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Supporting VulnerablePopulations: DSNP 101Florida Council on AgingJuly 2021 2021 United HealthCare Services, Inc. All Rights Reserved.
Agenda1234Dually Eligible IndividualsD-SNP ProductIntegration RequirementsProgram Design 2021 United HealthCare Services, Inc. All Rights Reserved.
1234Dually Eligible IndividualsD-SNP ProductIntegration RequirementsProgram Design 2021 United HealthCare Services, Inc. All Rights Reserved.
Dually eligible individuals represent aheterogeneous and vulnerable population thatmust navigate an uncoordinated set of benefits,eligibility criteria, providers, and cost-sharingrequirements. 2021 United HealthCare Services, Inc. All Rights Reserved.
Key Facts on Dually Eligible Individuals55%1 in 349%Of dually eligible individuals livebelow the poverty lineDually eligible individuals havetransportation needs gettingto/from medical appointments.Nearly half report they havemissed a medicalappointment because of thelack of transportationOf dually eligible individualsutilize long-term services andsupports (LTSS) 2021 United HealthCare Services, Inc. All Rights Reserved.
Key Facts onDually EligibleIndividuals inFlorida 2021 United HealthCare Services, Inc. All Rights Reserved.50%Percent of eligible dualsenrolled in D-SNPs19%Duals as a percent ofMedicare beneficiaries inFlorida
1234Dually Eligible IndividualsD-SNP ProductIntegration RequirementsProgram Design 2021 United HealthCare Services, Inc. All Rights Reserved.
What is Medicaid?Medicaid is health care coverage for people with low incomes. Pregnant women, children,the elderly and people with a disability may qualify.Most Medicaid programs cover:Doctor visitsHospitalstaysCare edicaid is the largest health insurance program in the nation.72MAmericans are on Medicaid*Covers health for more than 1 in 3 children*** Total monthly Medicaid/ CHIP enrollment, Feb. 2016 (Kaiser Family Foundation)**43% of Medicaid Population are children (medicaid.gov) 2021 United HealthCare Services, Inc. All Rights Reserved.8
What is Medicare?Medicare is a federal health insurance program by the Centers for Medicare and MedicaidServices (CMS).Medicare provides coverage for consumers who are: Age 65 and olderUnder 65 with certain disabilities, andAny age with End-Stage Renal DiseaseIndividuals who meet eligibility requirements are automatically enrolled by: Social Security Administration (SSA)Railroad Retirement Board (RRB) 2021 United HealthCare Services, Inc. All Rights Reserved.9
Medicare PartsMedicare consists of four parts: A, B, C and D. Parts A and B together are referred to as Original MedicareAll parts of Medicare include cost sharing and specific eligibility qualificationsMedicare Part A: Hospital Insurance Helps with the cost of inpatient hospital stays and skilled nursing home costsMedicare Part B: Medical Insurance Helps with the cost of medically necessary doctor visits and other medicalservices including outpatient care at hospitals and clinics, lab tests, somediagnostic screenings and some skilled nursing carePart C: Medicare Advantage Plans Combines services under Part A and B into one package (hospital and medicalinsurance) and generally offers additional benefits such as vision, dental andhearing, and many include Part D prescription drug coverageMedicare Part D: Prescription Drug Coverage Helps with the cost of prescription drug coverage 2021 United HealthCare Services, Inc. All Rights Reserved.10
What does Original Medicare Not Cover?Many consumers are unaware that Medicare does not cover all healthcare servicesand costs.Some examples of what Original Medicare does not cover are: Care while traveling outside of the U.S., except under certain circumstancesRoutine dentalRoutine eye careRoutine hearing care (exams, hearing aids and fitting hearing aids)Deductibles, coinsurance and copayments 2021 United HealthCare Services, Inc. All Rights Reserved.11
The D-SNP ProductD-SNPs are Medicare Advantage plans for people who qualify for both Medicareand Medicaid. The elderly, people with disabilities and/or people with limited incomesmay qualify. Individuals must live in the D-SNP’s service area. Most programscover:Hospital staysDoctor visitsPrescriptiondrugsCoordination ofcare betweenMedicare &MedicaidAdditionalbenefits suchas dental,transportation,over thecounter goodsD-SNPs can help make health care more affordable. 2021 United HealthCare Services, Inc. All Rights Reserved.12
How a D-SNP Covers ServicesMedicare is the primary payer of medicalservices.Medicaid acts as a wraparound program,covering some of the out-of-pocket costs andbenefits not covered by Medicare such asunlimited transportation and long-term care.Medicare covers medical care such as: Hospital (Part A),Physician, diagnostic tests, post-acuteand other services (Part B), andPrescription drugs (Part D).Medicare beneficiaries are subject to manyout-of-pocket costs; Medicaid picks up someof these for dual eligible beneficiaries. 2021 United HealthCare Services, Inc. All Rights Reserved.DSNPBeneficiaryMedicare Acute Visits Physicianservices SNF Acute HomeHealth DME Drugs (Part D)Medicaid Premiums Cost-sharing LTC/Waivers LT Home Health Supplies Other acute &drugs13
Additional D-SNP BenefitsTo meet the needs of this vulnerable population, D-SNPs offer additional benefitsand services outside of traditional Medicare and Medicaid.These benefits: Reduce barriers to care by supporting social and personal needs.Assist with independent living.Stretch members’ limited dollars.Whole Body Dental and VisionFoot careChiropracticAcupunctureHearing aidsAccess to Care 2021 United HealthCare Services, Inc. All Rights Reserved.Non-emergent andsocial needstransportationVirtual Visits24-Hour NurseLineFinancial OTC SuppliesFitnessMembershipAdult Day CareQuality of Life PersonalEmergencyResponse SystemFood and MealPrograms14
Value of D-SNPs Offer high-value benefitsand services nottypically available inMedicare or Medicaid. Offer comprehensivepackage with aconsumer-centric focus. 2021 United HealthCare Services, Inc. All Rights Reserved. Coordinate benefitscoverage betweenMedicare andMedicaid.Members have accessto more services andreceive morecoordinated care. Providers have greaterpotential to improvepatient compliance. The State has greaterpotential for costsavings through moreappropriate utilization
1234Dually Eligible IndividualsD-SNP ProductIntegration RequirementsProgram Design 2021 United HealthCare Services, Inc. All Rights Reserved.
D-SNP Plan Requirements As a Medicare Advantage Plan, D-SNPs must followCMS rules. Beneficiaries enrolled in a D-SNP must beeligible for Medicare and Medicaid. D-SNPs must coordinate Medicare andMedicaid benefits. D-SNPs offer supplemental benefitsbeyond required Medicare and Medicaidbenefits. D-SNPs requires a signed StateMedicaid Agency Contract (SMAC)with the State. 2021 United HealthCare Services, Inc. All Rights Reserved.D-SNPs areMedicare Advantageplans.
Federal D-SNP Policy Changes Coordination:2020Integration:2021 CMS clarified the definition of D-SNP in a way thatenhances Medicaid-Medicare coordination at themember levelD-SNPs must meet integration standards with Medicaidprograms 2021 United HealthCare Services, Inc. All Rights Reserved.Creates a moreseamless front-endexperience formembersAllows bettersystem levelintegration todecreasefragmentation18
Pathways to Meet Integration RequirementsD-SNP entity does not bearMedicaid riskCare Transitions DataSharing D-SNP– Medicare Advantage producttailored to duals, coordinated withMedicaid– Shares care transition data withstate and/or Medicaid plans when“high-risk” full dual is admitted tohospital or SNF– State defines details of caretransitions data sharing 2021 United HealthCare Services, Inc. All Rights Reserved.D-SNP entity bears Medicaid riskHIDE-SNP– Parent organization of D-SNP hascapitated managed long-termservices and supports (MLTSS)and/or behavioral health contract– Provides opportunity for alignmentin the same organization forMedicaid and Medicare benefitsFIDE-SNP– Either the D-SNP or an affiliatedMedicaid managed careorganization (MCO) offered by thesame legal entity as the D-SNPmust cover both institutional andcommunity-based LTSS– Behavioral health is required(unless carved out by State)– FIDE-SNPs may be eligible for apayment adjustment to account forthe cost of serving a highconcentration of frail individuals
1234Dually Eligible IndividualsD-SNP ProductIntegration RequirementsProgram Design 2021 United HealthCare Services, Inc. All Rights Reserved.
D-SNP Program Design FeaturesStates have flexibility to leverage different payment models andprogram design features to integrate careFlexibility CMS encouraging benefit designflexibility Ability to tailor D-SNPs topopulation needs 2021 United HealthCare Services, Inc. All Rights Reserved.SupplementalBenefitsImproved MemberExperience Healthy food Over the Counter (OTC) card One member card Improved care coordination Unlimited transportation
Topics to WatchInclusion of partial duals in DSNP plansLongevity of MMPdemonstrationBiden administration priorities 2021 United HealthCare Services, Inc. All Rights Reserved.
Questions?Sarah RubinPolicy Director, Dual Eligibles & Special NeedsPlansNational Policy & Influence TeamUnitedHealthcare Community & StateE sarah [email protected] 2021 United HealthCare Services, Inc. All Rights Reserved.23
Medicare Parts. 10. Medicare consists of four parts: A, B, C and D. Parts A and B together are referred to as Original Medicare All parts of Medicare include cost sharing and specific eligibility qualifications. Medicare Part A: Hospital Insurance Helps with the cost o
