Venn diagram of Medicare and Medicaid population with DSNP population in between.

9 min read

Executive Primer to Developing a High-Performing D-SNP Plan

Executive Primer to Developing a High-Performing D-SNP Plan

By Gen Gillespie and Mac Davis

Our experience tells us that organizations looking to enter the D-SNP space should undertake significant and time-intensive planning before launch.  Consider the following your executive primer to drive success and performance for your D-SNP product. 

Establishing Governance and Focus 

In the process of setting up your organization, it’s vital to think not only about the relative immediacy of your launch but also about the scope and opportunities for continued success. Creating operational accountability for long-term ownership — and constancy of quality, throughout — is an important piece of that puzzle. Whatever you launch today, your team will have to live with later. 

Establishing that measure of accountability and constancy relies heavily on understanding the unique complexities of your healthcare landscape. While there is some overlap between the Medicaid and D-SNP spaces, D-SNP is a relatively new product governed by the Centers for Medicare and Medicaid Services (CMS), and, in many cases, by state-specific Departments of Insurance. That reality means you’ll need to think about CMS Federal and State compliance as well as driving product success.   

Sound like a tall order? It can be. But here are some guiding principles: 

Do not establish a siloed D-SNP function. Instead, leverage the best-in-class assets, capabilities, and business processes you’ve already established and allow your core businesses to flourish in this dynamic D-SNP space.  

Create a forum and structure around Medicare accountability. In the majority of cases, Medicare provides both a richer benefit than Medicaid and more comprehensive compliance requirements. Orienting your governance around Medicare will not only equip you with the right internal safeguards, it will clarify the focus on Medicare aspects that need to be administered on behalf of CMS.   

Although you don’t have to set up dedicated Medicare Profit & Loss (P&L) leaders prior to launch, doing so is a proven best practice — in fact, it’s already strengthened many of the largest Medicare-Medicaid programs (MMP) available. Each of those programs reported benefits from being able to tailor their products for maximum performance in ways that deviate from Medicaid and other lines of business.  

Self-assess your experience. Belong Health’s team is well-versed in helping organizations assess their experience levels in respect to new and existing domains — but this is a process you can begin on your own!   

Consider evaluating each of your functions relative to experience and capacity, then grid those functions along four quadrants:

  • Strong Experience/Low Capacity
  • Low Experience/High Capacity
  • Strong Experience/High Capacity
  • Low Experience/Low Capacity

An honest evaluation, via this exercise, will help you form an initial hypothesis around which areas need focus for a successful launch. That hypothesis, in turn, provides vital information to test further planning, to support gap analyses, and to naturally guide the development of a strong timeline for launch.  

Build your D-SNP around key functions that can speed you to profitability. Our study of plans that transitioned into D-SNPs revealed they often struggle to find profit for the first three years with this product. This is little surprise, as there is no shortage of moving parts to consider — membership growth, underlying conditions, and early administrative costs among them — but getting to a point of profit is crucial, throughout.  

In the sections that follow, we’ll assume a launch of January 2024 as we explore five core functions to focus on to drive early plan performance — provided, of course, clear and consistent accountability remains in place.  

Core Function #1: The Bid Process

The bid process is nothing to take lightly. In addition to pricing the product you aim to create, a successful bid process assesses its level of profitability and competitiveness in the marketplace. Naturally, this discovery requires some serious research — Which competitors grew? Which didn’t? What benefits did they add or delete?  

Once Medicare releases its bid pricing tool and plan benefit package on April 1st, you’ll have only about two months (first Monday in June, at midnight) to turn in your bid.   

And once that bid process closes? You’ll immediately be back at work, ramping up the planning process for next year – What should expansion look like? What are competitive benefits? How do we stay ahead of other players in the space?  

These exhaustive processes benefit from year-round planning and an all-encompassing team effort. Involve your P&L leader, your finance lead, actuarial support, your sales team, and network analytics. All hands on deck!   

Core Function #2: Sales and Enrollment

Unsurprisingly, successful sales enrollment relies heavily on the health of the bid process outlined above. After all, it’s the bid that sets pricing and benefit structure to be marketed throughout the fall. And because you’re dealing with a benchmark-based program, sales and marketing work should begin in tandem with that bid process. Your sales and marketing lead will thank you for keeping them abreast of what product you’re taking to market and how you plan to get it there.  

In recent years, sales and enrollment processes have become more competitive than ever. Across nearly every geography in the country, there is now more choice for Medicare consumers.   

Remember: enrollment drives your top-line revenue and contributes to keeping your product afloat. To perform in Medicare Advantage, you’ll need a critical mass of membership.  Plans that outperform in Medicare sales and marketing typically get three things right – providing market-competitive benefits that address consumers’ needs and wants, contracting a competitive and marketable network, and implementing an effective planning process.  All three need to move in lockstep.  Why?  

Regarding benefits and network, consumers typically ask three questions of salespeople before picking a plan:  

  1. How much does it cost? (benefit and bid data)  
  2. Are my doctors in the network (network development data)  
  3. Are my needed services and drugs covered? (network development/sales data)  

With the benefit of strong groundwork from the bid and competitive networks aligned by end of Q1 prior to your launch year, Medicare sales teams can focus on using Q2 to test some of the backend functions you’ll use to enroll members and build campaigns for your sales team.   

And all this work positions a new Medicare plan well for Q3 — the most crucial quarter of all — when marketing efforts can begin in earnest, as Medicare confines marketing and sales to an Annual Enrollment Period (AEP) in Q4. If you can implement that planning process, by the time AEP arrives, you’ll be primed to swiftly generate leads, introduce them to customer service, and move them through an efficient sales pipeline.  

Core Function #3: Care Management

Care management is the center of a complex patient's healthcare experience. When done effectively, it forges invaluable relationships with physician networks as members’ healthcare journeys are made simpler.  

In developing your care management programs, you’ll need to decide upon your all-important model of care: essentially a guidebook that outlines how you provide for various populations.  

It is vital to develop your model of care through a team-based approach, engaging your Chief Medical Officer (CMO), head of Care Management, head of pharmacy, and other leaders from across your organization. Together, shape a program that deeply integrates customer service and centers around the member rather than the member’s health issues. After all, complex patients are far more than their individual conditions. 

Take note: Your model of care will need to be developed and submitted six months before the product launch. That means you’ll want to take a close look, as early as Q1, at how you’ll be implementing and delivering care.  

In Q2, you’ll submit your model of care while also evaluating your care management training to make sure it’s as effective as can be. In Q3, you can ramp up care management hiring — or even look internally to see how to make the most of the resources you may already have. By Q4, it will be time for readiness reviews and the training of your care team.  

Core Function #4: Risk Adjustment Strategy

The best time to work out your product’s risk adjustment strategy is before your first member is even enrolled. A strong and communicative relationship between provider and health plan fortifies this process and brings invaluable benefits to enrollees. Accurately capturing the overall clinical health of a member, and thereby arriving at a comprehensive risk score, isn’t just the best possible outcome for enrollees — it’s a signal all stakeholders are in fluid communication.   

In short, risk adjustment allows you to manage appropriate premium and payments in ways that yield extraordinary longitudinal health relationships and serve to build loyalty between enrolled member, program, and provider.  Health plans can then research the diagnosis codes that providers submit on claims to identify not only what types of benefits and programs are needed — but exactly who needs them. That all naturally folds into an approach to whole-person care that really does benefit everyone.  

Information gathering is essential to the health and effectiveness of your program, especially as it addresses the needs of the duals population. After all, these are people of many age groups, and of a wide variety of multiple compounding conditions and living situations, who resist easy categorization and who require truly empathetic and personalized support.  

Core Function #5: Network Development Strategy

In the Medicare Advantage space, network development strategy can be little more than a box-checking exercise. But in the D-SNP landscape, things get a lot more granular and complex to be successful. In such cases, it’s best to build your network specifically around the needs of the population you’ve set out to serve. It’s worth noting, for example, that D-SNP populations have a prevalence of mental health conditions — so your mental health network likely needs to be more robust than the minimum guidelines set forth by CMS.  

This attention to detail should extend to how you manage network performance later in the product lifecycle. Consider not just who is in your network but also why they are there and how best to engage with them in ways that drive performance. Mobilization of your provider network, and becoming a trusted partner with physicians, is just one way to set yourself (and your members) up for long-term success.  

Of course, building a strong and reliable network takes time — which is all the more reason to start working on this process as soon as possible. Perform a thorough gap analysis and get to know the geography and specificities of the population at hand. Reward risk, quality, and performance across your provider network. This analysis should extend to non-clinical community assets that are crucial for the D-SNP population. Mobilize and onboard community assets to be effective partners with you and your provider network in delivering life-changing support.     

With proper planning, accountability, focus on areas that drive early performance, and a splash of innovation, your D-SNP product will be a trusted and life-changing resource for countless members who might otherwise slip through the cracks of our system. 

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