States are increasingly seeking to better integrate Medicare and Medicaid for dually eligible individuals by aligning Medicaid managed care organizations with dual eligible special needs plans (D-SNPs). While Medicaid agencies are responsible for ensuring the quality and performance of managed care programs, they also play a role in D-SNP oversight. To develop D-SNP monitoring and oversight strategies, Medicaid agencies must understand Medicare policies for D-SNPs, the Medicare data available to support oversight, and how to use and interpret these data. So, how can Medicaid agencies build Medicare knowledge to get the results they want from D-SNP-based Medicare-Medicaid integrated care programs?

To answer this question, the Center for Health Care Strategies (CHCS) spoke with Medicaid officials from the District of Columbia, Minnesota, and Washington State. This blog post features insights from the conversations, including how the Medicaid agencies developed the Medicare knowledge necessary to establish monitoring and oversight for integrated D-SNP models.

Understanding Medicare’s Oversight of D-SNPs

Medicaid agencies have specific goals in mind when they partner with D-SNPs to develop integrated care programs for their dually eligible populations. To achieve these results, Medicaid agencies need to develop oversight strategies that align with their priorities. The District of Columbia (the District), Minnesota, and Washington State all focused on improving care coordination and better coordinating Medicaid long-term services and supports (LTSS).

In developing its integrated program, the District sought to enhance care coordination for its fee-for-service (FFS) home- and community-based services (HCBS) waiver population, who were enrolled in coordination-only D-SNPs, by improving enrollee engagement in care, and ultimately reducing avoidable emergency department visits and hospitalizations. To develop a care coordination oversight strategy for the HCBS waiver population enrolled in D-SNPs, the District’s Medicaid agency staff worked with its D-SNPs to understand Centers for Medicare & Medicaid (CMS) requirements for the D-SNPs’ Model of Care (MOC) and reviewed the National Committee for Quality Assurance’s (NCQA’s) criteria for MOC review and approval. The District also considered how these Medicare policies and processes compared to the District’s Medicaid managed care requirements and sought to avoid duplication of efforts. Specifically, the District chose to focus on areas without Medicare oversight, such as network adequacy requirements for providers of Medicaid LTSS.

Similarly, Minnesota, an early pioneer of Medicare-Medicaid integration, incorporated Medicaid LTSS elements into its MOC to further integrate and coordinate care for D-SNP enrollees and streamline state oversight. State Medicaid staff sought to learn about MOC requirements and how CMS audits D-SNPs’ care coordination activities. In seeking to better understand Medicare policies and processes, Minnesota found that the results from established CMS auditing processes were helpful in informing how to best focus Medicaid agency monitoring efforts. Washington State also prioritized understanding its D-SNP MOC and what aspects of state Medicaid agency contract (SMAC) requirements fit into the established D-SNP MOC requirements. Washington ultimately added state requirements into the MOC and developed MOC compliance tools to support plan and state monitoring efforts.

Using Existing Audit and Data Resources to Increase Staff Bandwidth for Oversight

Medicaid officials emphasized the importance of using existing Medicare audit reports and data resources to help stretch their internal agency bandwidth for oversight. For example, CMS requires D-SNPs to report on certain data, such as the Healthcare Effectiveness Data and Information Set (HEDIS), Healthcare Outcomes Set, and Consumer Assessment of Health Plans. In addition, CMS audits plan data on SNP care coordination and Part C organization determinations, appeals, and grievances. Medicaid agencies can add language to SMACs requiring D-SNPs to submit data reports or audit findings that are not readily available to the Medicaid agency. Medicaid agencies can use existing resources, such as D-SNP-specific HEDIS measure results, to eliminate duplicative reporting requirements and maximize staffing efficiency. However, Medicaid agencies should consider when additional oversight requirements are necessary. For example, Washington State — recognizing that some CMS-required data is reported only at the contract level and not the D-SNP level — carefully considered what D-SNP data to obtain from CMS and what data to collect on its own, increasing the effectiveness of its oversight strategy.

Evolving Strategies and the Need for Continuous Capacity Building

A Medicaid agency’s D-SNP oversight strategy will evolve as Medicare requirements change and the agency advances its Medicare-Medicaid integration goals. For example, CMS recently provided states the option to require certain D-SNPs to operate in single-state, D-SNP-only contracts, which can enhance states’ visibility into D-SNP quality and operations. Medicaid agencies pursuing this opportunity will likely need to rethink their oversight strategies since it will bring new opportunities for coordination and collaboration between states and CMS on program audits, MOC review, and provider network adequacy exceptions. All Medicaid agencies should periodically reassess their D-SNP oversight approach, identify where data are needed or where existing data are not being used, and map new state integration goals and Medicare requirements.

Once established, D-SNP monitoring and oversight strategies can be aligned with emerging quality improvement goals for dually eligible individuals and broader Medicaid population health strategies. Given the diverse needs among the dually eligible population, the impact of D-SNP enrollment and care coordination efforts may vary significantly. To address this issue, the District identified an ongoing need to enhance Medicaid agency capacity to assess: (1) whether all dually eligible subpopulations are able to access benefits for which they are eligible; and (2) how D-SNPs are performing compared to FFS Medicaid. This assessment requires the agency to obtain comparable data from different programs to understand D-SNP performance. To facilitate this understanding, the District developed internally facing care management dashboards to monitor trends in D-SNP performance and has goals to develop more dashboards of required reporting. Similarly, Washington State presented unblinded performance measures to its plans, comparing FFS Medicaid and MCO populations against D-SNP populations.

Staff from the three Medicaid agencies we interviewed described how they invested in developing their D-SNP oversight strategies over time. Washington State prioritized its oversight strategy to focus on encounter data from D-SNPs, Medicaid and Medicare network alignment, and aligned performance measures. Today, Minnesota’s oversight and monitoring efforts include obtaining Medicare encounter data directly from D-SNPs to monitor quality measures, contract compliance, and partnering with plans and providers on quality improvement efforts. As oversight efforts evolve, Medicaid agencies can also assess the need to develop compliance tools and enforcement mechanisms. Minnesota, for example, established Medicaid payment-withhold measures in partnership with D-SNPs to improve enrollee access to care.

Just as oversight strategies need to adapt as integrated care programs become more sophisticated and federal regulations change, a Medicaid agency’s Medicare knowledge needs to evolve, as well. In recent years, Washington State placed more emphasis on D-SNPs as a platform for Medicare-Medicaid integration and expanded its oversight infrastructure to keep pace with this change. After participating in CHCS’ Medicare Academy, Washington created an ongoing training series to help its Medicaid agency staff and stakeholders build and maintain Medicare knowledge.

Resources to Build Integrated Care Expertise

As Medicaid agencies refine D-SNP oversight strategies, they need to understand the Medicare policies and processes under which D-SNPs operate, CMS’ approach to D-SNP oversight, and how available Medicare audit reports and data resources can aid Medicaid staff in this work. The Medicaid agencies in the District of Columbia, Minnesota, and Washington used external resources from the Integrated Care Resource Center,  CMS’ Medicare-Medicaid Coordination Office, NCQA, and CHCS’ Medicare Academy to build Medicare capacity and develop D-SNP oversight and monitoring strategies. Additionally, Washington benefited from the support of Arnold Ventures’ Advancing Medicare & Medicaid Integration. These resources are readily available to other states seeking to improve care for D-SNP enrollees.