Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Types in 2023 and 2025

TIP SHEET

December 2022

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Definitions of Different Medicare Advantage Dual Eligible

Special Needs Plan (D-SNP) Types in 2023 and 2025

By Erin Weir Lakhmani, Mathematica

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan that only enroll

dually eligible individuals. D-SNPs were originally authorized in 2003, began operating in 2006, and were

made a permanent part of Medicare Advantage in 2018. Since 2013, D-SNPs have been required to hold

contracts with the state Medicaid agency in each state where they operate, and those contracts must

contain at least certain minimum elements.

D-SNPs differ from other types of MA plans in several important ways. For example, in addition to being

required to hold contracts with state Medicaid agencies, all D-SNPs must: (1) at least coordinate (and in

some cases cover) Medicaid benefits for their enrollees; (2) have a Model of Care that is approved by the

National Committee for Quality Assurance (NCQA) that describes how the D-SNP will coordinate care for

its enrollees; (3) engage contract-level enrollee advisory committees in conversations about ways to

improve access to covered services, coordination of services, and health equity for underserved enrollee

populations; and (4) screen their enrollees for health-related social needs starting in 2024. Additionally,

because D-SNPs solely serve dually eligible individuals, they can cater their plan benefits, including

supplemental benefits, to dually eligible populations, and state Medicaid agencies can use their contracts

with D-SNPs to advance coordination of care for D-SNP enrollees and/or integration of Medicare and

Medicaid benefits. (See Appendix A for more details on the ways that D-SNPs differ from other MA plans).

In April 2019, the Centers for Medicare & Medicaid (CMS) issued a final rule that established definitions

for “fully” and “highly” integrated D-SNPs (FIDE SNPs and HIDE SNPs, respectively) and “applicable

integrated plans” (AIPs).

In May 2022, CMS issued a final rule that updates those definitions, ultimately

demands greater levels of Medicare-Medicaid integration from FIDE SNPs and HIDE SNPs over time, and

In Brief: Key Points in This Tip Sheet

Dual Eligible Special Needs Plans (D-SNPs) must hold contracts with state Medicaid agencies, and states

can use contractual requirements to better integrate and coordinate care for individuals who are

dually eligible for Medicare and Medicaid. Federal rules issued in 2019 defined three different types of

D-SNPs: “fully” integrated D-SNPs (FIDE SNPs); “highly” integrated D-SNPs (HIDE SNPs); and

Coordination-only (CO) D-SNPs, and also defined “applicable integrated plans” (AIPs).

New rules

issued in May 2022 updated those definitions.

This tip sheet summarizes the updated definitions of FIDE SNPs, HIDE SNPs, CO D-SNPs, and AIPs for

2023 and compares the requirements for each D-SNP type. This information can be helpful to states as

they develop and implement programs that advance Medicare-Medicaid integration for their dually

eligible populations.

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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enables CO D-SNPs to qualify as AIPs in certain circumstances.

This tip sheet summarizes the definitions

of FIDE SNPs, HIDE SNPs, “coordination-only” (CO) D-SNPs, and AIPs for 2023 and compares the

requirements for each D-SNP type.

Fully Integrated D-SNPs (FIDE SNPs)

As of January 1, 2023, FIDE SNPs are D-SNPs that provide coverage of Medicare and Medicaid benefits

under a single legal entity that holds both: (1) an MA contract with CMS; and (2) a contract with the state

Medicaid agency that meets the requirements of a managed care organization as defined in section

1903(m) of the Social Security Act. FIDE SNPs must cover at least Medicaid primary and acute care services

and long-term services and supports (LTSS), including at least 180 days of nursing facility coverage during

the plan year.

FIDE SNPs must also coordinate Medicare and Medicaid benefits “using aligned care

management and specialty care network methods for high-risk beneficiaries” and employ “policies and

procedures approved by CMS and the State to coordinate or integrate beneficiary communication

materials, enrollment, communications, grievances and appeals, and quality improvement” (42 CFR

422.2).

Starting in 2025:

• FIDE SNPs

must operate with exclusively aligned enrollment (see Box 1) and

continue to cover primary and acute care services and LTSS (including at least

180 days of nursing facility coverage during the plan year), while also covering

all of the following additional Medicaid benefits: Medicare cost sharing;

behavioral health services; home health services; and medical equipment,

supplies and appliances.

• A FIDE SNP’s capitated contract with the state Medicaid agency (for coverage of the required

Medicaid benefits) must also cover the entire service area of the D-SNP.

Box 1. Exclusively Aligned Enrollment

Exclusively aligned enrollment occurs when state policy limits enrollment in a D-SNP to only full-benefit

dually eligible individuals who receive coverage of Medicaid benefits through the D-SNP or a Medicaid

managed care plan owned and operated by the same parent company as the D-SNP (referred to in this

tip sheet as an “affiliated” Medicaid managed care plan).

Exclusively aligned enrollment facilitates use of several strategies to integrate coverage of Medicare

and Medicaid benefits, such as fully integrated enrollee materials, single ID cards, and unified appeal

and grievance processes. These strategies are only feasible when D-SNPs operate with exclusively

aligned enrollment.

For more information about exclusively aligned enrollment, see the Integrated Care Resource Center

(ICRC)’s May 2022 webinar at: https://integratedcareresourcecenter.com/webinar/exclusively-aligned-

enrollment-101-considerations-states-interested-leveraging-d-snps.

Coming

in 2025

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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Highly Integrated D-SNPs (HIDE SNPs)

As of January 1, 2023, HIDE SNPs are D-SNPs that provide coverage of Medicaid benefits (through the D-

SNP or an affiliated Medicaid managed care plan), including coverage of LTSS, behavioral health benefits,

or both, under a capitated contract with the state Medicaid agency in the applicable state.

The capitated

contract with the state Medicaid agency may be executed directly with the D-SNP, with the D-SNP’s

parent organization, or with another entity that is owned and controlled by the D-SNP’s

parent organization.

Starting in 2025, a HIDE SNP’s capitated contract with the state Medicaid agency (for

coverage of the required Medicaid benefits) must cover the entire service area of the

D-SNP.

Coordination Only (CO) D-SNPs

As of January 1, 2023, CO D-SNPs are D-SNPs that meet minimum CMS requirements but do not qualify as

a HIDE SNP or FIDE SNP. CO D-SNPs must: (1) hold a contract with the state Medicaid agency in each state

of operation that meets the requirements described at 42 CFR 422.107; (2) coordinate the delivery of

Medicare and Medicaid services for its enrollees; and (3) meet the information-sharing requirements

described at 42 CFR 422.107(d) (see Box 2 for more information).

Applicable Integrated Plans (AIPs)

As of January 1, 2023, AIPs are D-SNPs that: operate with exclusively aligned enrollment (see Box 1) and

cover at least some Medicaid benefits (through the D-SNP or through an affiliated Medicaid managed care

plan operated by the same parent organization as the D-SNP). Specifically, starting in 2023, to qualify as an

AIP, a D-SNP must be either:

(1) A HIDE SNP or a FIDE SNP with exclusively aligned enrollment; or

(2) A CO D-SNP that has exclusively aligned enrollment and covers (through the D-SNP or an

affiliated Medicaid managed care plan) Medicaid primary and acute care benefits, Medicare

cost sharing, and at least one of the following additional Medicaid benefits: behavioral health

Box 2. Information-Sharing Requirements for CO D-SNPs

Per 42 CFR 422.107(d), CO D-SNPs must “[notify], or arrange for another entity or entities to notify, the

State Medicaid agency, individuals or entities designated by the State Medicaid agency, or both, of

hospital and skilled nursing facility admissions for at least one group of high-risk full-benefit dual eligible

individuals, identified by the State Medicaid agency. The State Medicaid agency must establish the

timeframe(s) and method(s) by which notice is provided. In the event that [the D-SNP] authorizes

another entity or entities to perform this notification, the [D-SNP] must retain responsibility for

complying with [this] requirement.”

Coming

in 2025

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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services; LTSS; home health services; or medical supplies, equipment and appliances. (42 CFR

422.561)

AIPs must implement unified plan-level appeal and grievance processes in accordance with the

requirements at 42 CFR 422.107(c)(9), 422.629 through 422.634, 438.210, 438.400, and 438.402. For

information about these unified appeal and grievance processes, see ICRC’s fact sheet on the topic.

Any of the three types of D-SNPs (CO D-SNPs, HIDE SNPs, and FIDE SNPs) can be designated as an AIP if the

D-SNP meets the requirements described above. See Appendix B for a table summarizing the key federal

requirements that define and distinguish each of these three types of D-SNPs from each other, as well as

the key requirements that define AIPs.

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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Appendix A. How D-SNPs Differ from Other Types of Medicare

Advantage Plans

D-SNPs differ from other types of Medicare Advantage plans in several ways:

Because D-SNPs only enroll dually eligible individuals, they can design their benefits (including

supplemental benefits) specifically to meet the needs of dually eligible populations. For

example:

• Because dually eligible populations have limited income and resources and may require

support for social needs like housing, food, and transportation, D-SNPs may offer

supplemental benefits that are designed to support those needs, such as meal/nutrition

services after hospital stays or transportation services that expand upon the non-

emergency transportation services offered through Medicaid.

• As 70 percent of dually eligible individuals have three or more chronic conditions,

D-SNPs

have also been more likely than other MA plans to offer Special Supplemental Benefits for

the Chronically Ill (SSBCI),

such as pest control services for people with certain chronic

diseases, since those services first became available in 2020.

• Because most dually eligible individuals qualify for coverage of Medicare cost sharing

through Medicaid, D-SNPs may also be more likely than other MA plans to use rebate

dollars to offer supplemental benefits rather than to reduce member cost sharing

responsibility.

D-SNPs must have a Model of Care approved by the National Committee on Quality Assurance

that describes how the D-SNP will coordinate care for, and meet the needs of, the dually eligible

populations it serves, including the D-SNP’s use of health risk assessments, individualized plans of

care, and interdisciplinary care teams (42 CFR 422.101(f)). CMS audits D-SNP care coordination

activities to ensure that the activities conducted align with what is stated in the Model of Care.

All D-SNPs are required to at least coordinate Medicaid benefits for their enrollees, including

helping enrollees access, request prior authorization for, and file grievances and appeals regarding

Medicaid benefits (42 CFR 422.562(a)(5)).

Starting in 2023, D-SNPs must establish and maintain at least one contract-level enrollee advisory

committee in each state where the D-SNP is offered. These committees must include a reasonably

representative sample of individuals enrolled in the D-SNP, and D-SNPs must use the committees

to solicit enrollee input on ways to improve access to covered services, coordination of services,

and health equity for underserved enrollee populations (42 CFR 422.107).

Starting in 2024, D-SNPs must collect information about their enrollees’ transportation, housing,

and food security needs during health risk assessments (42 CFR 422.101(f)(1)(i)).

Because all D-SNPs must hold contracts with the state Medicaid agencies in the states where the

D-SNPs operate, those state Medicaid agencies can impose additional requirements on D-SNPs to

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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promote coordination and/or integration of Medicaid benefits for D-SNP enrollees. For example,

states can require D-SNPs to:

• Cover Medicaid benefits through the D-SNP or an affiliated Medicaid managed care plan;

• Enroll only full-benefit dually eligible individuals (or enroll full- and partial-benefit dually

eligible individuals in separate plan benefit packages) to simplify plan benefits and

materials;

• Operate with exclusively aligned enrollment or maintain an affiliated Medicaid managed

care plan to promote aligned enrollment;

13,14

• Incorporate Medicaid requirements, tools, or processes into their Models of Care;

• Submit materials to the state for review to ensure accuracy and consistency of the

information shared by D-SNPs about Medicaid benefits;

• Collaborate with the state in developing supplemental benefits;

• Share data with the state to facilitate state awareness of D-SNP enrollees’ needs and

service use and/or facilitate state oversight of D-SNP activities.

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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Appendix B. Federal Requirements Defining CO D-SNPs, HIDE SNPs, FIDE SNPs, and AIPs

In the table below, asterisks (*) are used to denote requirements that will take effect starting in 2025. This table does not list all federal D-SNP

requirements – it only illustrates certain key requirements involved in differentiating one type of D-SNP from another.

Federal Requirement CO D-SNP HIDE SNP FIDE SNP AIP

Must hold a Medicare Advantage contract with CMS that meets minimum requirements for D-SNPs Yes Yes Yes Yes

Must hold a contract with the state Medicaid agency in each state where the D-SNP operates, and those

contracts must meet the minimum requirements described at 42 CFR 422.107

Yes Yes Yes Yes

Must have a contract with the state Medicaid agency that meets the requirements of a managed care

organization as defined in section 1903(m) of the Social Security Act

No No Yes No

May provide coverage of Medicaid services to full-benefit dually eligible enrollees via a Prepaid Inpatient

Health Plan (PIHP) or a Prepaid Ambulatory Health Plan (PAHP)

Yes Yes No Yes

Must provide coverage of applicable Medicaid benefits to full-benefit dually eligible enrollees through the

same legal entity that contracts with CMS to operate as an MA plan

No No Yes No

Must have a capitated contract with the state Medicaid agency to provide coverage of LTSS to full-benefit

dually eligible enrollees, consistent with state policy

No No

Yes No

Must have a capitated contract with the state Medicaid agency that provides coverage of a minimum of 180

days of nursing facility services to full-benefit dually eligible enrollees during the plan year

No No Yes No

Must have a capitated contract with the state Medicaid agency that provides coverage of behavioral health

services to full-benefit dually eligible enrollees, consistent with state policy

No No

Yes* No

Must have a capitated contract with the state Medicaid agency that provides coverage of Medicaid primary

and acute care benefits

No No Yes No

Must operate with exclusively aligned enrollment No No Yes* Yes

Must implement unified plan-level appeal and grievance processes in accordance with the requirements at 42

CFR 422.107(c)(9), 422.629 through 422.634, 438.210, 438.400, and 438.402

No No Yes* Yes

Must notify the state (or the state’s designee) of acute hospital and skilled nursing facility admissions for a

designated group of “high risk” full-benefit dually eligible enrollees in accordance with the requirements

described at 42 CFR 422.107(d)

Yes No No No

Table Notes:

If the D-SNP is a HIDE SNP or a CO D-SNP, this capitated contract may be with an affiliated Medicaid managed care plan operated by the same parent company as the D-SNP.

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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To qualify as a HIDE SNP, a D-SNP must either cover Medicaid behavioral health services or LTSS.

To qualify as an AIP, a CO D-SNP must cover Medicaid primary and acute care benefits, Medicare cost-sharing, and at least one of the following additional Medicaid benefits:

behavioral health services; LTSS; home health services; or medical supplies, equipment and appliances. A HIDE SNP could qualify as an AIP without covering Medicaid primary and

acute care benefits, and a HIDE SNP could qualify as an AIP without covering Medicaid behavioral health benefits if the HIDE SNP covers LTSS. Similarly, a HIDE SNP could qualify as an

AIP without covering LTSS if the HIDE SNP covers Medicaid behavioral health services. FIDE SNPs must cover primary and acute care benefits and LTSS, and FIDE SNPs must begin

covering behavioral health benefits (and operating as AIPs) starting in 2025.

If an AIP is a CO D-SNP, the D-SNP must comply with the information-sharing requirements at 42 CFR 422.107(d). HIDE SNPs and FIDE SNPs are not federally required to comply with

the information-sharing requirements at 42 CFR 422.107(d), but states can choose to include information-sharing requirements in their state Medicaid agency contracts with HIDE

SNPs and/or FIDE SNPs.

Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan Types in 2023 and 2025

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ABOUT THE INTEGRATED CARE RESOURCE CENTER

The Integrated Care Resource Center is a national initiative of the Centers for Medicare & Medicaid

Services Medicare-Medicaid Coordination Office to help states improve the quality and cost-

effectiveness of care for dually eligible individuals. The state technical assistance activities provided by

the Integrated Care Resource Center are coordinated by Mathematica and the Center for Health Care

Strategies. For more information, visit www.integratedcareresourcecenter.com.

Centers for Medicare & Medicaid Services (CMS). “Medicare and Medicaid Programs; Policy and Technical Changes to the

Medicare Advantage, Medicare Prescription Drug Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-

Service, and Medicaid Managed Care Programs for Years 2020 and 2021.” Federal Register, April 16, 2019. Available at:

https://www.federalregister.gov/documents/2019/04/16/2019-06822/medicare-and-medicaid-programs-policy-and-technical-

changes-to-the-medicare-advantage-medicare

CMS. “Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare

Prescription Drug Benefit Programs.” Federal Register, May 9, 2022. Available at:

https://www.federalregister.gov/documents/2022/05/09/2022-09375/medicare-program-contract-year-2023-policy-and-

technical-changes-to-the-medicare-advantage-and

The minimum elements for state Medicaid agency contracts with D-SNPs are described at 42 CFR 422.107.

CMS. “Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug

Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for

Years 2020 and 2021.” Federal Register, April 16, 2019. Available at:

https://www.federalregister.gov/documents/2019/04/16/2019-06822/medicare-and-medicaid-programs-policy-and-technical-

changes-to-the-medicare-advantage-medicare

CMS. “Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare

Prescription Drug Benefit Programs.” Federal Register, May 9, 2022. Available at:

https://www.federalregister.gov/documents/2022/05/09/2022-09375/medicare-program-contract-year-2023-policy-and-

technical-changes-to-the-medicare-advantage-and

Ibid.

Per 42 CFR 107(g)-(h), a D-SNP can receive CMS approval to qualify as a HIDE SNP or FIDE SNP even if its contract with the state

Medicaid agency has carve-outs of certain behavioral health services and/or LTSS, as long as those carve-outs: “(1) Apply primarily

to a minority of the beneficiaries eligible to enroll in the dual eligible special needs plan who use [behavioral health services/long-

term services and supports]; or (2) Constitute a small part of the total scope of [behavioral health services/long-term services and

supports] provided to the majority of beneficiaries eligible to enroll in the dual eligible special needs plan.”

Stringer, R. and A. Tourtellotte. “Integrated Appeal and Grievance Processes for Integrated D-SNPs with “Exclusively Aligned

Enrollment.” Integrated Care Resource Center (ICRC), June 2020. Available at:

https://integratedcareresourcecenter.com/resource/integrated-appeal-and-grievance-processes-integrated-d-snps-exclusively-

aligned-enrollment

ICRC. “Dually Eligible Individuals: The Basics.” 2022. Available at:

https://integratedcareresourcecenter.com/sites/default/files/ICRC_DuallyEligible_Basics.pdf

ATI Advisory. “Growth in New, Non-Medical Benefits Since Implementation of the Creating High-Quality Results and Outcomes

Necessary to Improve Chronic (CHRONIC) Care Act.” April 2022 Data Insight. Available at: https://atiadvisory.com/wp-

content/uploads/2022/04/Data-Insight-Growth-in-New-Non-Medical-Benefits-Since-Implementation-of-the-CHRONIC-Care-

Act.pdf

CMS. “Implementing Supplemental Benefits for Chronically Ill Enrollees.” Guidance to Medicare Advantage Organizations, April

24, 2019. Available at: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-

documents/Supplemental_Benefits_Chronically_Ill_HPMS_042419.pdf

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For information about Medicare Advantage rebate dollars, see the Medicare Payment Advisory Commission (MedPAC)’s

Medicare Advantage Payment Basics Brief at: https://www.medpac.gov/wp-

content/uploads/2021/11/MedPAC_Payment_Basics_22_MA_FINAL_SEC.pdf.

For information on exclusively aligned enrollment, see ICRC’s webinar at:

https://integratedcareresourcecenter.com/webinar/exclusively-aligned-enrollment-101-considerations-states-interested-

leveraging-d-snps

For information on promoting aligned enrollment in D-SNPs, see ICRC’s tip sheet at:

https://integratedcareresourcecenter.com/PDFs/ICRC_DSNP_Aligning_Enrollment.pdf