Medicare Advantage: D-SNP Compliance with Care Coordination Requirements

OBJECTIVE

In Medicare Advantage (MA), Dual Eligible Special Needs Plans (D-SNPs) are designed to better manage and coordinate care for high-need patients who are dually eligible for both Medicare and Medicaid. For most health conditions, D-SNPs receive potentially higher MA payments than most other types of plans to care for their high-need patients. In addition, D-SNPs must fulfill certain care coordination requirements that do not apply to non-SNP MA plans, including the requirement to maintain procedures for care coordination activities following enrollee health risk assessments (HRAs). Despite these higher payments and additional requirements, OIG and other researchers have raised concerns about MA plans’ use of HRAs to generate payments without also coordinating followup care, as required for all D-SNPs. This evaluation will assess the extent to which select D-SNPs complied with certain care coordination requirements. We also will identify the strategies that select D-SNPs use to ensure care coordination for their enrollees. NOTE: This is a spin-off report from Medicare Advantage: Questionable Use of Health Risk Assessments Among Dual Eligible Special Needs Plans (OEI-03-25-00210).

TIMELINE