D-SNPs: Integration & Unified Appeals & Grievance Requirements
|02/22/2021: CMS released a revised version of the Integration Status for Contract Year 2021 D-SNPs (rev. 02/22/2021). More information can be found below under "Integration."|
|12/09/2020: CMS released a revised version of the Integration Status for Contract Year 2021 D-SNPs (found below under "Integration"), and provided the CY 2021 Part C Reporting Updates for Applicable Integrated Plans and the Unified Appeals and Grievance Procedures and revised Coverage Decision Letter and associated OMB-Approved Memorandum (both found below under "Unified Appeals and Grievances").|
|12/03/2020: CMS released the Addendum to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance. More information can be found below under "Unified Appeals and Grievances."|
The Bipartisan Budget Act (BBA) of 2018 permanently authorized Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs), strengthened Medicare-Medicaid integration requirements, and directed the establishment of procedures to unify Medicare and Medicaid appeals and grievance procedures to the extent feasible for D-SNPs beginning in 2021. On April 16, 2019, CMS finalized rules to implement these new statutory provisions.
All D-SNPs must have executed contracts with state Medicaid agencies, referred to as the "State Medicaid Agency Contract" (SMAC) or MIPPA contract, that meet a number of requirements, including Medicare-Medicaid integration requirements and, for some D-SNPs, unified appeals and grievance processes.
Additional Information for D-SNPs and States
- April 16, 2019 Final Rule (see 84 FR 15696 - 15744)
- The Integrated Care Resource Center (ICRC) provides technical assistance to states to help with implementation of these requirements through briefs, technical assistance tools, tip sheets, webinars, appeals and grievance technical assistance tools, and sample contract language
- NEW! Integration Status for Contract Year 2021 D-SNPs (last updated 02/22/2021) (XLSX)
- State Medicaid Agency Contracts Submission Requirements for Contract Year 2021 released on May 26, 2020, outlines the submission process and deadline for review of State Medicaid Agency Contracts (SMACs) as well as provides information regarding training for the industry
- DSNPs COVID-19 CY2021 State Medicaid Agency Contract Requirements (04/13/2020) (PDF) outlines updated CMS processes for review and approval of state Medicaid agency contracts for Contract Year 2021
- Additional Guidance on CY2021 Medicare-Medicaid Integration Requirements for D-SNPs (01/17/2020) (PDF)
Unified Appeals and Grievances
- NEW! CMS released the final Addendum to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (PDF) for Applicable Integrated Plans. For more information on the Addendum, please see the December 3, 2020 Parts C & D Addendum Memorandum (PDF).
- NEW! CMS released the Coverage Decision Letter (ZIP), Letter about Your Right to Make a Fast Complaint (ZIP), and Appeal Decision Letter (ZIP), in English and Spanish for Applicable Integrated Plans to use for CY 2021. For more information on these notices, please see the November 20, 2020 CY 2021 D-SNP Integrated Notices Memorandum (PDF) and the December 7, 2020 OMB-Approved Coverage Decision Letter for Applicable Integrated Plans Memorandum (PDF).
- CY 2021 Denial notices for Medicare Advantage Organizations (MAOs) Integrating Medicare and Medicaid Benefits (PDF) identifies which version of the denial notice a MAO should use depending on the type of plan offered.
- NEW! CMS released the CY 2021 Part C Reporting Updates for Applicable Integrated Plans and the Unified Appeals and Grievance Procedures (PDF) which identifies Part C reporting updates for Applicable Integrated Plans.
- Medicare-Medicaid Integration and Unified Appeals and Grievance Requirements for State Medicaid Agency Contracts with D-SNPs for Contract Year 2021, a CMCS Informational Bulletin that summarizes the requirements of the April 2019 final rule and highlights important information that states need to ensure that D-SNPs in their market meet the new integration and unified appeals and grievance requirements beginning in 2021.
- CY 2021 Medicare-Medicaid Integration & Unified Appeals & Grievance Requirements for D-SNPs Memorandum (10/07/2019) (PDF) (PDF).
More information about D-SNPs can be found on the Medicare D-SNPs page.