The D-SNP Learning Series will reconvene in 2025. Stay tuned for more information!

Overview

CalAIM — DHCS’ multi-year, transformational reform of the Medi-Cal program — requires all Medi-Cal managed care plans to operate an Exclusively Aligned Enrollment (EAE) Dual-Eligible Special Needs Plan (D-SNP) by January 2026 with the goals of improving outcomes and streamlining care for the more than 1.7 million Californians who are dually eligible for Medi-Cal and Medicare. Given the complexity and timeline of standing up and operating Medicare D-SNPs, and because they are subject to different federal and state rules and regulations, local plans must begin planning and preparing now to ensure strategic and operational readiness for go-live.

Join us for this multi-part virtual learning series where you will learn from local plan leaders who have already implemented an EAE D-SNP, get updates on federal and state requirements, and hear insights from subject matter experts on what it takes to successfully stand up and operate a Medicare D-SNP. Developed with support from the California Health Care Foundation and The SCAN Foundation, the learning series will increase your knowledge and understanding of D-SNP compliance requirements, Medicare financing and risk adjustment, provider network considerations, Part D/pharmacy, marketing and communications and more.

The learning series will run through December 2025; stayed tuned for updates on upcoming sessions.

Upcoming Sessions

The D-SNP Learning Series will reconvene in 2025 and will cover topics such as the bid process; marketing communications and enrollment; Medicare Star Ratings, compliance, reporting and audits; and risk adjustment.

Stay tuned for more information!

Past Session Agendas 1-4

Session 1: Medicare Compliance
March 21, 2024 | 1:00 – 3:00 p.m.
Athena Chapman, President, Chapman Consulting LLC
Julie Mason, President, Integritas Medicare

• Medicare Advantage (MA) compliance requirements — seven required elements
• Centers for Medicare and Medicaid Services (CMS) perspectives on and expectations for MA compliance
• Roles of the plan compliance department and other operational areas
• Fraud, waste and abuse (FWA) — what CMS requires
• Differences between Medicaid and Medicare compliance requirements/expectations
• California-specific requirements and additional oversight

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Session 2: Medicare Financing
April 25, 2024 | 10:00 a.m. – 12:00 p.m.
Chris Esguerra, MD, Chief Medical Officer, Health Plan of San Mateo
Yvonne Tso, PharmD, MBA, Sr. Vice President, Integritas Medicare

• Understanding capitation payment methodology
• Ensuring payments sufficiently cover medical expenses
• Plan premiums and how rebates must be used (Part C and D)
• Coding intensity increases and impacts
• How quality bonus payments are realized
• Annual revenue reconciliation for Part D
• Annual Advance Notice

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Session 3: Provider Network & Reimbursement Considerations
May 30, 2024 | 1:00 – 3:00 p.m.
Mike Opich, Sr. Vice President & Network Development Consultant, Integritas Medicare
Kirk Fermin, Director, Provider Network, Inland Empire Health Plan
Dan Gomez, Vice President, Provider Experience, Inland Empire Health Plan
Rafael Gomez, Principal, El Cambio Consulting
Coline Ingalla Manager, Provider Network, Inland Empire Health Plan
Tracee Roque, Director, Provider Contracting, Inland Empire Health Plan
Danny Vargas, Director, Provider Contracting, Inland Empire Health Plan
*Additional speakers to be announced

• D-SNP network adequacy requirements — provider types and specialties, time and distance standards, county classifications
• Contract types and language requirements
• Centers for Medicare & Medicaid Services evaluation timeline and process for network development
• Network development strategy and provider reimbursement considerations
• Strategies for building a D-SNP network based on an existing Medi-Cal plan network

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Session 4: Medicare Part D/Pharmacy
June 25, 2024 | 1:00 – 3:00 p.m.
Yvonne Tso, PharmD, MBA, Sr. Vice President, Integritas Medicare
Ria Paul MD, Chief Medical Officer, Santa Clara Family Health Plan
Anna Yang, Director, Pharmacy, Santa Clara Family Health Plan

• Medicare Part D — what’s required of health plans
• How Part D works within the managed care construct
  • Covered benefits/services and what’s carved out
  • Beneficiaries enrolled in managed care plans vs Original Medicare (fee-for-service)
  • Delivery of Part D benefits
  • Transition requirements
  • Part D and STAR measures
• Formulary administration and pharmacy benefit manager (PBM) oversight
• Important changes impacting Medicare Part D — Inflation Reduction Act 2022, other regulatory priorities

Past Session Agendas 5-8

Session 5: Supplemental Benefits — Insights for D-SNP Implementation
August 29, 2024 | 10:00 a.m. – 12:00 p.m., Pacific Time
Nancy Archibald, MHA, MBA, Associate Director, Medicare and Medicaid Integration, Center for Health Care Strategies
Nils Franco, Senior Analyst, ATI Advisory
Alexandra Kruse, MS, MHA, Senior Fellow, Center for Health Care Strategies
Cheryl Meronk, MSG, MBA, Director, Medicare Program Development, CalOptima Health
Javier Sanchez, Executive Director, Medicare Programs, CalOptima Health

• Overview — supplemental benefits and member utilization data
• Strategies for evaluating supplemental benefit offerings given competition in the MA marketplace
• Supplemental benefits coordination with Medi-Cal services
• Selecting supplemental benefits that will meet members’ needs
• Federal oversight, requirements and guidance
• Plan perspectives on and best practices for the supplemental benefits market, delivery and coordination’

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Session 6: Model of Care
October 10, 2024 | 10:00 a.m. – 12:00 p.m., Pacific Time
Heidi Arndt, Sr. Compliance & Fraud Prevention Officer, Community Health Group
Amanda Asmus, Director, Care Management, L.A. Care Health Plan
Marco Avila, Senior Director, Medicare Product Management, L.A. Care Health Plan
Susan Stone, MD, Senior Medical Director, Care Management, L.A. Care Health Plan

• Model of Care essentials
  • Key components of the D-SNP Model of Care
  • Differences between D-SNP and Enhanced Care Management Models of Care
  • Plan self-assessments when making key decisions and developing the Model of Care
• Important milestones and timeline of deliverables
• Strategies for implementing a Model of Care that reflects internal health plan objectives and operations
• Considerations for overseeing the Model of Care and the delegation of its development or implementation
• Expectations for federal program audits  

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Session 7: Joint Strategies for Success in Serving the Dual-Eligible Population Within the Medicare Environment
October 30, 2024 | 10:00 a.m. – 12:00 p.m., Pacific Time
Jointly hosted with the California Primary Care Association
Daniel Santi, Chief Financial Officer, Shasta Community Health Center
Amy Turnipseed, Chief Strategy & Government Affairs Officer, Partnership HealthPlan of California
Ann Warren, Associate Chief Executive Officer, Community Health Group

Local plans and FQHCs have long been key partners in serving the Medi-Cal population. As Medi-Cal managed care plans prepare for Dual-Eligible Special Needs Plan (D-SNP) implementation and move into the Medicare environment, plans and health centers should explore how to work together to develop strategies for serving dual eligibles.

Hear from local plan and FQHC leaders about their strategies and approaches for working with their counterparts to prepare for successful D-SNP implementation. Participants will also hear perspectives and insights into some of the differences of operating a Medi-Cal plan vs. a Medicare product, as well as implications for quality, coding and other areas.  

• FQHC capacity to serve the Medicare population and build upon the contracting and operational framework developed through participation in Medi-Cal networks
• FQHC insights on challenges and lessons learned related to health plan contracts and expansions to new populations and services
• Best practices for plans interested in expanding relationships with FQHCs to support D-SNP network development and access for members
• Local plan insights, best practices and processes for:
  • Building upon and maintaining FQHC partnerships
  • Assessing the impacts that utilizing FQHC networks for the D-SNP product can have on reporting, quality performance and the patient experience

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Session 8: State Medicaid Agency Contract (SMAC)
November 14, 2024 | 10:00 a.m. – 12:00 p.m., Pacific Time
Anastasia Dodson, Deputy Director, Office of Medicare Innovation and Integration, Department of Health Care Services
Randy Haines, Manager, Regulatory Affairs – Medicare, Inland Empire Health Plan
Mary Russell, Principal, Duals & LTSS, Medicaid Policy & Programs, Aurrera Health
Christopher Tolbert, Health Program Specialist, Office of Medicare Innovation and Integration, Department of Health Care Services
Janit Vong​​​​, MS, CHC, Regulatory Affairs Liaison, Compliance, Inland Empire Health Plan 

• SMAC — overview of key areas and policies 
• Review of the D-SNP Policy Guide
• Compliance expectations for D-SNPs
• Process for completion, submittal and approval
  • How plans will interface with the process
• Plan perspectives and best practices for compliance and implementation

Learning Series Faculty

Nancy Archibald, MHA, MBA
Associate Director, Medicare and Medicaid Integration
Center for Health Care Strategies

Heidi Arndt
Sr. Compliance & Fraud Prevention Officer
Community Health Group

Amanda Asmus
Director, Care Management
L.A. Care Health Plan

Marco Avila
Senior Director, Medicare Product Management
L.A. Care Health Plan

Athena Chapman
President
Chapman Consulting LLC

Anastasia Dodson
Deputy Director
DHCS Office of Medicare Innovation and Integration

Chris Esguerra, MBA, FAPA, CHCQM
Chief Medical Officer
Health Plan of San Mateo

Kirk Fermin
Director, Provider Network
Inland Empire Health Plan

Nils Franco
Senior Analyst
ATI Advisory

Dan Gomez
Vice President, Provider Experience
Inland Empire Health Plan

Rafael Gomez
Principal
El Cambio Consulting

Randy Haines
Manager, Regulatory Affairs – Medicare
Inland Empire Health Plan

Coline Ingalla
Manager, Provider Network
Inland Empire Health Plan

Alexandra Kruse, MS, MHA
Senior Fellow
Center for Health Care Strategies

Julie Mason
Founder and President
Integritas Medicare

Cheryl Meronk, MSG, MBA
Director, Medicare Program Development
CalOptima Health

Mike Opich
Sr. Vice President & Network Development Consultant
Integritas Medicare

Ria Paul, MD
Chief Medical Officer
Santa Clara Family Health Plan

Tracee Roque
Director, Provider Contracting
Inland Empire Health Plan

Mary Russell
Principal, Duals & LTSS, Medicaid Policy & Programs
Aurrera Health

Javier Sanchez
Executive Director, Medicare Programs
CalOptima Health

Susan Stone, MD
Senior Medical Director, Care Management
L.A. Care Health Plan

Daniel Santi
Chief Financial Officer
Shasta Community Health Center

Christopher Tolbert
Health Program Specialist in the Office of Medicare Innovation and Integration
California Department of Health Care Services

Yvonne Tso, PharmD, MBA,
Sr. Vice President
Integritas Medicare

​Amy Turnipseed
Chief Strategy & Government Affairs Officer
Partnership HealthPlan of California

Danny Vargas
Director, Provider Contracting
Inland Empire Health Plan

Janit Vong​​​​, MS, CHC
Regulatory Affairs Liaison, Compliance
Inland Empire Health Plan

Ann Warren
Associate Chief Executive Officer
Community Health Group

Anna Yang
Director, Pharmacy
Santa Clara Family Health Plan

*Additional speakers to be announced

Registration

This learning series is developed with support from the California Health Care Foundation and The SCAN Foundation. Participation in the series is complimentary; however, registration is required.

The series will accommodate up to 300 participants per session. Registration will close after the deadline or once the seat limit has been reached.

Registration for Session 8 closed November 12 at 5:00 p.m.

Participating in the Webinar: You will only need a computer with an updated web browser (Google Chrome, Microsoft Edge, Mozilla Firefox or Safari are recommended). Participants may opt to listen to the webinar via telephone or device.