As the federal government sets about promoting more integrated care for patients eligible for both Medicare and Medicaid, it is also considering cracking down on a type of health plan that could complicate that goal.
These plans, referred to as dual-eligible special needs (D-SNP) plan "look-alikes," are designed and marketed to attract dual-eligible patients, who may enroll thinking they will receive integrated Medicare and Medicaid benefits and extra care coordination. Instead, they find themselves in general Medicare Advantage plans without the ability to integrate with Medicaid and miss out on benefits they could receive elsewhere, critics argue.
D-SNP look-alikes have drawn the wrath of health insurers that offer true D-SNPs, which hold contracts with both the CMS and a state Medicaid agency, as well as advocates who worry the look-alikes confuse vulnerable patients. The issue was a topic at this week's spring meeting of the Special Needs Plan Alliance, which is partnering with several insurers, including L.A. Care Health Plan, to encourage the CMS to curb look-alike plans.
"Dually eligible individuals may be enrolling in plans that do not provide any integration on the Medicaid side when in fact they could benefit from it," said Dr. Cheryl Phillips, CEO of the SNP Alliance. "Yes, they have the right to choose (their health plan), and we support that, but we want to make sure that choice is transparent."
The CMS seems to be listening to those concerns. While the agency isn't acting yet, it is considering various ways to curb enrollment in look-alike plans in future regulation, from better educating dual-eligible individuals on their options or even rejecting applications for Medicare Advantage insurers to offer non-integrated plans that appear to target dual-eligible patients, as the Medicare Payment Advisory Commission has suggested.
D-SNPs, which were first offered in 2006, are Medicare Advantage plans that limit enrollment to dual-eligible patients. These contracts allow states to encourage or require the D-SNPs to integrate Medicare and Medicaid benefits for their members. For example, a patient may receive hospital and physician services from Medicare Advantage, while Medicaid may pay for that patient's Medicare cost-sharing, behavioral health services or long-term care benefits.
Of the more than 10 million dually eligible individuals in the United States, 1.7 million were enrolled in D-SNPs in 40 states and the District of Columbia as of January 2018, according to MedPAC. Dual-eligibles, who are generally very poor with complex health needs, represented a fifth of Medicare beneficiaries but accounted for 34% of total Medicare spending in 2013, and made up 15% of Medicaid beneficiaries but accounted for 32% of total Medicaid spending, according to MedPAC.
While they are meant to offer integrated benefits, oftentimes D-SNPs have little integration because of administrative and operational challenges, MedPAC has noted. The Bipartisan Budget Act of 2018 sought to address that by laying out a "road map" to improve integration between Medicaid and Medicare in D-SNPs and streamline the grievance and appeals process for dual-eligible members, explained Alex Shekhdar, a Medicaid managed-care expert.
In theory, having dual-eligibles receive integrated Medicare Advantage, Part D and Medicaid benefits from one organization should eliminate those inefficiencies, provide more coordinated care, improve quality and lower the cost of that care. But comprehensive data on D-SNP quality and spending is lacking, several sources said.
The CMS is starting to put the budget act's requirements into motion by holding D-SNPs to a stricter standard of showing they are integrated with a state Medicaid agency, effective in 2021.
But D-SNP look-alikes get in the way of those goals, critics say.
"Members are not going to get the same level of care; they are not going to get the care coordination that they get in the fully integrated plan," said John Baackes, CEO of L.A. Care, which serves 16,000 dual-eligible members in California's Medicare-Medicaid demonstration plans. "So we are very concerned about them and looking for ways we can advise CMS and the state on ways they can isolate these programs so they are sold for what they are and not what they pretend to be."
The CMS also noted in its final call letter that the look-alike plans may undermine state integration efforts and impede goals of lowering cost and improving quality of care.
Still, some insurers say there are situations in which D-SNP look-alikes have a place.
Blue Shield of California, which offers a D-SNP look-alike, said in a statement: "While we wholeheartedly support integrated programs, our (D-SNP look-alike) plan makes managed care available to those members who choose not to enroll in our Cal MediConnect product and don't have the option to enroll in a D-SNP."
Look-alike plans have proliferated in recent years for various reasons. They started in California, but the SNP Alliance's Phillips said look-alike plans are now offered in an estimated 34 states. The latest data from MedPAC shows that in 2017, there were 19 look-alike plans with 95,000 combined enrollees in seven counties of California alone, compared with just four plans with 5,000 members in those areas in 2013. Enrollment in look-alike plans has surpassed enrollment in true D-SNPs, which served 72,700 members in those seven California counties in 2017.