Some 81% of long-term nursing home residents are eligible for both Medicaid and Medicare coverage, but the facilities they call home have rarely played a role in providing their health insurance.
But analysts at healthcare research and consulting firm ATI and the SNP Alliance say an impending regulatory transition presents a key opportunity for more skilled nursing providers to participate and potentially offer nursing plans. special needs designed for people with dual eligibility.
“Much of the political debate around Medicaid and Medicare integration focuses on people living at home or living in the community, and we need to do a better job of thinking about the role of integration for people living in nursing care facilities,” said Allison Rizer, director of the ATI. and leader of the firm’s Medicare-Medicaid Integration and LTSS Innovations practice.
Rizer and ATI Senior Analyst Cleo Kordomenos authored a November report examining ways states can combine successful elements of the Medicare-Medicaid plan model into dual-eligibility special needs plans, or D -SNP, fast growing. D-SNPs are the largest of the special needs plans, covering approximately 4.4 million of more than 11 million doubly eligible beneficiaries.
The MMP model will end in 2025, the Centers for Medicare & Medicaid Services announced in their 2023 Medicare Advantage and Part D Final Rule. CMS puts all of its dual-eligibility support behind D-SNPs, and ATI urges adoption of policies and flexibilities to drive plan improvements.
Rizer views state strategies that place greater emphasis on inclusion and care designed for dual-eligible people living in the SNF as a key need.
“There is a political opportunity to think specifically about the people who live in the nursing facility,” Rizer said. McKnight Long Term Care News Last week. “States are aware of this and are thinking about it. CMS is aware of this and thinking about it… All of this in my mind means there is an opportunity to move forward.
There were over 800 D-SNP options this year, up from 551 in 2020.
As was the case with Institutional Special Needs Plans, or I-SNPs, not too long ago, nearly all D-SNPs are currently offered by major insurers and managed care companies. But there is potential for financial rewards for providers who can bear the risk of being an insurer and managing participant quality outcomes.
While I-SNPs are contained within one or more facilities, provider-directed D-SNPs would cater to dual-eligibility patients who may very well still be living in the community.
This presents its own hurdles, but providers might be tempted to venture into offering their own plans if the right incentives and contract terms are on offer. Vendors best positioned to enter the D-SNP market have likely had experience with I-SNPs, similar plans for assisted living communities, or PACE programs, Rizer said.
American Health Plans is a rapidly growing I-SNP provider whose model includes an integrated nurse practitioner and case management services provided by partner TruHealth.
Hank Watson, director of development for American Health Partners, the parent company of American Health Plans, said it might make sense to consider ways to expand that care to serve additional patients beyond the home. nursing and in the community. The company is exploring possibilities with D-SNPs, institutional equivalent SNPs, chronic condition SNPs and other Medicare Advantage plans.
“It’s part of the untapped potential of I-SNP as a stand-alone product, but also as a basis for developing other products in the community,” Watson said this week. “If TruHealth already has nurse practitioners serving nursing home residents in a rural community, it may make sense for those same providers to support members of other senior housing communities who would otherwise be hard to reach.”
States in Need of D-SNP Advice
Through the upcoming transition, states could adopt policies that would make it more attractive for nursing homes to enroll as participants, but CMS needs to provide the right guidance, Rizer said.
States could create value for nursing home participants by ensuring that contracts promote value-based incentives. Unlike I-SNPs, states with D-SNPs can shape coverage through the use of required State Medicaid agency contracts. Such contracts could begin to use I-SNP as clinical models, or incentivize payments through a value-based approach to care.
A state, for example, could require its DNPs to develop a value-based model specifically with skilled, long-term nursing facilities in mind, which Rizer says is a tool that could be used to do to advance the quality of care and outcomes in a nursing setting.
Integrated plans could also help address labor shortages by providing more resources than Medicaid coverage alone; approaches could include paying bonuses to facilities that provide certain training or staff ratios or demonstrate their ability to retain employees in key roles.
But states will need more guidance, including best practices and sample language, from CMS to help them as they target eligible nursing home duplicates and others for inclusion.
“A lot of the DSNP environment is tied to a state’s priorities,” Rizer said. “So if you have a state that’s very focused on local delivery of care and local organizations that may be organizations at risk, those are states where I see a particular opportunity for provider organizations to put in place D -SNP.”
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