What Health Plans Should Know About Federal Changes for Dual Eligibles

Approximately 12 million people in the United States are dually eligible for Medicare and Medicaid. Because dual-eligible individuals and health plans serving this population must navigate two disparate coverage programs, their care is often fragmented and uncoordinated, and managed care plans may lack the ability to effectively manage the “whole person” across the two programs. While these problems are years old, the Centers for Medicare & Medicaid Services (CMS) and states are newly emphasizing a more integrated solution that puts a greater focus on managed care plans addressing the issue: Medicare Advantage dual-eligible special needs plans (D-SNPs), especially those considered “fully integrated” dual-eligible (FIDE) plans.

Earlier this year, CMS released its Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit programs’ final rule, which requires FIDE D-SNPs, or the health plans that offer them, to cover both Medicare and Medicaid benefits for the same enrollees and integrate their coverage. Implementing FIDE D-SNPs requires states and plans to be active participants in developing new coverage models, which presents myriad policy, regulatory and operational challenges, especially at the time when CMS is sunsetting other managed care models for duals.

In a new white paper, Manatt Health highlights five key takeaways from the CMS final rule that have important implications for health plans already operating in or considering entering the FIDE market.

To download the full white paper, click here.



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