By Emily Dykstra

Often seniors find the Medicare landscape difficult to navigate. Considering all the differences in plan availability by region and carrier, different programs and costs, some seniors, especially those with limited financial resources, can easily choose coverage that does not best suit their needs. This is especially salient for dual eligible individuals, who may not be receiving the help they are entitled to. This blog delves into the details of the various SNP configurations that can help agents and carriers get dual eligibles into the correct plan for their circumstances, and how the 2025PY CMS final rule will impact these plan types. Below, we break down all the different types of SNPs and the three levels of coordinated care of D-SNP.

Note: Date pulled from CMS enrollments in August 2024

Special Needs Plans: Special Needs Plans (SNPs) are a specific type of Medicare Advantage plan that provides additional benefits to members with specific conditions or certain health care needs, or who are eligible to be dually enrolled in Medicaid and Medicare. Since this requires a higher level of coordination, SNPs include care coordination services and tailor their benefits, provider choices, and list of covered drugs to best meet the specific needs of the groups they serve.

Chronic Condition SNPs (C-SNPs): Enrollment in C-SNPs is restricted to special needs individuals with specific severe or disabling chronic conditions. Due to these chronic illnesses, a higher level of care coordination is necessary, often coordinating between primary providers, medical and mental health specialists, inpatient and outpatient facilities, and ancillary services related to diagnostic testing and therapeutic management. C-SNP plans provide that coordination for their members.

Currently there are 15 specific chronic conditions that qualify individuals for a C-SNP plan: Chronic alcohol and other dependence, certain autoimmune disorders, cancer (excluding precancer conditions), certain cardiovascular disorders, chronic heart failure, dementia, diabetes mellitus, end-stage renal disease requiring dialysis, certain severe hematologic disorders, HIV/AIDS, certain lung disorders, certain chronic and disabling mental health conditions, certain neurologic disorders, and stroke.

Institutional SNPs (I-SNPs): Individuals who are in a care facility for longer than 90 days, ranging from a skilled nursing facility to an inpatient psychiatric facility, qualify for I-SNPs.

Dual Eligible SNPs (D-SNPs): These plans are for individuals that qualify to receive both Medicaid and Medicare benefits, which often requires a higher level of coordination of care for services received from the two programs. D-SNPS are divided into three categories based on the level of coordination they provide.

• Coordination-Only D-SNPs (CO D-SNP): Medicare and Medicaid coverage do not need to be with the same insurer; however, the D-SNP plan needs to coordinate the delivery of Medicare and Medicaid services for its enrollees.
• Highly Integrated D-SNP (HIDE SNP): Medicare and Medicaid coverage may be with the same insurer, or with another entity that is owned and controlled by the D-SNP’s parent organization. These plans coordinate long-term support services for members, including mental health services, between Medicare providers and MA plan providers.
  • CMS’ 2025 final rule states that in 2025, any HIDE SNP contract with the state Medicaid agency must cover the entire service area of the D-SNP.
• Fully Integrated D-SNPS (FIDE SNP): Medicare and Medicaid benefits are covered by the same insurer. All FIDE SNPs must cover Medicaid primary and acute care services and long-term services and supports (LTSS).
  • With the 2025 CMS final rule, all FIDE plans must operate with exclusively aligned enrollment. New D-SNP enrollments can only be for those with full-benefit dual eligibility or those with coverage through a Medicaid-managed care plan owned and operated by the same parent company as the D-SNP.
    • Exclusively aligned enrollment allows for full integration of enrollee materials, a single ID card, and a unified appeal/grievance process.
    • These plans must also cover primary and acute care services and LTSS (at least 180 days of nursing facility coverage during the plan year), while also covering all the additional Medicaid benefits: Medicare cost sharing; behavioral health services; home health services; and medical equipment, supplies, and appliances.

Conclusion: SNPs, especially D-SNPs, will likely experience some enrollment changes in the coming year thanks to the 2025 CMS final rule. Currently, for the 2024 plan year, Duals are only allowed to switch plans quarterly, to any plan type, including a standalone PDP. However, in 2025 Duals will be allowed to switch monthly from a lower level of coordinated care—such as a non-SNP MA plan or a CO D-SNP—into a HIDE/FIDE D-SNP, or into a standalone PDP. It seems that CMS is moving toward getting Duals into more highly integrated plans, and the 2025 final rule is one step in this direction. Carriers who currently support D-SNP, particularly HIDE/FIDE D-SNP, may be seeing some increased enrollment in the near future and may want to start gathering additional resources to assist these new enrollees.

Sources:

1. Lakhmani, M. (2023, June). Definitions of Different Medicare Advantage Dual Eligible Special Needs Plans (D-SNP) Types in 2023 and 2025. Integrated Care Resource Center. https://www.integratedcareresourcecenter.com/sites/default/files/ICRC-D-SNPDefinitions-2023-2025%20%284%29.pdf
2. Medicare.gov. (n.d.). Special Needs Plans (SNP). https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/SNP
3. CMS.gov. (2023, September 6). Dual Eligible Special Needs Plans (D-SNPs). https://www.cms.gov/medicare/enrollment-renewal/special-needs-plans/dual-eligible
4. CMS.gov. (2023, September 6). Chronic Condition Special Needs Plans (C-SNPS). https://www.cms.gov/medicare/enrollment-renewal/special-needs-plans/chronic-conditions
5. Medicare.gov. (n.d.). Special Needs Plans (SNP). https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/SNP
6. CMS.gov. (2024, April 4). Contract Year 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F). https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f
7. CMS.gov. (2024, June). Special Needs Plan Comprehensive Report. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/mcradvpartdenroldata/special/snp-comprehensive-report-2024-06
8. Date pulled from CMS enrollments in August 2024