What is a State Medicaid Agency Contract?

The Intersection offers advocates a lens for examining the intersection of affordability and accessibility of health care for older adults and adults with disabilities. Our first series will explore Illinois’ planned transition to Medicare Advantage Dual Eligible Special Needs Plan (D-SNP). Check out our previous post for more information on the planned transition and Avisery’s advocacy efforts. Up next, we will be looking at how the contract between Illinois Medicaid agency and D-SNPs will provide information on how Illinois D-SNP will be structured and can guide future advocacy opportunities.  

Every Medicare Advantage Dual Special Needs Plan (D-SNP) must have a State Medicaid Agency Contract (SMAC) executed with the state in which the plan operates. The SMAC includes a minimum set of requirements that every D-SNP must follow. States can include additional requirements in the SMAC for D-SNPs to have more Medicare and Medicaid integration.  Advocates can use the SMAC to track what the state requires from D-SNPs and to ensure that D-SNP enrollees have the most integrated coverage possible. In Illinois, the Illinois Department of Healthcare and Family Services (HFS) will administer the D-SNP SMAC. 

All D-SNPs must at least coordinate or cover Medicaid services. “Coordination-Only” D-SNPs will only assist enrollees to accessing their Medicaid benefits and in notifying the state when enrollees are admitted as an inpatient. There is minimal integration of Medicare and Medicaid benefits under this type of D-SNP. In contrast, “Highly Integrated” (HIDE) D-SNPs and “Fully Integrated “(FIDE) D-SNPs will cover Medicaid benefits, with HIDE D-SNPS potentially carving out Long Term Services and Supports (LTSS) and behavioral health coverage. States can choose which types of D-SNPs they want to contract with. All indications are that Illinois HFS plans to contract only with Fully Integrated D-SNPs (FIDE D-SNPs).   

Below are two lists of requirements that can be included in the SMAC. One lists the minimum requirements that every SMAC must have, and the other lists additional requirements that a state can choose to include. (For definitions of some of these requirements, check out Avisery’s State Medicaid Agency Contract Resource Guide). For sample language on how these requirements will be described in the SMAC, check out this series of tools from the Integrated Care Resource Center. 

Minimum requirements every SMAC will have:  

• Criteria for eligibility 

• Responsibility of Medicare cost sharing protections 

• Identification of Medicaid provider participation 

• Verification process of D-SNP enrollee’s eligibility for Medicare and Medicaid. 

• The service area of the D-SNP and the contract period.  

Illinois can choose to include additional requirements in the SMAC for D-SNPs to be more integrated. Some of the requirements that Illinois can include are available to the state because Medicaid Managed Care is in place. Below, we have bolded those requirements that we can assume will be in the SMAC based on the the Transition Plan HFS submitted to CMS and the fact that Illinois appears to be electing to pursue only FIDE D-SNPs.  

Optional requirements that Illinois can include:  

• Limit D-SNP enrollment to full dually eligible beneficiaries 

• Contract with D-SNP to cover Medicaid benefits including coverage for Long Term Services and Supports and behavioral health services. As well as Medicare cost sharing 

• Require D-SNPs to use specific or enhanced care coordination methods 

• Require D-SNPs to send data to the state for oversight purposes 

• Require the state to review D-SNP materials related to Medicaid benefits 

• Partner with D-SNPs to develop supplemental benefit packages that complement Medicaid benefits 

• Selectively contract with exclusively aligned plans 

• Require complete service alignment, allow or require default enrollment 

• Allow or Require default enrollment (this is also a requirement for all FIDE D-SNPs starting in 2025 based on the Center of Medicare and Medicaid Services Contract Year 2023 Final Rule) 

• Require a deeming period of a certain time frame  

• Contracting with community agencies 

• Require a continuity of care transition period of a certain time frame  

SMAC ADVOCACY 

Justice in Aging released a guide outlining opportunities for advocates to work in the interest of enrollees by ensuring D-SNPs are as integrated as possible. The advocacy opportunities we see as being particularly relevant to Illinois are:  

• Advocate for the State Medicaid Agency to have expertise in Medicare 

• Work with the State Medicaid Agency to develop and review performance criteria and ensure that the voices of marginalized communities are included 

• Advocate for consumers to have strong enrollment protections including easy to understand notices, continuity of care transition periods, and deeming periods.  

• Advocate for robust D-SNP supplemental benefits that do not duplicate Medicaid benefits  

Avisery is currently on the lookout for HFS’ release of the D-SNP SMAC. Due to the timing of the release of the SMAC and the November 2024 deadline for D-SNPs plans being finalized in Illinois, stakeholders may not be able to provide input on the SMAC for Contract Year 2026. However, the Illinois SMAC has the potential to be amended in the future. Avisery plans to review the released SMAC and monitor for future advocacy opportunities that stakeholders can participate in. Keep a look out for future blog posts on this topic!  

— by  Stella Van den Eeden, Avisery Training Specialist