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 1. Home
 2. HealthEdge Blog
 3. 4 Changes in the 2023 Final Rule that Every D-SNP Health Plan Should Know


4 CHANGES IN THE 2023 FINAL RULE THAT EVERY D-SNP HEALTH PLAN SHOULD KNOW

Published Date May 25, 2023 Author Maggie Brown


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 * 
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In the CY 2023 Final Rule, CMS made several changes that directly impact plans
offering Dual Eligible Special Needs Plan (D-SNP) programs, which are a type of
Medicare Advantage (MA) plan that are designed specifically for individuals who
are eligible for both Medicare and Medicaid.

In general, the 2023 changes are intended to make the D-SNP population more
attractive for providers, and therefore increase access to care for these
beneficiaries. For payers, these changes are intended to increase clarification
regarding different D-SNP programs and reduce the administrative burden of
offering separate MA and D-SNP programs. However, many payers are concerned
about the impact these changes will have on their bottom lines.

Here are four changes from the 2023 Final Rule that we believe deserve
additional consideration.

 1. Capturing Social Determinants of Health (SDOH) Data

The Final Rule requires D-SNPs to incorporate one or more questions in their
standard health risk assessments (HRA) addressing beneficiary housing, food
insecurities, and transportation. Acknowledging that many factors other than
physical health go into a person’s ability to maintain their health, many
physicians have already started collecting this type of information, which is
commonly referred to as social determinants of health (SDoH). The goal of taking
a more holistic view of a patient’s life, including psychological, functional,
and environmental factors, is to increase the likelihood of better health
outcomes and lower the total cost of care. Care management teams within many
health plans are also on board with collecting SDoH data and are already using
this data to tailor services beyond medical benefits to achieve optimal health
outcomes. Some care management platforms, like GuidingCare®, have already
released capabilities within their platform that help health plans more
systematically integrate SDOH into their care management programs.

 2. Recalculation of the Maximum Out of Pocket (MOOP)

CMS also finalized changes to the way Medicare Advantage plans calculate MOOP,
requiring plans to include all cost-sharing, including those paid by secondary
payers, in the calculation of the beneficiary’s MOOP. Previously, MOOP was
calculated only by the amount the enrollee had to contribute. The result?
Beneficiaries are likely to reach MOOP faster, and health plans will have to pay
100% of the service costs sooner. Some industry experts believe this change will
result in an additional $4B in costs to health plans, but the improvement in
health outcomes and improved access to medical and non-medical care is projected
to save $3B. Despite the pushback from health plans on this change, CMS
proceeded with the implementation of this and made it effective June 1, 2023.
The complexities and urgency of the implementation of this change is a perfect
example of why health plans need a modern, highly flexible core administrative
processing system (CAPS) like HealthRules® Payer.

 3. Enrollee Participation in Plan Governance

Medicare Advantage organizations offering a D-SNP must establish one or more
enrollee advisory committees in each state to solicit direct input from
beneficiaries on their experiences with the plan. Plans that operate D-SNPs in
multiple states had to establish multiple committees, one for each state.
Although these committees must have a representative sample of the population
enrolled in this plan, very little direction was given about the committee
meeting frequency, location, format and training.

 4. Bringing Greater Definition to multiple Types of D-SNPs

Historically, the fully integrated dual eligible (FIDE) and highly integrated
dual eligible (HIDE) SNP definitions have been confusing and inconsistent.
Through this final rule, CMS is making changes to the definitions, which will
support a greater understanding of the different types of D-SNPs, clarify
beneficiary options, and improve integration. According to a National Law Review
article, this means all FIDE SNPs, with the same legal entity holding the MA and
Medicaid contract: 1) be capitated (with certain exceptions) for all Medicaid
services, and 2) operate unified grievance and appeal processes. CMS also
clarified the definition of HIDE SNPs requiring the plan to cover long-term
services and supports, including i) community-based long-term services and
supports and some days of coverage of nursing facility services during the plan
year; or (ii) behavioral health services. For plan year 2025 and subsequent
years, the FIDE and HIDE SNP must cover the entire service area for the dual
eligible special needs plan. By helping health plans enroll the appropriate
beneficiaries into the right categories and having the ability to create tiered
or dual networks, HealthRules Payer enables health plans to quickly spin up
whichever type of D-SNP program they believe would be most valuable for the
communities they serve.

Turning Mandates into Advantages

While the only constant in government health plans, including D-SNP programs, is
change, health plans with a highly configurable CAPS can turn mandates into
competitive advantages. For example, health plans using HealthRules Payer now
have the opportunity to pursue D-SNP populations with less IT and administrative
burdens because the system can be configured to address the unique D-SNP
requirements. Health plans don’t have to implement an entirely new system.
Things like dual networks and tiered networks are completely configurable in
HealthRules Payer. The business flexibility HealthRules Payer gives health plans
is unmatched and dramatically lowers the cost of entry into new lines of
business.

In addition, the requirement to capture additional data, such as SDoH, is
another opportunity for health plans to convert mandates into competitive
advantages. With modern data analytics and reporting solutions from HealthEdge,
plans can easily turn data into actionable insights that can help drive improved
member outcomes, higher HEDIS scores, and better Star ratings. For example, SDoH
insights can help care management teams configure new non-medical services, like
transportation or meal support, for certain populations. Utilization management
data collected can be folded into benefit plan development, and even fed into
payment integrity initiatives to minimize provider and member abrasion with more
accurate payments.

Looking at the Whole Picture

When regulatory changes such as those mentioned above are put in place, health
plans often make the mistake of just looking at the one part of their business
that is directly impacted instead of taking an end-to-end approach to
implementing the changes across their enterprise. That’s where the professional
services team at HealthEdge can be a health plan’s biggest asset. With years of
experience in helping government-related health plans properly configure their
systems to support regulatory changes, the team knows how to guide health plans
through all aspects of the business that may be impacted so that everything from
enrollment to claims coming in and payment going out are aligned.

To learn more about how HealthEdge solutions help health plans turn mandates
into advantages, visit www.healthedge.com or email info@healthedge.com.


ABOUT THE AUTHOR

Maggie Brown has over 30 years of leadership experience in healthcare and
insurance marketplace. Maggie transitioned from health plan management roles to
implementing core business solutions for numerous health plans around the
country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare
Prescription Drug, Improvement and Modernization Act of 2003 she focused on how
to ensure a health plan could implement key technology solutions, meeting the
needs of their members, while being compliant in a rapidly changing regulatory
environment. Maggie has led implementations for government programs at both new
and established managed care companies. Maggie holds a Doctor of Religious Arts
degree with a major in Pastoral Psychology.

Follow on Linkedin More Content by Maggie Brown


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