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Table 1 Integration Options for Medicaid with Special Needs Plans for Dual-Eligible Medicare Beneficiaries

From: Strange Bedfellows: Coordinating Medicare and Medicaid to Achieve Cost-Effective Care for Patients with the Greatest Health Needs

Type of alignment (from least to most integrated) Description and requirements Payment model States and statistics
Dual-Eligible Special Needs Plans (D-SNPs) - Must contract with state Medicaid agencies.
- Subject to 8 minimum requirements to provide or arrange for Medicaid benefits, but integration not required.7
- Separate payments to Medicare and Medicaid.6
- No shared savings with Medicaid state programs.6
- 2.6 million enrollees.
- 480 plans.
- 42 states, PR and DC.4
D-SNPs with additional state-mandated covered services States can require D-SNPs to:3
- Cover Medicare premiums and cost-sharing (typically paid by Medicaid).
- Provide Medicaid acute care services not covered by Medicare (vision, dental, hearing, transportation, etc.).
- Provide or arrange for Medicaid MLTSS or behavioral health services.
- If the D-SNP covers Medicaid benefits, and no companion Medicaid plan exists, Medicaid capitated payments may go directly to the D-SNP.7 - Varies by state.
D-SNPs with Medicaid Managed Long-Term Services and Supports (MLTSS) plans - State Medicaid MLTSS plans either offer a companion D-SNP plan or states can require D-SNPs to operate MLTSS plans in the same geographic area.7
- Includes both Medicare and Medicaid benefits (LTSS and/or behavioral health services).5
- Allows for administrative alignment of these benefits when the plans are highly integrated.5
- If there is a companion Medicaid MLTSS plan, Medicaid capitated payments go directly to the Medicaid plan.7 -14 of 22 states with MLTSS programs have enhanced contracting between D-SNP and MLTSS.3
Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs) - Aligned Medicare and Medicaid benefits through a single managed care organization.2
- Integrated enrollment process and administrative alignment of Medicare and Medicaid.3
- Must cover Medicaid benefits with LTSS, and nursing facility services for at least 180 days per plan year.9
- Plan receives separate capitation payments from Medicare and Medicaid and integrates services.5, 6
- Savings from reduced Medicare service go to Medicare, no mechanism for shared savings with state.6
- 201,765 enrollees.
- 45 plans.
- 10 states.4