Review of Illinois Dually Eligible Special Needs Plans (D-SNP) Request for Proposal and Model Contract

The Illinois Department of Healthcare and Family Services (HFS) released the Request for Proposal (RFP) and Model Contract for Dually Eligible Special Needs Plans (D-SNPs) on their procurement website on September 3, 2024. Interested parties have already submitted their RFPs to the state. The state will announce the awarded D-SNP contracts in early 2025, with contracts running from July 2025 to December 32, 2029.  

The state uses a scoring system to determine the awarded D-SNPs.   A plan’s RFP must meet a minimum score before having the state’s consideration. If multiple plans score at or above the minimum score, the state will award D-SNP contracts to the top four scoring plans. If there is a tie for fourth place, more than four plans may be awarded contracts.  

HIGHLIGHTS FROM THE RFP AND MODEL CONTRACT THAT ADRESS SOME OF AVISERY’S CONCERNS 

States can ensure that D-SNPS provide integrated care though contract provisions. Avisery submitted feedback to HFS on integrated care provisions for the D-SNP contract. We then reviewed the contract and the RFP to check for the incorporation of the feedback.  

Similarities to the Medicare-Medicaid Alignment Initiative: HFS and the Center for Medicare and Medicaid Services aim to incorporate successful aspects of the Medicare-Medicaid Alignment Initiative (MMAI). Avisery’s interest in how similar MMAI and D-SNPs would be is through the lens of the beneficiaries and the counselors that assist them. The Model Contract did include provisions like those in MMAI. The eligibility criteria remain the same, meaning that all dually eligible individual can enroll, except those who are under the age of 21, receiving Developmental Disability waiver services and Developmental Disability institutional services , receiving Medicaid via Spenddown, enrolled in Illinois’ Medicaid breast and cervical cancer program, enrolled in a partial benefit program, and have comprehensive third-party insurance.  

D-SNPS will include care coordination as a covered service like MMAI, this service will assist enrollees in navigating their Medicare and Medicaid benefits under their D-SNP plan. The Model Contract includes requirements surrounding care coordination that are like MMAI requirements.  

Additionally, D-SNP enrollment is voluntarily like MMAI enrollment is, meaning that having D-SNP coverage will be the beneficiary’s choice. One aspect of MMAI that Avisery wanted to continue in D-SNPs is the continuity of care period that allows D-SNP enrollees to see out-of-network providers when they first enroll until the provider can join the network, or until the member finds another provider. Avisery recommended a continuity of care period of 12 months.  However, in the Model Contract, D-SNPS will have the same continuity of care period that MMAI had of 180 days. 

Working with Community Agencies:  Avisery called for the requirement that D-SNPs contract with Area Agencies on Aging (AAA) and community agencies to assist enrollee with connecting them to benefit enrollment, Senior Health Insurance Program (SHIP) counseling, Home and Community Based Services, and other social services. The Model Contract does require the D-SNP plans to work with community-based organizations in various places, including connecting enrollees to community services under care coordination and outreach.  

Deeming Periods:  A plan’s deeming period is the time that enrollees can continue to be covered by the D-SNP plan if their Medicaid is terminated due to no longer being eligible or because they missed their Medicaid redetermination due date. Avisery recommended a deeming period of up to six months, but HFS set it at only 90 days. This does mirror the 90-day reinstatement period that HFS currently has in place for Medicaid enrollees whose benefits are terminated but are still eligible. 

HIGHLIGHTS FROM HEALTH MANAGEMENT ASSOCIATES BRIEF 

In addition to these points identified through our own review of the RFP and model contract, Avisery also reviewed a brief recently issued by Health Management Associates (HMA), a consulting firm specializing in the Medicaid program. HMA summarized the Illinois D-SNP contract, noting its alignment with national trends in addressing health equity. The contract requires D-SNP plans to provide information on their responses to Health-Related Social Needs and innovations addressing Social Determinants of Health. This ensures that D-SNP plans respond to social needs that impact health on an individual level and on a population level. The state wants to know how plans will improve care to reduce health disparities among enrollees. Additionally, the plans must detail their experience with partnering with non-traditional Medicaid providers to meet enrollee needs, indicating their ability to provide care to hard-to-locate individuals. Other highlights of a health equity focus include the requirements for specific outcome data to be reported by race, ethnicity, and geography, essential for addressing population health, and monitoring health equity activities.   

NEXT STEPS 

The highly anticipated release of the RFP and Model Contract shed light on how D-SNPs will operate in Illinois. We have learned that there are similarities to MMAI such as eligibility standards, continuity of care, voluntarily enrollment, and care coordination. Avisery supports the inclusion of community agency collaboration to better serve enrollees. Lastly, the RFP and Model Contract indicate provisions that align with national trends in addressing health equity.  

Avisery continues to monitor the transition from MMAI to D-SNP and will provide updates as more policy decisions are made and their effects on beneficiaries and the community become clearer.