Why Dual-Eligible Medicare Advantage Plans Hold Promise for SNFs | #specialneeds | #kids


With more long-term care provider organizations embracing Medicare Advantage institutional special needs plans (I-SNPs), the time might be right for skilled nursing operators to explore the potential benefits of expanding D-SNPs, or dual-eligible special needs plans.

Special needs plans provide services to “special needs individuals” such as institutionalized individuals and people with severe or disabling chronic conditions, as specified by the Centers for Medicare & Medicaid Services (CMS).

D-SNPs enroll individuals entitled to both Medicare and medical assistance from a state plan under Medicaid — the so-called “dual eligible” population.

Allison Rizer, principal with ATI Advisory, thinks the D-SNP model, which has been made permanent by Congress and is getting more investment from various states, could provide more incentive for SNFs to integrate more fully in value-based care.

Though the transition to value-based care has been slower in the skilled nursing space than other health care sectors, some like American Health Care Association President and CEO Mark Parkinson think it’s time for operators to shift further toward a focus on outcomes and value.

I-SNPs have been a natural entry point for skilled nursing organizations, because these MA plans specifically are designed for individuals who need a nursing home-level of care. So, providers have started their own I-SNPs or partnered with Medicare Advantage insurers to offer I-SNPs to residents, as a means for them to access benefits tailored to their needs. The idea is that by providing these more targeted and coordinated services, I-SNPs support resident wellbeing and drive down costs to the insurers.

D-SNPs are a less natural option for SNF participation. One reason is that they include more Medicare patients who tend not to need skilled nursing-level care.

But Rizer sees SNFs as playing an important role for dual eligibles, as the “sit at that window between Medicare and Medicaid.”

“SNFs are in a really important place for dual eligible beneficiaries because they are at that intersection of a dual eligible transitioning from a Medicare service in their facility to Medicaid service in the person’s home,” she explained. “So that’s also where I think SNFs can be a strong partner in integration to states if they can help states with those transfers to the home.”

Creating models that allow SNFs to scale out into people’s private homes is a challenge, Rizer said. But she has found that nursing facilities with provider-led I-SNPs are interested in expanding their portfolio into D-SNPs to serve as a better partner to their state.

“We are seeing nursing facilities express interest in the roles that they can play in D-SNP, and in the opposite direction, we are hearing states express interest in how they can better partner with I-SNPs in the spirit of integration,” Rizer said.

Furthermore, the end goal for D-SNPs is a seamless experience for the individual regardless of setting.

“SNFs have an opportunity to have a very organically integrated environment for dual eligibles,” Rizer added.

One challenge that remains is the barriers to entry for D-SNPs that do not exist for I-SNPs, one example being that states must approve all D-SNPs. And ATI Advisory believes that the D-SNP program could be expanded and improved — for example, if more states required D-SNP plans to include Medicare-Medicaid integration elements that up until now have been available only in a small number of states through the Financial Alignment Initiative (FAI) that dates to 2011.

FAI grants flexibilities and includes provisions related to enrollment, benefits and models of care and other elements to promote “the greatest amount of integration” between Medicare and Medicaid for dual eligible beneficiaries, according to ATI Advisory’s report.

Because there are misaligned financial incentives between Medicare and Medicaid payers, Rizer sees a lot of value in the partnership between the long-term care provider and the acute-care provider in creating that seamless experience.

“Integration is only going to increase. States are only going to continue to push this and CMS is only going to continue to push this,” she added. “Integration was exponentially exploding right before COVID and so as the COVID dust settles, we absolutely will see a return to that focus and I think an exponential increase in that focus.”



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