To reduce health disparities and advance equity, policymakers, health care providers, and payers are increasingly identifying ways to better understand the needs and experiences of the individuals and communities most impacted by discrimination and socioeconomic and environmental disadvantages. In keeping with this expanding practice and the goals described in its health equity strategic plan, the Centers for Medicare & Medicaid Services (CMS) released a final rule on April 29, 2022, that includes two key provisions aimed at centering the voices and needs of dually eligible individuals in the care provided by Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs).
Dually eligible individuals are older adults and people with disabilities who have low incomes and are eligible for care under both Medicare and Medicaid. This population contains higher proportions of people with disabilities and people of color than the population eligible for Medicare only, and is disproportionately impacted by social and environmental determinants of health. D-SNPs are specialized Medicare Advantage plans designed to serve this population.
The new requirements establish an important opportunity for states and D-SNPs to make real progress advancing health equity among dually eligible individuals. Gathering information by engaging these individuals directly and asking them about their needs, priorities, and experiences can lead to meaningful changes to the policies and operations of programs serving this diverse population.
Program improvement through enrollee advisory committees
Well-run enrollee advisory committees can support the inclusion of enrollee voices in plan decision making. The April 29 rule requires D-SNPs to establish and maintain at least one enrollee advisory committee that includes a “reasonably [geographically and demographically] representative sample” of individuals enrolled in the D-SNP. D-SNPs must also solicit input from those committees on ways to improve access to covered services, coordination of services, and health equity among underserved populations within the plan. The Accountable Health Communities (AHC) Model has developed resources for including and engaging community members as full participants on advisory boards.
The new requirements for dually eligible individuals are intentionally flexible, and state Medicaid agencies can use their contracts with D-SNPs to add more prescriptive requirements based on the characteristics and expectations of D-SNP enrollees within their states. In considering more prescriptive requirements, states might be interested in some of the comments discussed in the rule. For example, some comments suggest requiring a specific number of members on each committee who represent particular populations of D-SNP enrollees.
Federal law already requires enrollee advisory committees for Programs of All-Inclusive Care for the Elderly, Medicaid managed long-term services and supports, and Medicare-Medicaid Plans operating as part of state Financial Alignment Initiative demonstrations. Research shows that these committees have helped Medicare-Medicaid Plans improve how they deliver services, including their approaches to member outreach and communications, the benefits they offer, and how they address members’ social needs. Extending this requirement to D-SNPs expands the scope of these committees and makes them a foundational tool in integrated care programs for dually eligible individuals.
Screening improvements to address social needs
In 2024, the April 29 rule will also require all Special Needs Plans, including D-SNPs, to incorporate questions into their health risk assessments that ask about enrollees’ access to housing, food, and transportation. This requirement could also play an important role in promoting health equity among D-SNP enrollees by requiring D-SNPs to discuss identified risks and potential options for addressing enrollees’ unmet needs (for example, by referring an enrollee to a local community-based organization for assistance). D-SNPs will also have data on their enrollees’ housing, food, and transportation needs and can use those data to develop expanded supplemental benefits to address those needs. At both state and national levels, policymakers can also choose to collect this data from D-SNPs to study and address the health-related social needs of D-SNP enrollees, and the needs of dually eligible populations more broadly.
Next steps and opportunities
CMS explains in the April 29 rule that it plans to issue sub-regulatory guidance by the end of 2022 to establish the specific assessment tools from which D-SNPs can select questions to incorporate into their health risk assessments. CMS notes that it intends this guidance to provide multiple options for validated and widely-used assessment tools. The proposed version of the rule acknowledged the Health-Related Social Needs (HRSN) Screening Tool that CMS developed for the AHC Model to assess patients’ housing, food, transportation, utility, and safety needs. These provisions from the rule generate opportunities for CMS, states, and D-SNPs to use tools and expertise from organizations such as Mathematica, including case studies from AHC, screening tools, and technical assistance on ways to effectively implement and develop the use of enrollee advisory committees.
Health-related social needs are especially prevalent within dually eligible populations, and efforts to address these needs often show a valuable return on investment. We hope this new rule encourages states, D-SNPs and other integrated care plans, and health care providers to continue incorporating lessons from the AHC Model, questions from the HRSN Screening Tool, and tips from CMS’s screening guide for providers, health plans, and other entities, into their programs and services for dually eligible individuals. By using social-needs screening in interactions with dually eligible individuals, these entities can better serve these populations, as we’ve seen recently with some Medicare Advantage plans.
We also hope that state Medicaid agencies will use their contracts with D-SNPs when appropriate to promote the development of enrollee advisory committees that meaningfully engage diverse populations of D-SNP enrollees within their respective states. Some states with integrated care initiatives for dually eligible individuals might also wish to build program-wide consumer advisory committees, similar to the One Care Implementation Council in Massachusetts, to inform ongoing state oversight of those programs and attention to health equity.