Medicaid glossary: Dual Special Needs Plans

Care coordination is the combined efforts of payers, health care staff and community-based organizations (CBOs) to organize and effectively collaborate on a patient’s information, health needs and activity to deliver the best possible care to that patient.¹

Care integration is the combination and application of different aspects of health (i.e., physical, behavioral, social) into a single, more unified approach to care. Typically, care integration aims to address the collective health concerns of individuals with complex conditions to improve quality of care and overall individual health.²

Complex care refers to services provided to high-need individuals who often require a higher level of care, resulting in higher costs than for an average individual. Complex care individuals often suffer from multiple chronic conditions or disabilities that require more clinically complex attention and care delivery.³

For individuals who become newly eligible for a Dual Special Needs Plan (DSNP), states can use default enrollment into a managed care organization’s (MCO) DSNP when a Medicaid-only individual enrolled with that Medicaid MCO obtains Medicare eligibility.⁴

Dual eligibility refers to an individual’s eligibility to enroll in both Medicaid and Medicare programs. Individuals who are eligible for both programs are commonly referred to as duals or dual eligibles.⁵

Dual Special Needs Plans (DSNPs) are specific Medicare Advantage plans made for duals or dual eligibles. Due to the often-complex nature of social, mental and physical care needs for duals, DSNPs help centralize the care from the two programs and provide patient-focused care that is easier to navigate.⁶

The federal poverty level (FPL) is an annual assessment of an individual’s total yearly income to determine social service coverage and other benefits, such as Medicaid or Children’s Health Insurance Program (CHIP) eligibility. The FPL can increase or decrease on a year-to-year basis, and eligibility depends on family size as well as total income, with an FPL that grows as an individual’s family size grows.⁷

A Fully Integrated Dual Eligible (FIDE) is a specific dually eligible individual who receives fully integrated Medicare and Medicaid benefits from a single managed care organization (MCO) through a Fully Integrated Dual Special Needs Plan (FIDE-SNP). FIDEs and FIDE-SNPs help streamline and declutter the often hard-to-navigate benefits and requirements that come with being dually eligible.⁸

A Highly Integrated Dual Special Needs Plan (HIDE-SNP) is an integrated care plan that combines the benefits of Medicare and Medicaid from a managed care organization (MCO) into a more unified care plan. Although less integrated than FIDE-SNPs, HIDE-SNPs still incorporate both behavioral health and Managed Long-Term Services and Supports (MLTSS) benefits into the plan.⁹

Coordinated across providers and settings, Long-Term Services and Supports (LTSS) include a range of services that assist individuals with functional limitations on their ability to carry out daily activities. Among the millions of children, adults, and seniors making use of LTSS in the United States, Medicaid is the leading payer.¹⁰

Managed Long-Term Services and Supports (MLTSS) refers to the way that Long-Term Services and Supports (LTSS) are delivered in capitated Medicaid managed care programs. More and more states are shifting to an MLTSS model to help expand Home- and Community-Based Services (HCBS), promote community inclusion and increase the efficiency of programs.¹¹

Serving more than 64 million Americans, Medicaid is a federal- and state-level program that helps with medical costs for eligible, low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid programs are designed at the state level, and most health care costs are covered for a person who qualifies for both Medicare and Medicaid.¹²

Medicare is the federal health insurance program that covers three main groups of Americans: individuals who are 65 or older, some younger individuals who have disabilities, or individuals with End-Stage Renal Disease (ESRD), which involves kidney failure that requires dialysis or a transplant. Today, there are more than 40 million Medicare beneficiaries in the country.¹³

Medicare Advantage Plans, while still approved by the federal government, are offered to eligible individuals through private managed care organizations (MCOs). UnitedHealthcare is an example of an MCO that offers Medicare Advantage plans.¹⁴

Passive enrollment is a process by which an eligible individual is automatically enrolled into a specific program. It’s used frequently in Medicaid programs, but is uncommon in Medicare. Current federal policy generally limits Dual Special Needs Plans (DSNP) passive enrollment to instances where an individual’s existing aligned experience is involuntarily disrupted (e.g.,  an aligned organization is not re-procured for Medicaid) and there’s another aligned option available with a comparable provider network and benefits package.¹⁵

System integration specifically integrates high-level information-sharing among a care team. This is used to drive patient care through the development of a comprehensive treatment plan to address a person’s biological, psychological and social needs.¹⁶

This glossary is intended to be informational only and relates to terms used commonly in Medicaid programs and design. In most cases, terms are derived from publicly available sources. Terms covered in this glossary are subject to change and may have alternate definitions when used in relation to other programs or products, or by other sources or companies.