Toolkit for State Medicaid Agency Contracts Enhances Consumer Protections

A new toolkit has been developed to assist policymakers and advocates in creating State Medicaid Agency Contracts (SMACs) that cater to the needs of dually eligible populations. This toolkit offers guiding principles and template language, allowing stakeholders to tailor their approach according to the unique integration models of their state.

Consumer Protections in D-SNPs

Part VI of the toolkit emphasizes consumer protections related to provider network adequacy, expanding on prior sections that addressed consumer rights within Dual Eligible Special Needs Plans (D-SNPs), such as member engagement and support. Additional areas such as eligibility, enrollment, supplemental benefits, marketing, and care coordination are also comprehensively covered.

This publication draws on Justice in Aging's issues brief and guiding principles, underscoring the importance of strong consumer protections, health equity, and person-centered care. It highlights best practices from D-SNP model contracts and financial alignment models, aiming to enhance consumer protections where public contract language is limited.

Addressing Network Complexity

Unlike Original Medicare, beneficiaries of Medicare Advantage (MA) plans must verify that providers are within-network, a task that becomes complex for dually eligible individuals due to numerous required providers and fluctuating network details. The Centers for Medicare & Medicaid Services (CMS) has issued guidance on cost-sharing protections, yet concerns about confusion and improper billing persist.

D-SNPs are designed to streamline access by aligning Medicare and Medicaid benefits, ensuring robust provider network access. Federal regulations, specifically 42 CFR 422.116, mandate that MA plans, including D-SNPs, maintain an adequate provider network, meeting specific standards for time, distance, and provider type to ensure equitable access to services.

State-Specific Approaches

State-specific SMACs display varied strategies: Massachusetts emphasizes diverse provider networks and prohibits discrimination, while Minnesota mandates out-of-network coverage when in-network options are insufficient. States like Washington and California align provider networks with Medicaid to prevent service interruptions for enrollees, especially those using integrated models.

D-SNPs must comply with billing protection regulations, prohibiting providers from charging dual eligible enrollees amounts beyond what is state-permitted. Proper alignment with Medicaid networks is vital to minimizing care disruptions, and fully integrated plans should ensure seamless coordination between Medicare and Medicaid services.

Enhancing Directory Accuracy

Federal laws dictate specific requirements for MA plan directories, enforced by regulations like 42 CFR 422.111(b)(3). Policy changes, such as those in the Consolidated Appropriations Act, aim to enhance directory accuracy and cost-sharing protections, though increased state oversight could further improve transparency.

Ohio and Minnesota have enacted strict directory requirements, including state pre-approval and synchronization with Medicaid. These measures are designed to improve informed decision-making for enrollees by providing accessible and verified provider information.