Termination of dual‐special needs plan “look‐alikes” and subsequent insurance enrollment

Dual-Eligible Special Needs Plans (D-SNPs) are Medicare Advantage (MA) plans that integrate Medicaid and Medicare insurance coverage for dual-eligible beneficiaries, a population with high medical and social needs and disproportionately greater health spending.1 Enrollment in D-SNPs increased from 1.3 million in 2013 to 5.1 million beneficiaries in 2023.2 In recent years, plans known as D-SNP “look-alikes,” nonintegrated MA plans that primarily enroll dual-eligible beneficiaries,3 have proliferated, growing 11-fold from enrolling 20,900 dual-eligibles in 2013 to 220,860 dual-eligibles in 2020.4 These plans have raised concerns because they do not have the same requirements to integrate Medicaid and Medicare coverage yet aggressively market themselves to dual-eligible enrollees who may benefit from integration.3 Beginning January 1, 2023, the Centers for Medicare and Medicaid Services (CMS) restricted the availability of D-SNP “look-alikes” by terminating the contracts of non-D-SNP plans in which the proportion of dual-eligible enrollees was 80% or greater as of January 2022.5 We evaluated the characteristics of the beneficiaries affected by these terminations. Furthermore, because the primary goal of these terminations was to shift beneficiaries into more integrated care options, we identified their subsequent insurance enrollment in 2023. We used publicly available CMS plan data to identify D-SNP “look-alikes” that were terminated in January 2023 and those classified as such in 2023 (and therefore subject to potential termination in 2024). We linked these data to publicly reported star-rating and plan benefit data. Using the 100% Medicare Master Beneficiary Summary file, we identified beneficiaries' demographic characteristics, including age, sex, presence of end-stage renal disease, disability, state, dual-eligibility, and race and ethnicity (defined using the RTI race code), in terminated look-alike plans and other MA plans. We also tracked insurance enrollment in 2023, where Highly Integrated D-SNPs (HIDEs), Fully Integrated D-SNPs (FIDEs), and Program of All-Inclusive Care for the Elderly (PACE) plans were combined as these models have the highest levels of integrated Medicare and Medicaid coverage. Tests for statistical significance included χ2, t-test, and Analysis of variance (ANOVA). This work was deemed exempt by the Brown University IRB. All analyses were conducted in Stata 17. A total of 200,476 beneficiaries experienced D-SNP “look-alike” termination and survived at least 1 day in 2023. Those in terminated look-alikes were more likely to be Asian (16.5% vs. 5.3%) and Hispanic (24.3% vs. 11.7%), reside in the West (82.8% vs. 13.8%), specifically California (69.0% vs. 4.3%), and have lower rates of disability (35.6% vs. 52.3%) compared with enrollees in D-SNPs (Table 1). After the termination, 98,734 of enrollees (49.3%) joined a non-SNP MA plan, 64,492 (32.2%) selected a Coordination-Only D-SNP, 13,970 (7.0%) were in another SNP, 12,667 (6.3%) chose a highly integrated D-SNP, fully integrated D-SNP, or Program of All-Inclusive Care for the Elderly (PACE), 7750 (3.8%) switched to Traditional Medicare, and 2797 (1.4%) chose another D-SNP “look-alike” by 2023 definition (Figure 1A). After terminations, beneficiaries enrolled in lower-rated plans (mean star-rating 3.97 before termination vs. 3.61 post-termination), with the largest drop in star-rating among Asian and Hispanic beneficiaries (Figure 1B). Most Black, American Indian/Alaska Native, and White beneficiaries selected non-SNP MA plans (Figure 1C) after termination. The proportion of White beneficiaries (8.9%) who enrolled in a highly integrated D-SNP or fully integrated D-SNP was greater than all other racial and ethnic groups with Asian and Black enrollees having the lowest proportions at 2.3% and 2.6% respectively (Figure 1D). D-SNP “look-alike” terminations in 2023 disproportionately impacted Hispanic and Asian beneficiaries and shifted beneficiaries to lower quality plans. Though terminations were intended to move dual-eligible beneficiaries to plans that integrate Medicare and Medicaid coverage, the majority of beneficiaries did not experience higher levels of integration after the termination, with Black beneficiaries having the lowest rate of enrolling in a care option with higher levels of integration. The lack of movement towards more integrated plans may be explained by the fact that affected MA insurers managed the transition process, and CMS did not explicitly direct dual-eligible enrollees to enroll in more integrated plans, meaning they were allowed to transfer beneficiaries to a non-SNP MA plan within the same organization.6 Of the beneficiaries who experienced a “look-alike” termination, 69.0% resided in California, which may explain the disproportionate impact on Hispanic and Asian beneficiaries; whether these findings generalize to other states is unclear. However, analysis of this specific termination is important because CMS intends to broaden the policy by lowering the threshold for look-alike termination in 2024 to 60% of a plan's enrollees being dually eligible.7 As CMS moves forward with further terminations, the lower star-ratings of subsequent insurance plans raise concerns about the quality of care and care disruptions for impacted beneficiaries. Further, after the termination, the majority of affected beneficiaries did not enroll in plans that integrate Medicare and Medicaid benefits. The impact of contract terminations on care and outcomes for dual-eligible beneficiaries warrants close monitoring. Study concept and design (all authors), acquisition of data (Meyers, Trivedi), analysis and interpretation of data (Dixit), drafting of manuscript (Dixit), and critical revision of manuscript (Meyers, Trivedi). DJM reports receiving personal fees from ORAU as a Senior Advisor to the Center for Medicare and Medicaid Innovation within CMS. This work does not reflect the views of CMMI, CMS, or the federal government. The authors have no other conflicts to disclose. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. This study was supported by the National Institute of Aging award P01AG027296, National Institute of Diabetes and Digestive and Kidney Diseases award R01-DK129388, National Institute on Minority Health and Health Disparities award R01-MD017080, and a grant from Arnold Ventures. Mr. Dixit had full access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.