tennessee

• CY 2025 Tennessee AIP D-SNP Model Materials Memo (ZIP)
• CY 2025 Tennessee AIP D-SNP Model Materials (ZIP)

Virginia

• CY 2025 Virginia AIP D-SNP Model Materials Memo (PDF)
• CY 2025 Virginia AIP D-SNP Model Materials (ZIP)

Wisconsin

• CY 2025 Wisconsin AIP D-SNP Model Materials Memo (ZIP)
• CY 2025 Wisconsin AIP D-SNP Model Materials (ZIP)

Information about D-SNP Look-Alikes

• List of Contract Year 2024 D-SNP Look-Alikes (v2) (XLSX)
• List of Contract Year 2023 D-SNP Look-Alikes (XLSX)
• List of Contract Year 2022 D-SNP Look-Alikes (XLSX)

Integration

• Integration Status for Contract Year 2025 D-SNPs (09/2024) (XLSX)
• 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)

D-SNP Enrollee Advisory Committees

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

Unified Appeals and Grievances

• CMS released the 2025 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 July 26, 2024. Plans must begin using the updated Coverage Decision Letter on January 1, 2025.
• CMS released the 2024 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. Plans must begin using the Coverage Decision Letter no later than January 15, 2024.
• 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).

D-SNP Research

• 2024 Beneficiary Experience Research Results for the Dual Eligible Terms and Experience (DETE) Study in Minnesota and Arizona (10/24/2024) (PDF)

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

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