Operational Strategies for Successful D-SNPs Part 3: Care & Clinical

This is the final post in our three-part blog series discussing challenges and opportunities for health plans to administer Dual Special Needs Plans (D-SNPs), which are an emphasis for both the Centers for Medicare and Medicaid Services (CMS) and individual states. This final installment dives into indispensable care and clinical management planning and functions, which are the “secret sauce” of effective and successful integrated D-SNPs. This segment is co-written with Lisa Smith RN, an SS&C Product Manager of care management technology.

Embracing the opportunity

Coverage of dual eligibles is an expanding opportunity for managed care plans. CMS and half of the states have a strategic, bi-partisan interest in integrating Medicare and Medicaid coverage into single coverage entities.

If you haven’t had the opportunity to review the previous blogs in this series, you have missed building your strategy around:

• Staffing, system and administrative modifications needed for enrollment and claims adjudication
• Integral technology for the operation of the D-SNP program

Distinct Model of Care D-SNP Requirements

A key requirement distinguishing a D-SNP from traditional Medicare fee-for-service and standard Medicare Advantage plans is its Model of Care (MOC). Reviewed and approved by CMS, the MOC is tailored to serve the plan’s targeted dual eligible members and specifies the plan’s operational patient care strategy. The MOC must be submitted to CMS as part of the plan’s application, and is the blueprint on how it will engage and employ Care Management (CM). CMS reviews the MOC and its evaluation vendor, the National Committee for Quality Assurance (NCQA), and must detail the following:

Target Population for SNP

The target population submission describes the sub-population’s health status (medical, social, cognitive, living conditions, comorbidities) and health disparities (language, literacy, socioeconomic status, caregiver access). The MOC must include detailed demographics for its service area (population by age, gender, ethnicity, language and education level) and drill down to identify the most vulnerable sub-populations they’ll serve, such as those with multiple chronic conditions, cognitive limits, recurring emergency/urgent care use, multiple medication usage and/or functional limitations. The MOC must also provide a description of the services specifically tailored for such members, including community partnerships.

Care Coordination

The heart of a D-SNP MOC is the strategy and tactics used to coordinate the care of its vulnerable plan membership. For the MOC, a D-SNP provides a detailed description of how administrative and clinical staff facilitate care coordination, including health needs, member preferences and data, as well as how staff are trained to implement the model. Core operational components of every D-SNP MOC are:

• • Comprehensive initial and annual health risk assessment of each member’s physical, psychosocial and functional needs, using a comprehensive risk assessment tool  
  • Using assessment results, assemble an interdisciplinary care team (ICT), which includes key providers delivering care to the member
  • Development of a comprehensive individualized plan of care for each member, developed through the ICT, identifying goals and objectives with measurable outcomes, as well as specific services and benefits to be provided

Provider Network

D-SNPs must ensure their networks have specialized expertise and capacity to treat members the plan targets to cover, and that providers conduct evidence-based care and use recognized clinical and care transition protocols. This includes training the participating providers on these standards and requirements.

Quality Measurement and Performance Improvement

In addition to Medicare Advantage Star ratings, a D-SNP MOC must propose and measure metrics for:

• • Access to care
  • Improved health status
  • MOC process requirements
  • Prescription drug management
  • D-SNP’s MOC strategy’s impact on health outcomes

The plan is also advised to conduct member surveys and use survey and performance measures to support quality improvement.

Care Management Operational Strategies

The primary reason for establishing an integrated D-SNP is the cross-program synchronization and management that won’t otherwise occur when a dual eligible receives separate, less coordinated fee-for-service coverage under federal Medicare and state Medicaid. Integrated CM by FIDE or HIDE SNPs synchronizes the sometimes-misaligned incentives between Medicare (which doesn’t cover daily living, long-term care and social needs) and Medicaid (which won’t cover core acute medical and hospitalization treatment). For example, a care manager only responsible for Medicaid coverage coordination may not be concerned about patients’ frequent use of urgent care and ER use, and a Medicare-focused care manager won’t be as concerned about patients who need assistance with daily activities.

In addition to coordinating the two programs, D-SNP care managers must manage a population with greater care and social needs than typical individuals within either Medicare or Medicaid. According to 2021 CMS data on dual eligibles living in the community:

• 40 percent had fair or poor health.
• 55 percent had four or more chronic conditions.
• They were more than twice as likely to have difficulties performing several activities. of daily living than Medicare-only beneficiaries.

This data excludes dual eligibles residing in assisted living or skilled nursing facilities.

For typical insured individuals, care managers are usually engaged temporarily for specific high-cost procedures, such as hip or knee replacements or fractures, discharge planning or temporary common episodes, such as pre-natal, labor, delivery and post-partum care. In these situations, care managers focus on the procedure and transitions between acute and non-acute settings, including discharge planning to ensure needed services are in place. For dual eligibles, care coordination is an ongoing effort and can involve weekly or even daily monitoring and intervention. This commitment drives the required MOC processes listed earlier.

Initial and Annual Assessment: Plans arrange for, and should be in direct contact with, a member and/or their caregiver for a face-to-face (including telehealth) encounter, to include a thorough inventory of medical, functional, cognitive, psychosocial and mental health diagnoses and needs. Plans can stratify results for dissemination to the care team to develop or modify a Plan of Care. CMS just finalized a 2027 regulation requiring integrated D-SNPs to conduct health risk assessments for both Medicare and Medicaid coverage, rather than assess separate program-specific needs.

Interdisciplinary Care Team (ICT): This team, assembled by the plan, includes various providers beyond just a primary care physician. Each member brings demonstrated expertise and training, fulfilling specific roles aligned with their licensure to effectively treat individuals like the dual eligible members and the plan’s targeted population. Membership of the ICT is shaped by the needs identified in the assessment, and it is not simply an informal touch-base, since CMS requirements dictate that meeting minutes be taken. The ICT meets at least annually and is involved in the development of the member’s care plan.

Individualized Care Plan (ICP): The ICP is developed directly from diagnoses and needs identified in the initial assessment, and is created through the ICT. It is a vital tool for effective management of dual eligible members, serving as the road map of the plan’s goals and objectives.

The ICP maps out the direct care needs of each insured member, including specific services, treatments and benefits. Developed in collaboration with each member, it contains general plan-wide strategies applied to all members, with personalized service and treatment schedules tailored to each member. It also includes both broad and precise care authorizations tailored to the members’ needs.

The ICP should be updated after every annual re-assessment and after any discharge from hospital or nursing facility care.

Care Management Tactics

Completing the CMS MOC documentation alone doesn’t ensure the success of an integrated D-SNP program. Success or failure is largely determined by ongoing CM activities. This requires monitoring a generous, comprehensive benefit package with no member cost sharing, which covers a population with limited means, multiple chronic conditions, and often face social, behavioral, cognitive and/or functional impairments. Continuous, consistent or even aggressive daily care interventions are necessary to drive members to seek and maintain outpatient and drug treatment to manage their conditions. The goal is to keep members informed, supported and educated—minimizing the need for emergency room visits or treatments in hospitals or nursing homes. When acute facility care is required, the CM team steps in to authorize necessary care and coverage. The CM team will oversee member discharge and carefully manage transition to the next appropriate care setting.

On paper, an assessment, ICT and care plan sounds great, but they’re only as good as the effort that creates, supports and coordinates them, which include:

Care Management Staff: Compassionate, knowledgeable, versatile and creative plan clinical staff are critical to properly understand, respond and help members live fuller lives, retain them in the plan, and engage and coordinate their providers. CM staff must also help ensure that only medically necessary care is covered, helping maintain the plan’s financial sustainability.

Care management staff for integrated D-SNP plans must include expertise in Medicare and Medicaid, which means both clinical knowledge of medical and pharmacy treatment and social work skills. The team will be required to support activities related to the member’s daily living, which could include food, dressing, hygiene, transportation, social engagement and economic need. Covering both clinical and social needs is not simple, as staff often focus on one of the fields. Given the multiple health and functional conditions that dual eligibles typically suffer from, care managers must be versatile in multiple areas of medicine and coordinate care across multiple specialties.

Prior Authorization: A cost and quality control strategy, prior authorization ensures members receive only necessary, evidence-based, cost-effective and quality care by requiring plan review and approval of requested services and medications prior to approval and payment. Such reviews are more poignant for D-SNPs because of member health conditions and the plan’s generous coverage. For example, many integrated Medicare-Medicaid plans under the CMS Financial Alignment demonstration required prior authorization on all covered services, except for annual preventative care. CMS and states give D-SNPs substantial authority in setting prior authorization policy, and plans should be prudent in setting authorization parameters, considering what is critical to review versus what will displease providers (who can encourage members to leave the plan for traditional Medicare). Prior authorization decision technology can somewhat alleviate the latter issue, by generating real-time authorization decision responses for frequent coverage requests.

Provider Engagement: Plans need both dedicated care managers and engaged, cooperative provider relationships to achieve their MOC goals. Engaging providers can be as difficult as engaging members, given the complexity of treating dual eligibles with multiple health conditions, socio-economic challenges and demands. Cooperative providers commit to participating in specific ICTs and care plans, and successful integrated D-SNPs have strong provider collaboration and communication. Plans should consider financial incentives and prioritize sharing of data (such as member assessments and care plans) to help educate providers on patients’ needs beyond their specialty. Additionally, plans should collaborate with providers’ quality staff in large health systems to align with the systems’ CMS and Medicaid merit-based and accountable care objectives. One tool that will assist in information and collaboration is the mandated Provider Access API, to be implemented by 2027. Using this API, Medicare and Medicaid plans are required to share medical, drug and clinical data of patients with their attributed network providers via the Fast Healthcare Interoperability Resources (FHIR) data exchange standard for viewing of electronic medical record (EMR) system applications.

Care Management System Platform: A medical management platform, interfaced with plan medical and drug claims and customer service systems, is vital to aggregate utilization and engagement data, collect and organize clinical data, and distribute it across the care team. These platforms empower staff with information about proactive activities to improve member care outcomes.

A D-SNP’s CM platform requires modules to support member assessments, integrated case management, disease management, population health, management of long-term supports and services, home health, behavioral health and utilization management. All CM staff managing members should have access to assessments, care plans, communications, claims data, appointments and authorizations for a full health profile of the member. Other key system features to empower CM staff are:

The 2027 Provider Access API mandate for Medicare and Medicaid plans requires sharing health plan data via FHIR with providers. Additionally, the Prior Authorization FHIR API must establish a real-time data exchange with provider health record systems by 2027. This will enable easier and timelier exchanges of patient treatment information and care coordination between providers and plans.

Diligent, steadfast CM strategies and methods, employed with effective technology and undertaken in partnership with the member’s primary care provider, caregivers and local resources, are key to improving outcomes and quality of life for dual eligible beneficiaries by ensuring preventive treatment, reducing unnecessary care and limiting institutionalization. These methods also lead to a high-quality, effective and well-subscribed D-SNP program. For summary information on all the topics covered in this blog series, download our "A Comprehensive Guide to Effectively Managing Dual-Eligibles Through D-SNPs" whitepaper.

Reimagine your D-SNP program with SS&C—where cutting-edge technology meets decades of healthcare expertise. From seamless pharmacy claims processing with Domani Rx to robust medical claims solutions via AMISYS Advance, we deliver an integrated platform that powers every aspect of claims, enrollment and encounter management. But we don’t stop at technology. As your consultative partner, we bring actionable insights, strategic expertise and tailored recommendations to help you optimize operations, navigate complexity and elevate outcomes for your dual eligible members. Let’s build a smarter, stronger D-SNP program together.

Contact us today to see how SS&C can help your plan embrace the opportunity and succeed in serving dual eligibles.