Dual Eligible Special Needs Plans in California
Return to MLTSS & Duals Integration Workgroup
Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage (MA) health plans which provide specialized care and wrap-around services for dual eligible beneficiaries (eligible for both Medicare and Medicaid). D-SNPs must have a State Medicaid Agency Contract (SMAC) with the Department of Health Care Services (DHCS) and DHCS can choose whether to contract with D-SNPs. The Bipartisan Budget Act (BBA) of 2018 permanently authorized D-SNPs, modified integration requirements, and established unified grievances and appeals procedures.
Transition to Statewide MLTSS and D-SNP Structure under CalAIM
Under the California Advancing and Innovating Medi-Cal initiative (CalAIM), DHCS is proposing to transition Cal MediConnect (CMC) and the Coordinated Care Initiative (CCI) to a statewide aligned Managed Long-Term Services and Supports (MLTSS) and D-SNP structure. DHCS will work with health plans, stakeholders, and CMS to transition and expand integrated care statewide. This policy is intended to help meet the statewide goals of improved care integration and person-centered care, under both the CalAIM and the California Master Plan for Aging and includes:
- Transitioning to mandatory MLTSS enrollment for dual eligible beneficiaries;
- Expanding availability of aligned D-SNPs for voluntary enrollment for dual eligible beneficiaries; and
- Strengthening care coordination and integration standards for plans serving dual eligible beneficiaries.
DHCS is convening the CalAIM MLTSS and Duals Integration Workgroup to work with stakeholders to support this transition beginning in February 2021.
D-SNP State Medicaid Agency Contract (SMAC) Boilerplates
Under aligned enrollment, beneficiaries can enroll in a Medi-Cal managed care plan (MCP) and D-SNP that are operated by the same parent organization for better care coordination and integration. The aligned enrollment will take place at different times depending on the county. In the Coordinated Care Initiative (CCI) counties, aligned enrollment begins in 2023. In non-CCI counties, aligned enrollment will phase-in as plans are ready and able, but not later than contract year 2025.
Difference Between Cal MediConnect Plans and Aligned D-SNPs
CMC is a demonstration project (part of the CCI) that combines both Medicare and Medi-Cal benefits (acute, primary, institutional, and home and community-based services) into a single benefit package for individuals who are fully eligible for both programs. CMC plans coordinate dual eligible members' Medicare and Medi-Cal benefits under a single health plan.
Aligned D-SNPs are MA plans operated by the same parent organization as a member's MCP. Unlike CMC plans, D-SNPs only offer Medicare benefits, but they must coordinate with a member's Medi-Cal benefits. California decided to use this D-SNP model to expand the care coordination and integration that duals in CCI counties were receiving from CMC plans on a statewide scale.
Standing-up New D-SNPs
Health plans may not stand up a new D-SNP in CCI counties prior to the end of the CCI (December 31, 2022), as Cal MediConnect plans will still be available to provide a high level of coordinated care. In accordance with California Welfare and Institution Code section §14132.277 subsection (d):
“[…] the department shall offer D-SNP contracts to D-SNP plans that were approved for the D-SNP plan's service areas as of January 1, 2013. In Coordinated Care Initiative counties, the department shall enter into D-SNP contracts with D-SNP plans only for excluded beneficiaries and for those beneficiaries identified in paragraphs (2) and (5) of subdivision (g)."
In non-CCI counties, DHCS will continue to contract with new D-SNPs. One year before aligned enrollment is effective in a county, DHCS will only newly contract with D-SNPs operated by an MCP in that county.