The Centers for Medicare & Medicaid Services (CMS), the agency that oversees the Medicare program, recently proposed a rule to help deter Medicare Advantage (MA) plans from deceptively targeting people who are dually eligible for Medicare and Medicaid. If the proposals go into effect, dual eligibles could face less confusion in plan selection and may be less likely to enroll in a plan that does not meet their needs.

Dual Eligible Special Needs Plans (D-SNPs) are a type of MA plan that is intended to meet the specific needs of people who have both Medicare and Medicaid. Historically, D-SNPs provided some coordination of benefits between the Medicare and Medicaid programs. In recent years, Congress and CMS have required D-SNPs to do more to ensure that dually eligible people can more easily get the care they need. For example, D-SNPs must create a single appeals process for both Medicare and Medicaid appeals to ensure enrollees can find answers and access their care.

As the requirements for D-SNPs have increased, however, MA plans have arisen that look a lot like D-SNPs but do not offer the same services. Often called “look-alikes,” these plans are marketed aggressively to dual eligibles. Because the look-alikes do not  provide the health delivery system coordination of D-SNPs, they can exacerbate the challenges dually eligible individuals face in accessing and managing their care.

In a proposed rule, CMS announced its intention to curtail such look-alikes by ending the contracts of non-D-SNP MA plans that over-target dually eligible individuals. People who are enrolled in such plans will be able to choose another plan, including a real D-SNP, or select Original Medicare instead.

Medicare Rights is encouraged to see CMS taking this issue seriously. MA plans must be held to a high standard to serve the Medicare population and true D-SNPs can play a valuable role in helping dual eligibles access the care they need. The look-alike plans are interfering with efforts to better serve people who are dually eligible for both Medicare and Medicaid.

In our comments on the proposed rule, we will urge CMS to do more to strengthen protections and weed out deceptive plans. This proposal would be an important step toward eliminating a risk to dually eligible individuals.

Read the proposed rule.

Read more about D-SNP look-alikes from Justice in Aging.