D-SNPs: Integration & Unified Appeals & Grievance Requirements

D-SNPs: Integration & Unified Appeals & Grievance Requirements
SPOTLIGHT & RELEASES
01/08/2025: CMS released the Frequently Asked Questions (FAQs) and Enrollment Scenarios for § 422.514(h) to prepare for implementation of the provisions beginning in CY 2027, as well as the State Medicaid Agency Contracts Submission Requirements for Contract Year 2026 & a revised Integration Status for Contract Year 2025 D-SNPs. More information is available below.
12/02/2024: CMS released the 2025 Coverage Decision Letter & accompanying Memo for Applicable Integrated Plans on 07/26/2024. Plans must begin using these models 01/01/2025. More information can be found below.
11/22/2024: CMS released the updated Addendum to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (effective 01/01/2025), & accompanying Memo, for Applicable Integrated Plans. More information can be found below.
10/24/24: CMS released the 2024 Beneficiary Experience Research Results for the Dual Eligible Terms and Experience (DETE) Study (Minnesota and Arizona). More information can be found below.
10/17/2024: CMS released the New SEPs for Dually Eligible and LIS Individuals. 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

 

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! Frequently Asked Questions (FAQs) and Enrollment Scenarios for § 422.514(h) (PDF)

The provisions at § 422.514(h) adopted in the Contract Year 2025 Medicare Advantage and Part D final rule, which go into effect beginning 2027, limit enrollment in certain D–SNPs to those individuals who are also enrolled in an affiliated Medicaid managed care organization (MCO) and limits the number of D–SNP plan benefit packages an MA organization, its parent organization, or entity that shares a parent organization with the MA organization, can offer in the same service area as an affiliated Medicaid MCO. CMS developed these FAQs to help MA organizations, states, and other interested parties prepare for implementation of the provisions at § 422.514(h) beginning in CY 2027. 

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

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

D-SNP Enrollee Advisory Committees

Unified Appeals and Grievances

D-SNP Research

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

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Page Last Modified:
01/08/2025 04:16 PM
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