A Game Changer for Dual-Eligible Plans: CMS’s Proposed HRA Integration Rule
Navigating the healthcare landscape is becoming increasingly complex, especially for individuals eligible for both Medicare and Medicaid. As policymakers seek ways to streamline processes and improve care coordination, a new proposed rule could be a game changer for dual-eligible plans. This proposal aims to simplify health risk assessments (HRAs), reducing administrative burdens while enhancing the quality of care for millions.
Understanding Dual Eligible Special Needs Plans (D-SNPs)
Dual Eligible Special Needs Plans (D-SNPs), Institutional Special Needs Plans (I-SNPs), and Chronic Condition Special Needs Plans (C-SNPs) are specialized Medicare Advantage plans designed to cater to specific populations:
- D-SNPs serve individuals eligible for both Medicare and Medicaid, ensuring a comprehensive approach to their healthcare needs.
- I-SNPs focus on individuals requiring institutional-level care, such as nursing homes.
- C-SNPs address the needs of individuals with severe or disabling chronic conditions, offering tailored care management.
As of 2024, approximately 12 million people were enrolled in dual-eligible plans. The market is highly fragmented, with 1,333 dual-eligible plans available, reflecting the diverse needs of this population.
Currently, dual-eligible individuals must complete separate Health Risk Assessments (HRAs) for Medicare and Medicaid. These assessments are crucial for identifying beneficiaries’ health needs and risks, enabling health plans to develop personalized care plans. However, state-specific Medicaid HRA requirements often differ from the Centers for Medicare & Medicaid Services (CMS) guidance for Medicare HRAs, leading to inefficiencies and inconsistencies. This fragmented approach can result in duplicated efforts, increased administrative burdens, and potential gaps in care coordination.
The New Proposed Rule
To address these issues, CMS has proposed a rule for 2026 that would require a single integrated HRA for dual eligibles. This aims to streamline processes, reduce administrative burdens, and improve care coordination by having one comprehensive assessment for both Medicare and Medicaid. The proposed rule is expected to enhance the accuracy and completeness of HRAs, ensuring that all relevant health information is captured in a single, unified assessment. By consolidating the HRA process, dual-eligible individuals will receive more cohesive and efficient care, ultimately leading to better health outcomes.
Impact on Health Plans
Some health plans already implement custom HRAs to enhance member experience and deliver cost-effective care. These custom HRAs are tailored to meet the specific needs of their members, providing a more personalized approach to health risk assessment. For example, plans may include questions that address social determinants of health, such as housing stability, food security, and access to transportation, which are critical factors influencing health outcomes.
The ConXus HRA engine is known for its flexibility and cost-effectiveness in creating and supporting custom HRAs. It allows health plans to design HRAs adaptable to various platforms and member needs, whether digital, paper, or phone-based. This adaptability is crucial for reaching diverse populations and ensuring high completion rates. Health plans can leverage the ConXus HRA engine to develop integrated HRAs that align with the proposed CMS rule, facilitating a smoother transition to the new requirements.
Digital HRAs: Higher Completion Rates & Better Data
Compared to paper or phone-based assessments, digital HRAs provide significant advantages:
- Convenient – Members can complete them at any time.
- User-friendly – Accessible on any device.
- Enhanced data collection quality – More accurate and reliable.
- Lower costs – Reducing administrative overhead.
- Quick access to results – Enabling faster care interventions.
Many plans have successfully increased HRA completion rates through member incentives, simplified processes, and proactive outreach. These strategies drive higher engagement and satisfaction, ultimately improving health outcomes.
Looking Ahead
The proposed rule for an integrated HRA promises several benefits. By consolidating the HRA process, dual-eligible individuals will receive more cohesive and efficient care. This integrated approach is expected to lead to better health outcomes, as it facilitates timely identification of health risks and needs, enabling prompt and appropriate interventions.
Stakeholders should prepare for the implementation of the proposed rule by considering the adoption of integrated HRA solutions. This proactive approach will ensure a smoother transition and better outcomes for dual-eligible members. Health plans should also invest in training and resources to support the implementation of integrated HRAs, ensuring that staff are equipped to conduct comprehensive assessments and utilize the information effectively. By embracing these changes, the healthcare system can move towards a more coordinated, efficient, patient-centered approach to care for dual-eligible individuals.
Stay Tuned
We’ll be following this proposed rule closely and providing more insights soon. Stay tuned for upcoming content and a webinar deep dive into the implications for health plans.
References
https://www.kff.org/medicare/issue-brief/medicare-advantage-2024-spotlight-first-look/