Dual Eligible Special Needs Plans for Medicare and Medicaid Enrollees

Individuals who are eligible for or have both Medicare and Medicaid are what is called dual eligible—they are “dual eligible” for both health care programs. Dual eligible individuals must meet the federal qualifications for Medicare eligibility and the QUEST Integration (QI)-specific qualifications for Medicaid eligibility.

Some dual eligible individuals qualify for all Medicare and Medicaid benefits. These individuals are called full benefit dual eligible individuals (FBDE). Others qualify for all Medicare benefits, but do not qualify for all Medicaid benefits. They may only receive assistance with Medicare premiums, copays, and deductibles. These individuals are called partial benefit dual eligible individuals. 

A Dual Eligible Special Needs Plan is a Medicare Advantage plan that has a model of care and benefits designed specifically to serve the unique needs of dual eligible individuals. D-SNPs include requirements that the plan help coordinate Medicaid benefits for the member. 

There are five D-SNPs in Hawaii, all of which also operate a QI Medicaid Managed Care Organization (MCO). These organizations include: AlohaCare, HMSA, Kaiser, Ohana, and United.  

In Hawaii, only full benefit dual eligible (FBDE) individuals, including those in the Qualified Medicare Beneficiaries (QMB) Plus and Specified Low-Income Medicare Beneficiary (SLMB) Plus programs, and other FBDE individuals can enroll in a D-SNP. QMB Plus enrollees qualify for full Medicaid benefits, and receive Medicaid assistance with their Medicare Part A and B premiums and cost sharing. Enrollees in SLMB Plus similarly qualify for full Medicaid benefits, but receive Medicaid assistance for Medicare Part B premiums only.   

In 2024, Hawaii will have two types of D-SNPs: Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs), and Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs).

• It is important to note that to enroll in a FIDE SNP, individuals must be enrolled in the same organization’s QI MCO, in what is called aligned enrollment (See Question 11).
• This is different from HIDE SNPs, where an individual can be enrolled in one organization’s HIDE SNP for their Medicare benefits, and another organization’s QI MCO for their Medicaid benefits (See Question 7).

A HIDE SNP is a type of D-SNP in Hawaii that has a model of care and benefits designed specifically to serve the unique needs of dual eligible individuals and also has a contract with MQD to provide coverage of primary, acute, and most all behavioral health, and long-term services and supports (LTSS) benefits.

Note that there are some Medicaid behavioral health and LTSS benefits that HIDE SNPs do not provide for certain dual eligible individuals.

• Dual eligible individuals with intellectual/developmental disabilities (I/DD) who receive LTSS via the state’s 1915(c) home- and community-based (HCBS) I/DD waiver; and/or
• Dual eligible individuals with serious mental illness (SMI) who receive behavioral health services exclusively through Ohana’s Community Care Services (CCS) program.

Question 19 provides further detail for how individuals with I/DD and/or individuals with SMI enrolled in the CCS program will have their needs further coordinated and supported by both FIDE SNPs and HIDE SNPs in 2024.

Four organizations will offer a HIDE SNP in 2024. These organizations include: AlohaCare, HMSA, Ohana, and United. Kaiser will not offer a HIDE SNP in 2024.

In Hawaii, FBDE individuals including those in the QMB Plus and SLMB Plus programs, and other FBDE individuals can enroll in a HIDE SNP.

Unlike enrollment into a FIDE SNP (See Question 10), dual eligible individuals can be enrolled in one organization’s HIDE SNP for their Medicare benefits, and another organization’s QI MCO for their Medicaid benefits.

In Hawaii, a FIDE SNP is a type of D-SNP that, like the HIDE SNP, has a model of care and benefits designed specifically to serve the unique needs of dual eligible individuals and contracts with MQD to provide coverage of primary, acute, and most behavioral health, and LTSS benefits.

In addition to these requirements, FIDE SNPs must also provide members with a single ID card, a single care manager who can manage across all services, an integrated provider and pharmacy directory and formulary reflecting their Medicare and Medicaid benefits and services, one customer service line for talking to someone about their Medicare and Medicaid coverage, and one process for filing plan-level Medicare and Medicaid appeals and grievances.

FIDE SNPs also give members a more streamlined care experience through what is known as ‘exclusively aligned enrollment’ (See Question 11 and Question 12).

Of the five Hawaii D-SNPs, three will offer a FIDE SNP in 2024. These organizations include: AlohaCare, Ohana, and Kaiser. United and HMSA will not offer a FIDE SNP in 2024.

Like enrollment into HIDE SNPs, FBDE individuals, including those in the QMB Plus and SLMB Plus programs, and other FBDE individuals can enroll in a FIDE SNP in Hawaii.  

Unlike enrollment into HIDE SNPs, individuals whose Medicare benefits and Medicaid benefits are provided under different organizations will not be eligible to enroll in FIDE SNPs. To enroll in a FIDE SNP, an individual’s Medicare D-SNP and QI Medicaid MCO must be ‘aligned’ under the same organization (See Question 11). This means that a dual eligible individual must be enrolled in a QI MCO in order to enroll in the same organization’s FIDE SNP.

Aligned enrollment is when an individual’s QI MCO and D-SNP are through the same organization. This makes their QI Medicaid benefits and Medicare benefits more coordinated, compared to separate organizations providing coverage of each benefit package. This can make for a more streamlined care experience for the member. Members may elect to align their enrollment in either a FIDE SNP or HIDE SNP.

As noted in Question 11, aligned enrollment can occur based on an individual’s choice in either FIDE SNPs or HIDE SNPs.

However, a key difference between FIDE SNPs and HIDE SNPs is that FIDE SNP enrollment is limited to only those dual eligible individuals whose QI MCO and Medicare D-SNP are aligned under the same organization. This enrollment into FIDE SNPs is referred to as ‘exclusively aligned’, because enrollment is limited exclusively to aligned individuals.

Dual eligible individuals exclusively aligned in FIDE SNPs can expect more seamless experiences across Medicare and Medicaid, compared to even those dual eligible individuals whose enrollment is aligned in HIDE SNPs. This is because a FIDE SNP’s entire membership is receiving Medicare and Medicaid benefits from the same organization, which allows them to provide members a single ID card for both Medicare and Medicaid benefits, an integrated provider and pharmacy directory, an integrated formulary, one health plan customer service number, a single care manager who can manage across all services, one process for appeals and grievances, and more seamless care coordination with most all benefits covered under the same organization.

However, timing will be important for dual eligible individuals wishing to enroll in a FIDE SNP, as exclusively aligned enrollment in Hawaii requires that a dual eligible individual must first be enrolled in a QI MCO in order to enroll in the same organization’s FIDE SNP.

For example, a dual eligible individual wishing to enroll in a FIDE SNP, but whose QI and Medicare benefits are provided by different organizations, would first need to request to enroll in the QI MCO offered by the same organization that offers their desired FIDE SNP enrollment choice. In most cases, MQD limits QI MCO changes to the Annual Plan Change Period in October of each year. This means that most new enrollments into FIDE SNPs will be limited to the QI Annual Plan Change Period, which is typically October 1 – October 31 annually. (See Question 14 for how Hawaii’s modified Annual Plan Change Period, effective through July 31, 2024, impacts enrollment into FIDE SNPs).

There are some circumstances where dual eligible individuals may enroll in a FIDE SNP outside of the QI Annual Plan Change Period. For example, a dual eligible individual whose Medicare and Medicaid enrollment is aligned under their current HIDE SNP would be able to enroll into that organization’s FIDE SNP throughout the year as long as they have an available Medicare Special Election Period (SEP).

Effective April 1, 2023, through July 31, 2024, all MQD QI members, including dual eligible individuals, are allowed to change their QI MCO at any time after 12 months of membership in a particular QI MCO. This will allow individuals to enroll in FIDE SNPs not offered by their current QI MCO at any point up until July 31, 2024, as long as they have an available Medicare SEP.

This scenario applies to current AlohaCare and Ohana HIDE SNP members, as both of these plans will be retaining their HIDE SNP in 2024.

For members that are currently aligned, these members will have received in September 2023 a Plan Annual Notice of Change to inform them of the upcoming transition to the FIDE SNP and EAE, as well as any additional changes to their plan/benefits. These aligned members will then be seamlessly transitioned into the FIDE SNP, effective 1/1/24.

For members that are currently unaligned, these members will have also received a Plan Annual Notice of Change describing any changes to their plan/benefits. These unaligned members will remain in the plan’s HIDE SNP, effective 1/1/24.

This scenario applies to current Kaiser HIDE SNP members, as this is the only plan closing its HIDE SNP for 2024.

For members that are currently aligned, these members will have received a Plan Annual Notice of Change to inform them of the upcoming transition to the FIDE SNP and EAE, as well as any additional changes to their plan/benefits. These aligned members will then be seamlessly transitioned into the FIDE SNP, effective 1/1/24.

For members that are currently unaligned, these members will be disenrolled from their current HIDE SNP, and will have been sent in September 2023 a “loss of special needs status notice” explaining that they no longer qualify for the plan because they do not meet the eligibility qualifications for the plan (i.e., their Medicare D-SNP and QI Medicaid enrollment is not aligned). (See Question 17 for more information on the “loss of special needs status” notice). These members will have a SEP to enroll in a new Medicare Advantage Plan or Original Medicare and a Part D plan starting the month they no longer qualify for their plan.

Unaligned members in Kaiser’s HIDE SNP will have received in September 2023 what is known as the “loss of special needs status” notice explaining that they no longer qualify for the plan because they do not meet the eligibility qualifications for the plan.

This is a written notice that the Centers for Medicare & Medicaid Services (CMS) requires all Medicare Advantage Special Needs Plans, including D-SNPs, send to members upon losing eligibility for their plan. This notice provides members with information on the Medicare SEP for which these members are eligible for, so that they may elect an alternative Medicare coverage option, such as a Medicare Advantage Plan or Original Medicare and a Part D plan.

While these members no longer qualify to remain with Kaiser’s new FIDE SNP – on the basis of being unaligned – they may still choose (during an available Medicare SEP) to enroll in the FIDE SNP of their current QI MCO, if their current QI MCO is offering a FIDE SNP in 2024. For example, if a member is receiving their QI Medicaid benefits with AlohaCare, they may choose to enroll in AlohaCare’s new FIDE SNP during an available SEP. Alternatively, they may choose to enroll in the HIDE SNP of their choosing, regardless of whether their desired HIDE SNP choice is aligned with their current QI MCO.

Lastly, these members may also choose to enroll in Kaiser’s FIDE SNP at a later time, by taking action to switch to Kaiser’s QI MCO during a QI Plan Change Period. Typically, members may change their QI MCO once annually from October 1 – 31, however, there are some exceptions where members may change their QI MCO outside of this Annual Plan Change Period (See Questions 13 and 14). Upon successful enrollment in Kaiser’s QI MCO, these members would be able to enroll into Kaiser’s FIDE SNP, because their QI MCO would now be aligned with their desired FIDE SNP choice.

For 2024, HIDE SNPs and FIDE SNPs will be similar in some areas, and different in others. A high-level comparison of key features is below:

There are some Medicaid behavioral health and LTSS benefits that neither FIDE SNPs nor HIDE SNPs provide for certain dual eligible individuals. These include:

• Services for dual eligible individuals with I/DD who receive LTSS via the state’s 1915(c) HCBS I/DD waiver; and/or
• Services for dual eligible individuals with serious mental illness who receive behavioral health services exclusively through Ohana’s CCS program.

In 2024, both FIDE SNPs and HIDE SNPs will provide greater care coordination for these dual eligible individuals who, despite being enrolled in a FIDE SNP or HIDE SNP, may still have to navigate across two or even three different organizations for their Medicare and Medicaid benefits. Care coordination enhancements for these dual eligible individuals include D-SNP staff education and training for how individuals receive services from CCS or the I/DD Waiver, and required D-SNP care managers to serve as a point of contact to help enrollees’ coordinate across their D-SNP and CCS and/or I/DD Waiver services. This single care manager will manage both the individual’s FIDE SNP and QI MCO services and benefits.