Expanding Opportunities to Integrate Care for Dual Eligibles:Rethinking Federal Approaches to Measuring Network Adequacy for DSNPs

In large sections of rural America, a dual eligible special needs plan (DSNP) isn’t available in the Medicare Advantage program.  Often, the underlying reason is the difficulty involved in building a multispecialty provider network that complies with extensive Medicare Advantage network adequacy standards that are more suited to urban communities.

The rigid application of Medicare Advantage network adequacy standards that impedes entry into rural counties for DSNPs leads to several unwelcome consequences for Medicare-Medicaid dually eligible individuals:

·      Integrated care across Medicaid and Medicare is not possible when a dual eligible is enrolled in a Medicaid MCO but there is no available DSNP for primary and specialty medical care from the same organization;

·      Dual eligibles are deprived of an organized system of care to receive their Medicare benefits, including a Model of Care, attention to quality and access, available care coordination and care management, and access to supplemental Medicare benefits; and

·      Individuals who are Medicaid-only and then become dual eligibles (e.g. by aging into Medicare) often are disenrolled from an organized system of care in a Medicaid MCO and moved into unmanaged fee-for-service Medicare.

It’s time to rethink this.  As described in the accompanying policy brief, there are at least three alternative approaches CMS could consider.