Medicare Advantage DSNP Plans 2025
For those eligible for both Medicare and Medicaid, the upcoming Medicare Advantage DSNP plans 2025 introduce pivotal changes. This article breaks down what you’ll need to navigate these enhancements—from enrollment thresholds and streamlined coordination of care to improved appeal rights, targeting a more efficient system for dual-eligible individuals.
Key Takeaways
- CMS is introducing significant policy updates to Dual Eligible Special Needs Plans (DSNPs) for 2025, aimed at enhancing care coordination and expanding enrollment for Medicare and Medicaid dual-eligible individuals, including monthly special enrollment opportunities and more integrated services.
- To streamline DSNP operations and payment accuracy, CMS is standardizing the Risk Adjustment Data Validation (RADV) appeals process for Medicare Advantage plans and implementing new contracting standards for DSNP look-alikes.
- CMS is proposing measures to improve health equity in DSNPs, including an annual health equity analysis of utilization management policies, addressing social risk factors, and expanding behavioral health coverage to include more provider specialties and outpatient services.
Compare Plans in One Step!
Enter Zip Code
Understanding the 2025 Changes to DSNP Plans
DSNPs are specifically tailored to enhance coverage and coordinate care for individuals enrolled in both Medicare and Medicaid, commonly referred to as dual-eligibles. This population is recognized for having high costs and special care needs. Embracing this challenge, CMS has proposed significant policy updates for 2025 aiming to:
- Streamline processes
- Align benefits
- Lower enrollment thresholds
- Enhance appeal rights for DSNP members
This proactive strategy is expected to pave the way for substantial improvements in the quality of care and service delivery.
The proposed changes are timely, considering the growing interest in D-SNPs. Over the past few years, D-SNP enrollment has witnessed a 60% growth rate, outpacing the 38% growth in non-SNP plans. Given this trend, the 2025 policy updates could have a broader impact, potentially reshaping the healthcare experience for a large number of dual-eligible beneficiaries.
The proposed policy updates span across several key areas – from increased integration with Medicaid services and adjustments to enrollment thresholds to enhanced appeal rights for DSNP members.
Each of these areas brings unique advantages and opportunities, promising a more seamless service delivery and improved care outcomes for dual-eligible individuals.
Integration with Medicaid Services
To provide dual-eligible individuals with more integrated care, CMS is proposing measures to increase the percentage of dually eligible Medicare Advantage enrollees who receive integrated Medicare and Medicaid services. This effectively streamlines processes and provides more opportunities for enrollment in integrated plans.
One such measure is the revision of the current quarterly special enrollment period to a monthly opportunity.
This allows those receiving low-income subsidies, including the dually eligible, to elect an integrated Dual Eligible Special Needs Plan. Additionally, D-SNPs are required to have contracts with state Medicaid agencies meeting integration requirements and establishing unified appeals and grievance processes.
By simplifying the coordination of coverage for individuals eligible for both Medicaid and Medicare, CMS aims to overcome challenges posed by separate financing and administrative structures.
Adjustments to DSNP Enrollment Thresholds
Another crucial area of focus in the 2025 policy updates is the adjustment to DSNP enrollment thresholds. By lowering these thresholds for D-SNP look-alikes, the CMS aims to enhance the quality of care and service delivery for dually eligible individuals.
The CMS proposes a phased approach, reducing the enrollment threshold from 80 percent to 70 percent in 2025, with a further reduction from 70 percent to 60 percent in 2026. This progressive lowering of thresholds is designed to ensure that dual-eligible individuals choose the most integrated product type available, thereby maximizing the potential benefits of their coverage.
Enhanced Appeal Rights for DSNP Members
Recognizing the importance of fair and effective appeal processes, CMS is proposing to align Medicare Advantage plan regulations with those of Traditional Medicare, ensuring that traditional Medicare beneficiaries experience enhanced enrollees’ appeal rights for non-hospital service coverage terminations.
Under the proposed ruling, Quality Improvement Organizations will be allowed to review untimely fast-track appeals regarding the termination of services in home health agencies, comprehensive outpatient rehabilitation facilities, and skilled nursing facilities for MA enrollees.
Additionally, MA enrollees will no longer forfeit their right to appeal the decision to terminate services if they leave the facility before the initially planned termination date. This extension of appeal rights stems from policy developments initiated by the Bipartisan Budget Act of 2018, which directed unifying Medicare and Medicaid appeals processes for D-SNPs.
Streamlining DSNP Operations
Efficiency and accuracy in operations are paramount in healthcare delivery. To this end, CMS is proposing to standardize the Risk Adjustment Data Validation (RADV) appeals process for Medicare Advantage (MA) plans. The goal is to enhance payment accuracy and performance measurements, thereby streamlining DSNP operations.
Additionally, CMS is implementing new contracting standards for D-SNP look-alikes. This ensures they meet similar requirements to D-SNPs, further reinforcing the integrity of these plans. By taking on the responsibility for coordinating care and bearing risk for Medicare and, in some cases, Medicaid spending, D-SNPs play a crucial role in managing the care for the dually eligible population.
These proposed changes mark a significant step towards enhancing the operational efficiency of D-SNPs, ultimately improving service delivery and ensuring a better healthcare experience for dual-eligible enrollees.
Risk Adjustment and Data Validation Reforms
In the quest to enhance payment accuracy and performance measurements, CMS is proposing the standardization of the RADV appeals process for MA plans. This standardization is a key component of the reforms initiated to improve the operational efficiency of DSNPs.
Under the proposed rules, Medicare Advantage organizations must follow a sequential approach when appealing medical record review determinations and payment error calculations. Here is the process:
- Appeal the medical record review determination.
- Once the medical record review determination appeal has concluded, CMS will provide a revised audit report with a recalculated payment error calculation.
- Appeal the payment error calculation.
This sequential approach ensures that all relevant factors are considered before any adjustments are made.
This ensures a transparent and thorough review process, enhancing the accuracy of payments and the overall performance of DSNPs.
Contracting Standards for DSNP Look-Alikes
To maintain the standard of care provided to dual-eligible individuals, CMS proposes new contracting standards for D-SNP look-alike plans. These standards ensure that look-alike plans meet requirements similar to those of D-SNPs, thereby guaranteeing a consistent level of service provision.
These new standards include a phased reduction in the D-SNP look-alike threshold from 80% to 70% in 2025 and then further to 60% by 2026. This gradual lowering of the threshold ensures that the quality of care provided by these look-alike plans is maintained while also allowing for the integration of more dual-eligible individuals into the most suitable product type.
Enhancing Health Equity in DSNPs
In the pursuit of healthcare excellence, equity is key. Recognizing this, CMS is proposing measures to enhance health equity in DSNPs. This includes requiring an annual health equity analysis of utilization management policies and procedures for DSNPs.
Such an analysis is expected to yield insights into the systemic factors influencing health outcomes, thereby informing strategies to improve care for dual-eligible individuals.
The proposed health equity analysis would need to incorporate eight specified metrics. These metrics include denial rates, appeal overturn rates, and determination turn-around times. The CMS is seeking input on which enrollee groups, items, or services should be further analyzed for health equity, particularly in terms of utilization management policies. Specific comments on these areas are being requested.
The performance of D-SNPs has significant implications for health equity; given that a significant proportion of D-SNP enrollees are Black, Hispanic, or other people of color, the interaction between utilization management policies and social risk factors becomes particularly salient. Therefore, these proposed measures will play a crucial role in addressing disparities and promoting health equity.
Annual Health Equity Analysis Mandate
In a move to better serve traditionally underserved subpopulations that form a significant number of D-SNP enrollees, CMS mandates an annual health equity analysis. This mandate is an important step towards understanding and addressing the disparities that exist within the healthcare system.
Through this analysis, D-SNPs can gain valuable insights into how their services are being utilized by different subpopulations. This information can then be used to tailor interventions and policies to better meet the needs of these groups, ultimately improving health outcomes and promoting equity.
Addressing Social Risk Factors
In addition to the annual health equity analysis, CMS aims to address social risk factors and enhance care coordination for dual-eligible individuals, particularly those of color. Dual-eligible individuals have a greater prevalence of chronic and disabling health conditions when compared to Medicare-only beneficiaries, with nearly half living alone or in institutional settings, which can impact their health or overall function.
To address these social risk factors, CMS has authorized payments for services like Community Health Integration and Principal Illness Navigation provided by community health workers and peer support specialists.
These services are particularly beneficial in instances when social needs pose challenges to healthcare provision. By addressing these factors, CMS aims to ensure that heightened coverage and management strategies result in fair and equitable care for all dual-eligible individuals.
Improving Behavioral Health Access
In response to the growing need for comprehensive behavioral health services, CMS has proposed enhancements to Medicare Advantage plans. These include the inclusion of additional provider specialties and the expansion of outpatient behavioral health coverage.
Beginning January 1, 2024, mental health counselors and marriage and family therapists have been made eligible to enroll as providers in Medicare. This allows these professionals to:
- Bill for services provided to Medicare clients
- Increase the pool of providers available to beneficiaries
- Improve access to essential mental health services
Moreover, CMS is proposing to recognize ‘Outpatient Behavioral Health’ as a new facility-specialty type for Medicare Advantage plans. This includes a broad range of providers, thereby improving access to comprehensive outpatient rehabilitation facility services and community mental health centers.
Inclusion of Additional Provider Specialties
A vital part of improving behavioral health access is expanding the range of provider specialties that are eligible to enroll as Medicare providers. As a result, starting January 1, 2024, mental health counselors and marriage and family therapists will be eligible to enroll as Medicare providers and bill for services to Medicare beneficiaries.
This inclusion is a significant step forward, as these professionals play a crucial role in the provision of mental health services. Furthermore, in accordance with relevant legislation and regulatory guidelines, CMS intends to:
- Mandate Medicare Advantage plans to include these professionals within their provider networks
- Enhance network adequacy
- Ensure that beneficiaries have access to a diverse range of mental health services.
Expansion of Outpatient Behavioral Health Coverage
To further improve access to behavioral health services, CMS proposes to recognize Outpatient Behavioral Health as a new facility-specialty type in Medicare Advantage network adequacy standards.
This encompasses a wide range of behavioral health care providers, including mental health counselors, marriage and family therapists, and addiction medicine physicians, all of whom can offer behavioral health counseling.
The new rules also include a provision for Medicare Advantage plans to include a sufficient quantity of Outpatient Behavioral Health facilities within their provider networks. Additionally, the expansion of covered behavioral health services now includes new service types, such as intensive outpatient programs (IOP) and services from Opioid Treatment Programs (OTPs).
These enhancements promise to significantly improve access to comprehensive behavioral health services for beneficiaries.
Fostering Transparency and Beneficiary Protections
CMS’s proposed changes for 2025 focus significantly on measures that:
- Bolster beneficiary protections
- Improve access to behavioral health care
- Enhance equity in coverage
- Expand supplemental benefits
These measures include implementing enhanced ‘guardrails’ for agent and broker compensation and ensuring transparency through the notification of unused supplemental benefits.
CMS is proposing to implement enhanced ‘guardrails’ for agent and broker compensation to set upper compensation limits, thereby reinforcing protections for beneficiaries. These restrictions ensure that the incentives of agents and brokers do not negatively impact Medicare beneficiaries.
Furthermore, CMS is striving to foster transparency by proposing that Medicare Advantage plans must issue a ‘Mid-Year Enrollee Notification of Unused Supplemental Benefits’ annually. This notification serves to encourage better utilization of supplemental benefits, thereby maximizing the benefits for beneficiaries.
Notification of Unused Supplemental Benefits
To promote transparency and encourage the utilization of special supplemental benefits, CMS proposes that Medicare Advantage plans must issue an annual ‘Mid-Year Enrollee Notification of Unused Supplemental Benefits.’ This notification, personalized to each enrollee, lists supplemental benefits not accessed during the first six months of the year.
The notification must include:
- A detailed description of each benefit
- Cost-sharing details
- Instructions on accessing the benefit
- Any network application information for each available benefit
- A customer service number for additional assistance
By providing a comprehensive list of unused benefits with relevant details, the mid-year notification is intended to encourage better utilization of the DSNP supplemental benefits that are being underutilized.
Regulation of Agent and Broker Compensation
In an effort to enhance beneficiary protections, CMS is proposing to redefine ‘compensation’ for agents and brokers. The proposal aims to set a uniform rate across Medicare Advantage enrollments, which is proposed to be $642 as opposed to the existing national compensation cap of no more than $611.
The proposal also aims to generally prohibit contract terms resulting in volume-based bonuses or incentives for agent and broker enrollment into specific Medicare Advantage plans. This ensures that financial incentives do not lead to anti-competitive steering.
Additionally, under the new rules, administrative payments that were previously considered separate from compensation will be classified under the same regulatory limits as commissions. This prevents circumventing established caps and ensures fair compensation practices.
Summary
As we’ve journeyed through the proposed changes for DSNP plans in 2025, it’s evident that CMS is making concerted efforts to improve care coordination and access for dually eligible enrollees. From increasing integration with Medicaid services and adjusting DSNP enrollment thresholds, to enhancing appeal rights for DSNP members, CMS is paving the way for a significant transformation in the healthcare landscape for dual-eligible beneficiaries.
Furthermore, the proposed measures aimed at streamlining DSNP operations, enhancing health equity, improving behavioral health access, and fostering transparency and beneficiary protections all serve to create a more efficient and equitable healthcare system. As we anticipate these changes, it’s clear that the future of DSNPs holds promising potential for improving healthcare outcomes for dual-eligible beneficiaries.
Frequently Asked Questions
→ What is the proposed rule for Medicare Advantage 2025?
The proposed rule for Medicare Advantage 2025 includes a slight cut to payments, with average benchmark payments for plans being reduced by 0.2%. This was outlined in the proposed rules released by the Biden administration.
→ What are the changes in Medicare 2025?
In 2025, Medicare will see changes such as a $2,000 out-of-pocket spending cap, the elimination of the coverage gap phase, and adjustments to drug costs in the catastrophic phase. These changes aim to improve Medicare coverage and reduce out-of-pocket expenses.
→ What is the deductible for Medicare Part D in 2025?
The deductible for Medicare Part D in 2025 is $2,000, as annual out-of-pocket costs will be capped at this amount.
→ What are the main changes proposed for DSNP plans in 2025?
In 2025, the proposed changes for DSNP plans involve increasing integration with Medicaid services, adjusting enrollment thresholds, enhancing appeal rights, streamlining operations, improving health equity and behavioral health access, and fostering transparency and beneficiary protections.
→ How are the DSNP enrollment thresholds being adjusted?
The DSNP enrollment thresholds are being adjusted through a proposed phased approach, lowering from 80 percent to 70 percent in 2025 and then to 60 percent in 2026. This adjustment aims to gradually reduce the enrollment thresholds for DSNPs.
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.