D-SNP: For dual-eligible members, the time is now
Since the Medicare Modernization Act of 2003, the United States has steadily shifted away from traditional Medicare Part A and B, towards coverage under privately administered Medicare Advantage (MA) plans. Today, 25M Medicare beneficiaries (nearly 40% of people eligible for Medicare) are enrolled in MA, and an estimated 90% of Medicare-eligible individuals receive prescription drug coverage under Medicare Part D. This array of Medicare options is no doubt familiar to many Americans.
A lesser-known, and less-understood, growth area of Medicare Advantage is the ‘Special Needs Plan’ (SNP): an option uniquely designed for individuals who are simultaneously eligible for Medicare and Medicaid. Although SNP eligibility applies to 11 million individuals in the U.S. and boasts an annual growth rate of 7.3%, only 4 million individuals are currently enrolled in its program.
Why does such a broadly applicable program lag behind the enrollment success of Medicare Advantage? Put simply: SNP’s novelty and complexity have kept members at arm’s length. Although today SNP is a permanent fixture in the healthcare landscape, it was once (as recently as 2019!) little more than a demonstration project between the Centers for Medicare and Medicaid Services (CMS) and State Medicaid agencies. Moreover, members who are eligible for SNPs often experience complex circumstances; those who stand to benefit most from SNP enrollment have multiple physical and mental health challenges accompanied by a variety of social and disability needs.
Additionally, SNP’s promise to better manage the conditions of, and to provide a better experience to, many of a community’s most vulnerable individuals — namely, those over 65 who are experiencing poverty and those under 65 who experience disability — places a direct focus on complex populations most health plans have little experience in actively enrolling, managing, or engaging.
For many experts used to more ‘traditional’ healthcare arrangements, the contracting and administration aspects of SNP may seem a bit daunting. Navigation of SNP requires (at minimum) coordination of benefits between Medicare and Medicaid, or (at maximum) a full integration of benefits in a three-way contract between an MCO, State Medicaid Authority (SMA), and CMS. But while this no doubt layers complexity onto a traditional health plan’s operating model, it simultaneously creates a tremendous opportunity for that same plan — because, prior to the formation of a SNP, benefits and services covered by Medicare and Medicaid are wholly uncoordinated. Where once healthcare was approached in a piecemeal fashion, SNP requirements emphasize coordination and integration of Long Term Support Services (MLTSS) and behavioral health services. The result fashions a model of care that provides life-changing relief for members who are homebound, disabled, or who deal with challenging mental health and/or substance abuse issues.
