Medicare Innovations and Policy Considerations: A Guide for Integrated Programs

Medicaid-Medicare IntegrationPolicy Analysis and Development
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On December 18th, Health Affairs published Innovating Without Compromising Integration: Considerations for Medicare in their Forefront Medicare and Medicaid Integration series. The article addresses how the Centers for Medicare & Medicaid Services (CMS) CY 2025 Medicare Advantage (MA) and Part D Final Rule requirements intended to benefit dual eligible individuals may present challenges for states that are exploring integrated care options for their members.

New Medicare Policies: Considerations for Integrated Programs and Beneficiaries  

The Health Affairs article highlights the following five Medicare policy updates outlined in the CY 2025 MA and Part D Final Rule:

  1. Updating the Medicare Special Enrollment Periods,

  2. Improving MA prior authorizations processes,

  3. Implementing Medicare Star Ratings,

  4. Increasing Accountable Care Organization engagement, and

  5. Changing enrollment thresholds for D-SNP Look-Alike plans.

These updates have the potential to yield many positive outcomes, such as improved member experience and reduced complexity for both providers and beneficiaries. However, some of these well-intentioned policies will likely have adverse impacts on Dual Eligible Special Needs Plans (D-SNPs), and the state agencies overseeing them. D-SNPs cover individuals eligible for both Medicare and Medicaid who are often in poorer health than Medicare-only beneficiaries. Therefore, there is a need for increased cross-collaboration, administrative coordination, and oversight to ensure D-SNP policies are properly implemented.

Looking to the Future: Evolving CMS Policies

To optimize the likelihood of successful policy outcomes with minimal burden, it is vital that states prioritize collaboration with CMS. CMS is working to address some of the policy issues raised in our Health Affairs article, including prior authorizations, through the CY2026 Medicare Advantage Policy and Technical Changes Proposed Rule published on November 26, 2024, and is soliciting public comments here until 5pm ET on January 27, 2025. We encourage states to submit comments to ensure CMS understands the full implications of potential requirements.  If you are interested in learning more about Aurrera Health Group’s work supporting state policy development related to D-SNPs, please reach out to Kristal Vardaman.

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