Dual Special Needs Plans (D-SNPs) are rapidly transforming the healthcare landscape. These plans offer specialized care coordination for a critical population: individuals who qualify for both Medicare and Medicaid (dual-eligible). As Managed Care Organizations (MCOs) increasingly embrace D-SNP plans, optimizing their implementation and management becomes essential. To see success with D-SNP and HMO D-SNP Models of Care (MOCs), organizations must adopt current best practices, such as ensuring compliance with CMS requirements, building strong interdisciplinary care teams, and fostering patient-centered care through data-driven decision making.
Explore some of the top strategies MCOs can use to effectively optimize a D-SNP model of care.
D-SNP Members: A Complex Population
D-SNPs are a type of Medicare Advantage plan designed specifically for dual-eligible individuals. To qualify for a D-SNP, individuals must be enrolled in both Medicare and Medicaid and reside in the service area offered by the D-SNP program.
- Dual Eligibility: Medicare eligibility typically comes with age (65+) or disability, while Medicaid is a needs-based program for low-income individuals and families. Common conditions that qualify individuals for dual eligibility include chronic diseases, disabilities, and low-income status. These criteria create an overlap suggesting potential health complexities, financial limitations, or functional impairments.
- Complex Needs: Dual-eligible individuals often have a wider range of medical and social needs compared to the general Medicare population. They may manage multiple chronic conditions, require assistance with daily living activities, or face mental health challenges.
- SDoH Factors: The income limitations associated with Medicaid eligibility can also indicate social determinants of health that can negatively impact well-being. Factors like reliable access to healthy food, safe and consistent housing, and reliable transportation can all influence health outcomes, particularly for D-SNP
Members of dual special needs plans often face a combination of medical, social, and economic challenges that make them vulnerable within the healthcare system. But D-SNPs are designed to address these vulnerabilities by providing coordinated care that caters to their specific needs.
The Challenges of Managing D-SNPs
Managed care organizations face many difficulties when managing dual special needs plans. The biggest obstacle is developing plans that address diverse medical, social, and economic needs, which are broader compared to the typical Medicare population. But there are other roadblocks that make D-SNP management daunting:
Navigating the Regulatory Landscape
D-SNP plans operate under a specific set of regulations established by the Centers for Medicare & Medicaid Services (CMS). These regulations encompass requirements for MOC standards, conducting Health Risk Assessments (HRAs), and ensuring care coordination. Staying up to date on these regulations and verifying compliance adds an administrative layer of complexity for MCOs.
Financial Considerations
Reimbursement structures for D-SNPs can differ from traditional Medicare Advantage plans. MCOs need to adapt their financial models to account for these differences and ensure program sustainability while delivering quality care.
Fragmented Care Systems
Historically, Medicare and Medicaid have operated somewhat independently. MCOs managing D-SNPs must bridge this gap and foster a more integrated care delivery system, which can require significant effort and collaboration with different healthcare providers and institutions.
Despite these challenges, D-SNPs hold significant potential for improving the lives of dual-eligible individuals. By providing comprehensive care coordination, D-SNPs can improve member health outcomes and potentially reduce overall healthcare costs.
Optimizing a D-SNP Model of Care
The model of care is the cornerstone of effective D-SNP implementation. It serves as a roadmap and quality improvement tool for care management and coordination processes, ensuring the unique needs of every enrolled dual-eligible member are identified, addressed, and continually monitored. By optimizing the MOC, managed care organizations can unlock the full potential of D-SNP plans, leading to improved member outcomes, enhanced program efficiency, and greater regulatory compliance.
Successful managed care organizations partner with an experienced consultant like Clearlink to adopt the following strategies:
- Compliance with CMS Requirements: MCOs must fully understand and adhere to CMS guidelines, including model of care standards, health risk assessments, and care coordination requirements. Clearlink can help you submit a D-SNP model of care and keep your staff trained and well-informed moving forward.
- Building Strong Interdisciplinary Teams: Effective D-SNP care requires collaboration between various healthcare professionals. Clearlink can help build and train interdisciplinary teams comprised of primary care providers, specialists, social workers, behavioral health professionals, and pharmacists. Through clear delineation of roles and specialized instruction, our experts ensure each team member understands their role in delivering comprehensive care while adhering to CMS regulations.
- Effective Care Management: Personalized care plans are critical for D-SNPs, which require the latest technology and best practices to develop and manage for each member. This includes leveraging EHRs for seamless information sharing, telehealth services for improved access to care, and regular follow-ups with care plan adjustments as needed.
- Enhancing Care Coordination: Strong community partnerships ensure access to vital social services, transportation, and housing assistance. Dedicated care coordinators and case managers can also facilitate smooth care transitions, especially during critical moments like hospital discharges.
- Patient-Centered Approaches: Patient engagement by involving members and caregivers in the care planning process is important. Through patient education initiatives, shared decision-making tools, and regular feedback mechanisms, D-SNPs can reflect individual needs and preferences, leading to better health outcomes and satisfaction.
- Data-Driven Decision Making: Advanced analytics can be used to identify at-risk members and prevent adverse events. Clearlink helps you establish key performance indicators to monitor D-SNP program effectiveness and employ health information exchanges for comprehensive data sharing and coordination. Through continuous data collection, analysis, and feedback loops, MCOs are able to refine care strategies for ongoing program improvement.
Finding a D-SNP Improvement Partner
Clearlink has helped many MCOs navigate the complexities of D-SNP model of care development, approval, product launching, and management. We have also provided support during product launch and continued post-implementation, providing advisory services for enrollment procedures, go-live stabilization, and vendor oversight and management.
Our expertise in regulatory compliance, care management, interdisciplinary team building, and other areas of clinical and operational management empower MCOs to optimize their D-SNP or HMO D-SNP programs for optimal long-term performance.
Is your organization looking to launch or optimize a D-SNP program? Contact us to learn how we can help you succeed.
Interested in seeing a case study that exemplifies our expertise? Read a free case study on D-SNP product design and delivery to learn how Clearlink helped a 400,000-member government program-focused managed care organization successfully launched its new D-SNP solution to provide high-value care for its members.