CMS Pub. 100-16, ch. mc86c16b, § 20.2.4.2

When MA organizations submit bids for the upcoming contract year, each D-SNP must identify

whether or not the D-SNP has Medicare zero-dollar cost sharing. In HPMS, D-SNPs have the option

of one of the following two indicators:

1. Medicare Zero-Dollar Cost Sharing Plan, or

2. Medicare Non-Zero Dollar Cost Sharing Plan.

These two indicators are used in multiple areas within HPMS, and use of the accurate indicator is

essential to the proper display of benefits in Medicare Plan Finder.

We strongly encourage states and D-SNPs to finalize D-SNP eligibility criteria in their State

Medicaid Agency Contracts well in advance of D-SNP bid submissions. However, if a state changes

the Medicaid eligibility criteria it requires the D-SNP to use through the State Medicaid Agency

Contract after bid submission and before contract approval, the MA organization will have the ability

to change the D-SNP’s (or D-SNPs’) Medicare Zero-Dollar Cost Sharing D-SNP designation(s) in

HPMS.

20.2.4.2.1 Definition of Medicare Zero-Dollar Cost Sharing Dual Eligible Special

Needs Plans

(Rev.128; Issued:06-30-23; Effective: 06-30-23; Implementation: 06- 30-23)

A Medicare Zero-Dollar Cost Sharing D-SNP is a D-SNP under which all Medicare Part A and B

services are provided with no Medicare cost sharing to all enrollees who remain dually enrolled in

both Medicare and Medicaid. This term encompasses the following types of plan designs:

1. Where cost sharing for enrollees is $0 as part of the plan design (i.e., cost sharing for all Part

A and B benefits has been reduced to $0 as part of the supplemental benefits provided by the

D-SNP); and

2. Where there is cost sharing in the plan design, but all individuals who are eligible to enroll in

the D-SNP are protected by sections 1848(g)(3)(A) and 1866(a)(1)(A) of the Act from cost

sharing, or otherwise qualify for Medicaid coverage of cost sharing (see section 1852(a)(7) of

the Act and 42 CFR 422.504(g)(1)(iii) for cost sharing protections afforded non-QMB full-benefit dually eligible individuals).

CMS uses the designation of a Medicare Zero-Dollar Cost Sharing D-SNP to ensure that information

provided to beneficiaries is accurate, clear, and consistent with the requirements on MA organizations

at 42 CFR 422.111 and 422.2260-422.2267.

For a Medicare Zero-Dollar Cost Sharing D-SNP, information on Medicare Plan Finder on

Medicare.gov describe all Part A and B services under the D-SNP, such as inpatient hospital stays

and doctor visits, as available at no cost to the enrollee. Plan materials may also describe the D-SNP

benefits that way. Such descriptions are accurate – even if the D-SNP plan benefit in the MA

organization’s bid to CMS includes cost sharing for Medicare Part A and B services – if all

individuals who are eligible to enroll in the D-SNP are protected from cost sharing (see number 2

above). An MA plan, including a D-SNP, that has no cost sharing for services under Medicare Part A

and B in its plan bid will also have such benefits described as available with no cost sharing, both in

plan materials and on Medicare Plan Finder. This information helps dually eligible enrollees

understand what costs they will have when choosing a plan and allows D-SNP materials to clearly

show that costs are not a barrier to accessing covered services. When the “Medicare Zero-Dollar Cost

Sharing D-SNP” designation is not available, plan materials and Medicare Plan Finder will indicate

that cost sharing for Medicare varies depending on the enrollee’s category of Medicaid eligibility.

Like all MA plans, both Medicare Zero-Dollar Cost Sharing D-SNPs and other D-SNPs can reduce

Medicare Part A and B cost sharing as a supplemental benefit. CMS bid review applies the same

standards for all D-SNPs.

A D-SNP that includes cost sharing in its plan design may designate itself as a Medicare Zero-Dollar

Cost Sharing D-SNP provided that it meets all of the following criteria:

1. The D-SNP plan benefit package limits enrollment, under the terms of its State Medicaid

Agency Contract, to dual eligibility categories with Medicare cost sharing protections:

o QMB Only;

o QMB Plus;

o SLMB Plus and;

o Other Full Benefit Dual Eligibles (FBDE).

If the D-SNP enrolls members of dual eligibility categories that do not have Medicare cost

sharing payable by Medicaid (i.e., SLMB-only, QI, or QDWI), the D-SNP cannot (and

must not) be designated as a Medicare Zero-Dollar Cost Sharing D-SNP.

2. The D-SNP provider contracts (1) require that providers accept the D-SNP’s payment and any

Medicaid payment of Medicare cost sharing (whether paid by the Medicaid agency, the D-SNP itself, or a Medicaid managed care plan) as payment in full and (2) prohibit providers

from collecting from a dually eligible enrollee any Medicare cost sharing that is payable under

Medicaid (42 CFR 422.504(g)(1)(iii) and 74 FR 1494-1499 (January 12, 2009)).

Per 42 CFR 422.504(g)(1)(iii), such D-SNP provider contract provisions must also apply to

SLMB Plus and FBDE enrollees for whom Medicare cost sharing protections are more

limited, if those groups are eligible to enroll in the D-SNP. SLMB Plus and FBDE enrollees

cannot be charged Medicare cost sharing above any Medicaid copay applicable to the same

service under the Medicaid state plan or a waiver. In the rare instance that a Part A or B

service is not covered under the Medicaid state plan or a Medicaid waiver, the cost sharing for

a SLMB Plus or FBDE enrollee is the Medicare cost sharing under the MA plan benefit

because of the limits in Medicaid coverage. (This is because 42 CFR 422.504(g)(1)(iii) applies

when the State is responsible for coverage or payment of the Medicare cost sharing.)

However, States may elect in their Medicaid State Plan to pay all Medicare cost sharing for all

FBDE individuals (including SLMB Plus individuals), even for Medicare services not covered

by Medicaid under the State Plan. To comply with § 422.504(g)(1)(iii), Medicare Advantage

plans in those states must ensure that their network providers in those states do not charge a

SLMB Plus or FBDE enrollee Medicare cost sharing for any Medicare Part A or B service

above the Medicaid copay for the same service as covered under the Medicaid State Plan (see

2020 Medicaid Section E of the Coordination of Benefits and Third Party Liability

Handbook, Available online at: https://www.medicaid.gov/medicaid/eligibility/coordination-of-benefits-third-party-liability/index.html). MA organizations can determine if states have

made such an election by checking the Medicaid State Plan. We encourage states and D-SNPs

to include this information in their State Medicaid Agency Contracts.

Providers can never charge a QMB Only or QMB Plus enrollee Medicare cost sharing for any

Medicare Part A or B service above any applicable Medicaid copay per section 1902(p)(3) of

the Act.

3. The providers contracted with the D-SNP do not charge Medicaid copays, deductibles, or

coinsurance for any Medicaid service that is also a Medicare Part A or B service. If a D-SNP

operates in a state that imposes Medicaid copays on dually eligible enrollees for specific

services, then the D-SNP must list those Medicaid copays in its plan materials for those

services and may not be designated as a Medicare Zero-Dollar Cost Sharing D-SNP, unless:

o The D-SNP or Medicaid managed care plan responsible for Medicaid payment of

Medicare cost sharing does not impose Medicaid copayments for enrollees (i.e., the

plan pays the provider the copay in lieu of payment by the dually eligible enrollee); or

o The state limits its payment of Medicare cost sharing to the Medicaid rate for the

service, and the amount the D-SNP pays the provider for the service is equal to or

greater than the Medicaid rate, including in any deductible phase of the benefit. (In this

circumstance, no Medicaid payment is made so there is no Medicaid copay.)

20.2.4.2.2 Special Considerations for PPO D-SNPs

(Rev.128; Issued:06-30-23; Effective: 06-30-23; Implementation: 06- 30-23)

D-SNP PPOs that that are designated as a Zero-Dollar Cost Share D-SNP may not describe out-of-network services in plan materials as available at “zero cost” because non-contracted providers that

are not enrolled in Medicaid may charge the Medicare cost sharing under the plan benefit to non-

QMBs. QMB Plus and QMB Only beneficiaries would pay $0; other full-benefit dually eligible

individuals would pay the plan benefit cost sharing rate (see sections 1848(g)(3) and 1866(a)(1)(A) of

the Act for provisions protecting QMBs regardless whether the MA organization has a contract with

the provider that prohibits the collection of cost sharing per 42 CFR 422.504(g)(1)(iii)). For example,

an out-of-network service with 30 percent coinsurance under the plan benefit would be described as

“$0 or 30 percent.” For D-SNPs designated as Zero-Dollar Cost Share, Medicare Plan Finder will

continue to show the cost sharing in the plan benefit for out-of-network services, and in-network cost

sharing will show $0.

20.2.4.2.3 Medicare Zero-Dollar Cost Sharing D-SNPs and Enrollee Lapse in

Medicaid Eligibility

(Rev.128; Issued:06-30-23; Effective: 06-30-23; Implementation: 06- 30-23)

D-SNPs can provide up to six months of deemed continued eligibility for enrollees who have lost, but

are expected to regain, Medicaid eligibility, per 42 CFR 422.52(d). The Medicare cost sharing

protections for enrollees in a Medicare Zero-Dollar Cost Sharing D-SNP lapse if an enrollee no

longer has Medicaid eligibility for any of the dual eligibility categories with cost sharing protections.

During periods when Medicaid eligibility for Medicaid coverage of cost sharing for Medicare Part A

and B benefits has lapsed and the individual remains enrolled in the D-SNP, plan providers may

collect Medicare cost sharing under the MA plan benefit for the service. Enrollee materials from

Medicare Zero-Dollar Cost Sharing D-SNPs, including any required plan notice related to the loss of

Medicaid eligibility, must explain that the enrollee may be billed cost sharing for Medicare Part A

and Part B benefits if the enrollee loses Medicaid eligibility. This ensures that the materials are

accurate as required by 42 CFR 422.111(b)(2)(iii) and 422.2262(a)(1)).