Impact of CMS’s Proposed Rule

Starting in 2022, CMS is proposing to no longer enter into or renew contracts with Dual Eligible-Special Needs Plan (D-SNP) “look-alike” Medicare Advantage plans in states where other dual-focused plans are present (e.g., D-SNPs or plans participating in CMMI’s Financial Alignment Initiative). CMS proposes to transition enrollment in look-alike plans, which CMS defines as a non-D-SNP plan with enrollment that is 80% or more duals, to other MA plans. Based on 2020 projected enrollment, CMS estimates that there are 67 look-alike plans nationwide. Of these 67 plans, CMS identified 62 look-alike plans whose 180,758 enrollees would be subject to transitioning to another MA plan.

If finalized, CMS’s proposal could result in notable shifts in enrollment, especially in CA, where, according to MedPAC, many look alike plans are present. For example, an Avalere analysis found that in CA Medicare Advantage organizations who offered a look-alike plan but did not also offer a D-SNP in that same county enrolled approximately 52,000 beneficiaries in the look-alike plan. This represented 46% of all beneficiaries enrolled in look-alike plans in CA in 2019.

Under the proposed rule, these organizations could establish a new D-SNP for these enrollees.  However, the ability of these organizations to create a new D-SNP is limited.  In particular, CA has imposed its own restrictions on new D-SNPs entering the market in certain counties that are part of the Financial Alignment Initiative.

Look-alike enrollees could also be transitioned to non-SNP MA plans operated by the same parent organization, but only if the plan meets established criteria set by CMS in the proposed rule. As a result, it is unclear if the transitioned enrollees would move into a non-SNP MA plan with similar benefits or switch to a plan run by a different parent organization altogether. Recognizing the dynamics of the local MA market is key to understanding the ultimate impact of CMS’s proposal on plans and beneficiaries.

Background

Under the proposed rule, following their discontinuation, look-alike plans run by a parent organization that also has a D-SNP in the same county would be able to transition eligible beneficiaries into that D-SNP. For organizations that do not have a D-SNP (or will not establish one in the following year), enrollees in a terminated look-alike plan could be transitioned to a non-SNP MA plan that meets certain criteria established under the proposed rule. Specifically, this transition could occur only if the non-SNP MA plan:

• Is located in the same service area as the look-alike plan
• Has a combined Part C and D beneficiary premium of $0 (after taking the Part D low-income subsidy into account) for full-subsidy-eligible individuals
• Would not have 80% or more dual eligible enrollment after the transition from the look-alike plan is complete

Beneficiaries enrolled in impacted look-alike plans would also have the option to choose another MA plan or Medicare fee-for-service coverage.

Plans will need to consider how to best transition enrollees, as well as evaluate the opportunity to create new D-SNPs in counties where they do not currently offer one. CMS’s proposal could also create additional complexity as plans seek to coordinate with state Medicaid programs and adhere to integration requirements.

Comments on the proposed rule are due April 6, 2020.

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