As Medicaid agencies enhance their contracting with dual eligible special needs plans (D-SNPs) and enrollment in these health plans increases, it is important to develop strategies that address health inequities affecting people eligible for both Medicare and Medicaid. To achieve this, Medicaid agencies are aligning D-SNP contract requirements and oversight with broader Medicaid goals, including those focused on advancing health equity. Given the disparities faced by this population, a critical question to address is: How are Medicaid agencies working to advance health equity for dually eligible individuals and build needed Medicare knowledge to support this goal?

To answer this question, the Center for Health Care Strategies (CHCS) spoke with Medicaid officials from California, Kentucky, and Oregon, where health equity is a growing priority within their D-SNP landscape. These states are working to improve care delivery and health outcomes for dually eligible individuals by addressing the interdependent factors that influence health equity, while also developing an understanding of evolving federal D-SNP requirements. This blog post features insights from these states, including how the agencies are developing the Medicare knowledge necessary to advance their health equity goals.

A Medicaid Population Health Strategy: Where Do D-SNPs Fit?

A Medicaid agency’s broader population health strategy can act as a springboard for D-SNP program efforts to improve care access and outcomes. Each of the three states we interviewed created a mechanism to prioritize and address disparities in outcomes for their D-SNP populations, aligning these efforts with their broad health equity objectives.

In California, the Department of Health Care Services (DHCS) prioritizes equity in its quality strategy for the state’s Medicaid program, focusing on high-risk populations. This focus prompted DHCS to review race and ethnicity data within its integrated D-SNP program. DHCS is considering using the health equity goals embedded in the state’s quality strategy and available Medicare and Medicaid data to compare care and health outcomes for dually eligible subpopulations.

Oregon has demonstrated a deep commitment to health equity, releasing an ambitious strategic plan in 2024 to eliminate health inequities by 2030 — emphasizing community voice and culturally and linguistically competent care. To advance its plan, the Oregon Health Authority engages extensively with the communities it serves — deepening its knowledge of historic inequities and integrating community voice into agency efforts beyond where it is required by statute. Oregon also closely aligns the expectations of D-SNP and Coordinated Care Organization (CCO) contracts regarding language and disability access, as well as care coordination and quality improvement. Additionally, quality strategies were developed between D-SNPs and CCOs, which require the collection of race, ethnicity, language and disability and sexual orientation and gender identity data to improve care for dually eligible individuals.

Kentucky’s focus on better and more equitable health outcomes led to the creation of its Equity and Determinants of Health Branch within the Division of Quality and Population Health and a chief equity officer role within the Department for Medicaid Services. This branch collaborates with Medicaid managed care organizations and other partners to address health-related social needs and promote whole-person care. This branch also supports D-SNP program staff in developing strategies to advance health equity for D-SNP enrollees.

How States Are Partnering with D-SNPs to Address Inequities

Medicaid agencies can pursue multiple strategies to promote health equity. California, Oregon, and Kentucky are using their foundational knowledge of Medicare Advantage requirements and making policy decisions to broaden their states’ health equity efforts to include D-SNP populations.

Oregon created a transformation quality strategy that requires meaningful collaboration across Medicaid and Medicare Advantage plans through yearly mandated projects. These projects offer an opportunity for both quality improvement and innovation in care and care delivery, focusing on both improving outcomes for dually eligible individuals with special health care needs (such as chronic conditions or long-term services and supports needs) and fostering partnerships between D-SNPs and the state’s CCOs. Each project includes a requirement to use demographic data to uncover and track health disparities across groups within a priority population.

In California, D-SNPs are required to stratify reporting on HEDIS measures by race and ethnicity. DHCS also developed data profiles to better understand the state’s dually eligible population, including an analysis of language and cultural demographics. These profiles can help identify disparities and guide the development of health equity goals. For example, data might suggest requiring D-SNPs to translate enrollee materials into additional languages, beyond the Medicare translation standard, to help more dually eligible subpopulations understand their full scope of coverage. California also receives important insights into the care experiences of the dually eligible population by combining standardized quality metrics with stratified enrollee utilization data. For example, the state’s Long-Term Services and Supports Dashboard sheds light on opportunities to address disparities and improve care delivery across the state.

Kentucky plans to apply an equity lens when evaluating D-SNP Models of Care and health risk assessments to help identify health disparities. The state is also planning to examine how access to and use of Medicare Advantage supplemental benefits may vary by race, ethnicity, and gender. In doing so, the state and D-SNP partners will better understand potential access barriers among subpopulations and can devise appropriate strategies to remove them.

As Medicaid agencies and D-SNPs collaborate to create a more equitable system of care for dually eligible individuals, they can also capture valuable enrollee perspectives through D-SNP enrollee advisory committees (EACs). D-SNPs are required to use EAC findings to improve access to covered services, coordination of services, and health equity among underserved populations within the plan. State officials in Kentucky, for example, attend EAC sessions to learn from enrollees and regularly meet with D-SNPs to discuss enrollee issues or trends related to health equity that are identified through the EAC.

Understanding Federal Requirements: Resources to Enhance Medicare Capacity

As Medicaid agencies work to reduce health disparities for their dually eligible populations, they need to understand the Medicare policies and processes under which D-SNPs operate and how the Centers for Medicare & Medicaid Services (CMS) approaches health equity.

Medicaid agencies engaged in CHCS’ Medicare Academy have increased awareness of and capacity around evolving federal requirements, as well as how Medicaid agencies and health plans can use data to identify disparities. Since participating in the Medicare Academy, California continues to build its Medicare knowledge through its partnerships with the CMS’ Medicare-Medicaid Coordination Office, its D-SNPs, and member advocates. Kentucky, a recent Medicare Academy participant, is similarly building its knowledge and exploring new D-SNP partnerships.

The following resources are also available to Medicaid agencies to support Medicare capacity building:

• Technical assistance available through the State Data Resource Center is enhancing the capacity of states, like California, to develop reporting requirements to address health inequities.
• States can stay abreast of CMS’ efforts to address disparities in care and outcomes through resources from the Integrated Care Resource Center, including changes in Medicare Advantage regulations and D-SNP policy.
• Medicaid agency staff just beginning to develop their Medicare capacity can use CHCS’ Medicare Advantage Policy Basics video series to build a foundational understanding of what Medicare Advantage program features matter for Medicaid agencies contracting with D-SNPs.
• Policymakers can explore a new database, The People Say, that catalogues older adult perspectives on health care access, caregiving support, transportation, and other critical issues. The interactive tool draws insights from hundreds of interviews, amplifying voices often overlooked in policymaking, including people of color, those with low incomes, and individuals from geographically underrepresented areas.

These resources are readily available to Medicaid and partner agencies seeking to improve care for D-SNP enrollees.