Dual Eligible Special Needs Plans (D-SNPs): What Advocates Need to Know

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan designed to serve individuals who are dually enrolled in Medicare and Medicaid (“dual eligibles” or “dually eligible individuals”). Enrollment in D-SNPs has increased by over 70% in the past five years, with current D-SNP membership at over six million individuals.^[1]

An increasing number of states are focusing on D-SNPs as a primary vehicle for integrating care and improving coordination of services for their dual eligible populations.^[2] At the same time, many enrollees in Medicare Advantage plans report that they experience narrower provider networks and more instances where their requested services will be subject to review and prior authorization. This makes it especially important for advocates to advance strategies for integrating care while maintaining and improving access to services and supports.

This issue brief provides advocates with an overview of D-SNPs, where they operate, their structures, and the rules governing them. It also identifies specific areas where advocates can engage with their states to ensure that D-SNPs work effectively to coordinate care and benefits for dually eligible individuals, including strategies for centering equity from the outset in the design of D-SNPs.

For more information on an individual’s choice to enroll in a D-SNP, see Justice in Aging’s Dual-Eligible Special Needs Plans: Frequently Asked Questions. For more information on advocacy to make D-SNPs work better, see Justice in Aging’s State Medicaid Agency Contract (SMAC) Toolkit and Justice in Aging’s Guiding Principles for Designing and Implementing Integrated Models for Individuals Dually Eligible for Medicare and Medicaid.

The Basics: What Are D-SNPs & Where Do They Operate

Special Needs Plans (SNPs), a subset of plans within the Medicare Advantage program, were launched in 2006 to serve specific populations within Medicare managed care.

There are three categories of SNPs:

1. D-SNPs, which serve individuals who are dually eligible for Medicare and Medicaid;
2. Institutional Special Needs Plans (I-SNPs); which serve individuals who are receiving long-term services and supports in institutions such as nursing facilities or in the community; and
3. Chronic Condition Special Needs Plans (C-SNPs), which serve individuals with specific chronic conditions.^[3] SNPs first began operating under temporary authority and were made permanent in 2018.^[4]

D-SNPs form the largest category of SNPs, both in enrollment and in number of plans offered.^[5] D-SNP enrollment is about 20% of total Medicare Advantage enrollment and grew from 3.5 million in May 2021 to 6.5 million in May 2026.^[6] During the same time period, the number of D-SNP plans increased from 627 to 1,082.^[7]

As of May 2026, D-SNPs operate in Puerto Rico, the District of Columbia and every state except Alaska, New Hampshire, and Vermont.^[8] Although enrollment levels vary greatly by state and by region within states, more than 9 in 10 dually eligible individuals live in a county where at least one D-SNP is available.^[9]

D-SNPs Are Subject to Both Federal and State Oversight

As a subset of Medicare Advantage plans, D-SNPs are subject to federal oversight and must comply with Medicare Advantage regulations and guidance.^[12] For example, each D-SNP must develop an evidence-based Model of Care built around the characteristics of the population it serves and approved by the National Committee for Quality Assurance.^[13] D-SNPs must coordinate Medicaid benefits; screen for transportation, housing, and food security needs; and establish and maintain an Enrollee Advisory Committee.^[14]

The Enrollee Advisory Committee must reasonably represent the population served by the D-SNP and solicit member input to improve access to covered services, coordination, and health equity.^[15] For more information on Enrollee Advisory Committees and other opportunities for the state and D-SNPs to gather feedback from members, see Justice in Aging’s Member Engagement and Support for D-SNP State Medicaid Agency Contracts.

D-SNPs are unique among Medicare Advantage plans because states also have a significant role in setting requirements and overseeing D-SNP performance. Each D-SNP sponsor must enter into a contract with the state in which the D-SNP operates.^[16] Federal law sets out minimum requirements for these contracts, called State Medicaid Agency Contracts (SMACs).^[17]

States can impose additional requirements regarding enrollee categories, details of how plans will manage care and benefit coordination with Medicaid, cost-sharing responsibilities of D-SNPs and other matters.^[18] For example, North Dakota uses its SMAC to require continuity of care for individuals temporarily losing Medicaid, and California requires D-SNPs to offer more robust consumer protections in the appeals process.^[19]

States Have Options for Imposing Enrollment Restrictions For D-SNPs

As with any Medicare Advantage plan, enrollment in a D-SNP is limited to individuals with both Medicare Part A and Part B coverage.^[20] Further, to be in a D-SNP an individual must be dually enrolled for both Medicare and Medicaid.^[21] States have the option of setting additional enrollment restrictions.

Enrollment of Partial Duals

States may allow enrollment of “partial duals,” that is, individuals who are only enrolled in a Medicare Savings Plan such as Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Individual (QI). As of 2021, a majority of states (36) permit enrollment of partial duals into D-SNPs.^[22] States may limit D-SNP enrollment to full-benefit dually eligible individuals or set even more restrictive enrollment criteria through the SMACs.

For example, a state may authorize a D-SNP that only enrolls individuals who are full benefit dually eligible individuals and receiving long-term services and supports in the community, or a D-SNP that only enrolls dual eligible individuals who require nursing facility level of care.^[23] A state can also require that a D-SNP either cover partial benefit dually eligible individuals or full benefit dually eligible individuals, but not both.

Aligned Enrollment

When a Medicaid Managed Care Organization (MCO) has a particular relationship with a D-SNP (e.g., through a parent company),^[24] that Medicaid MCO is considered “affiliated” with the D-SNP.^[25] A person who receives their Medicaid benefits through the D-SNP or an affiliated Medicaid MCO are considered to have “aligned enrollment.”^[26]

Because there is a relationship between the Medicaid MCO and D-SNP, and a shared financial incentive, many policymakers believe that plans will facilitate a more integrated experience when there is aligned enrollment.^[27] In states that use MCOs to deliver Medicaid benefits, states may encourage aligned enrollment by limiting D-SNP contracts to plan sponsors that also operate a Medicaid MCO in the same service area.

Exclusively Aligned Enrollment

When a D-SNP’s enrollment is limited to only allow individuals who receive their Medicaid benefits through the D-SNP or the D-SNP’s affiliated Medicaid MCO, this policy is referred to as “exclusively aligned enrollment.”^[28] D-SNPs with exclusively aligned enrollment do not allow enrollment by members who are in an unaligned Medicaid MCO or who are receiving their Medicaid benefits through fee-for-service Medicaid.

Further, exclusively aligned D-SNPs may not enroll any members who are partial duals, since those members are not enrolled in any Medicaid MCO. Exclusively aligned enrollment has been promoted as a way to improve the experience of dually eligible individuals by facilitating coordination of benefits, integrated appeals, and integrated enrollee communication. There are exclusively aligned D-SNPs in at least 21 states, Puerto Rico, and D.C.^[29] Note that some D-SNPs may have exclusively aligned enrollment without it being required to by the state or federal government.

There are state and federal rules that require exclusively aligned enrollment in certain circumstances.^[30] For example, all FIDE SNPs must have exclusively aligned enrollment. As of 2021, Idaho, Massachusetts, Minnesota, and New Hampshire had provisions in their SMACs that require exclusively aligned enrollment.^[31] California requires exclusively aligned enrollment for most, but not all, D-SNPs in the state.^[32]

Default Enrollment into a D-SNP

Default, or automatic, enrollment into a D-SNP can occur when an individual with Medicaid becomes newly eligible for Medicare either through age or disability, and the individual is in a Medicaid managed care plan operated by the same sponsor as the D-SNP.^[33] A D-SNP must meet certain criteria and have both state and CMS approval before using default enrollment.^[34] As of 2026, 82 D-SNPs in 16 states and Puerto Rico use default enrollment.^[35] As of plan year 2025, D-SNPs submitted almost 40,000 default enrollment transactions.^[36]

Before being subject to default enrollment, at a minimum, the individual must receive at least a 60-day prior notice of the upcoming default enrollment and an opportunity to opt out.^[37] Some states like California have more consumer protections built into the default enrollment process.^[38] D-SNP members, like all dually enrolled individuals, also have multiple opportunities during the year in which to change plans or move to Original Medicare.^[39]

D-SNP Levels of Integration With Medicaid Can Vary Markedly

The extent to which D-SNPs coordinate with Medicaid varies significantly. CMS has developed several categories of D-SNPs, each with different definitions and minimum integration requirements. The landscape of D-SNP plans varies by state and often states only have one or two types of D-SNPs.^[41] See Appendix A for state-specific details.

The main categories of D-SNPs are:

• Fully-Integrated D-SNPs (FIDE SNPs), currently serving over 700,000 people in 17 states.

• Highly-Integrated D-SNPs (HIDE SNPs), currently serving 2.3 million people in 20 states, D.C., and Puerto Rico.

• Coordination-only D-SNPs (CO D-SNPs), currently serving 3.4 million people in 41 states and D.C.

• Applicable Integrated Plans (AIPs), which is a designation that can apply to FIDE SNPs, HIDE SNPs, and CO D-SNPs. AIPs currently serve 1.9 million people in 21 states, D.C., and Puerto Rico (note that these 1.9 million people are also included in the numbers above for FIDE SNPs, HIDE SNPs, and CO D-SNPs).

Fully-Integrated D-SNPs (FIDE SNP) are the most integrated D-SNPs. FIDE SNPs are single plan entities that hold capitated contracts to provide both Medicare and Medicaid services and whose contracts on the Medicaid side cover essentially all Medicaid services, including long-term services and supports and behavioral health services. All FIDE SNPs are required to have exclusively aligned enrollment, and all FIDE SNPs are AIPs.^[42] See below for more on AIPs.

Highly-Integrated D-SNPs (HIDE SNPs) hold Medicare and Medicaid contracts but can do so either directly or through separate entities controlled by the same sponsor.^[43] To qualify as a HIDE SNP, the sponsor’s Medicaid contracts must cover most Medicaid services, including long-term services and supports or behavioral health, but are not required to cover both.^[44] HIDE SNPs that have exclusively aligned enrollment are AIPs, described in more detail below.

If a D-SNP is not a FIDE SNP or a HIDE SNP, it is called a “coordination only” D-SNP (CO D-SNP). The federal integration requirements for CO D-SNPs are not as robust as those for FIDE SNPs or HIDE SNPs. A CO D-SNP’s obligations to coordinate with Medicaid services are only very generally defined in federal regulations. Like other D-SNPs, CO D-SNPs must assist enrollees in accessing Medicaid services.^[45]

Additionally, CO D-SNPs must, for at least one subset of dually eligible enrollees^[46], provide notice to the state when a member is admitted to a hospital or skilled nursing facility.^[47] A CO D-SNP may or may not have aligned enrollment with a Medicaid MCO and may or may not be an AIP. See below for more on AIPs.

Applicable Integrated Plans (AIPs) are D-SNPs that meet certain requirements. All FIDE SNPs are AIPs. AIPs can also include HIDE and CO D-SNPs. D-SNPs that are AIPs must have a unified appeals and grievances process that takes into consideration both Medicare and Medicaid.^[48] All AIP D-SNPs must have exclusively aligned enrollment and the D-SNP must cover some Medicaid benefits.^[49]

As discussed earlier, a HIDE SNP can be an AIP if it operates with exclusively aligned enrollment. A CO D-SNP can also be an AIP, but must (1) Have an affiliated Medicaid MCO; (2) Have exclusively aligned enrollment by limiting enrollment to individuals in the affiliated Medicaid MCO; and (3) Cover, through the D-SNP or the affiliated Medicaid MCO, certain Medicaid services and Medicare cost-sharing.^[50]

States have the authority to limit the types of D-SNPs that operate in their state and to add additional requirements in D-SNP contracts to address concerns around access to care and align with state integration goals.^[51]

The type of D-SNP that can operate in a state depends in part on that state’s Medicaid managed care landscape. As of 2024, 47 states allowed at least some dually eligible individuals enroll in a Medicaid MCO for some or all Medicaid services.^[52] Many states with Medicaid managed care leave out certain services from the MCO contract, often referred to as a “carve out.”^[53] As described above, if a state does not employ Medicaid managed care, or has carve outs for behavioral health or long-term services and supports, this can limit what types of D-SNPs can operate in the state.^[54]

D-SNP Benefit Packages Can Include Supplemental Benefits

As with other Medicare Advantage plans, D-SNPs may offer supplemental benefits beyond those covered by Medicare Part A or Part B. These can include extra health-related benefits such as dental visits or adult day health services, as well as non-medical benefits such as pest control or transportation for non-medical needs.^[61] Through the SMAC contracting process, states have leverage to help ensure that supplemental benefit packages are appropriate for and accessible to D-SNP enrollees.^[62]

One issue of concern is supplemental benefits that duplicate or overlap with Medicaid benefits already available to dually eligible D-SNP enrollees. CMS permits D-SNPs to offer such benefits, for example, a D-SNP may offer non-emergency medical transportation services or some dental coverage that overlaps with benefits also provided under the state’s Medicaid program.^[63]

In many cases, overlapping services are of limited benefit to the D-SNP member and can be difficult for the member to navigate. States can, however, use the SMAC process to require that D-SNPs offer supplemental benefits that complement, rather than duplicate Medicaid benefits. For more information on overlapping benefits, see Justice in Aging’s toolkit on Eligibility, Enrollment, and Supplemental Benefits for D-SNP State Medicaid Agency Contracts.

Another important issue regarding supplemental benefits offered by D-SNPs is that information is limited. D-SNP enrollees do not necessarily have access to clear information about whether they may be eligible for supplemental benefits and how to access them.^[64] At the same time, information is limited concerning how many D-SNP enrollees actually receive the supplemental benefits offered and, importantly, whether those who are most disadvantaged and those with the most needs have full access to the benefits. Data collection on uptake of supplemental benefits, including specifically demographic data, is a necessary first step to determining whether supplemental benefits are being provided equitably.

The limited information that is available raises concerns. For example, a county-level analysis of the availability of supplemental benefits found that the number of Medicare Advantage plans, including but not limited to D-SNPs, that offered any non-medical supplemental benefit was, on average, lowest in counties with the highest poverty rates.^[65] CMS has taken strides to improve this information. In December 2023, CMS finalized a rule to require Medicare Advantage plans to report utilization and cost data for all supplemental benefit offerings, though this information is not required to be broken out by demographic data.^[66]

It can be hard to understand what supplemental benefits a person may be eligible for, and how a person can use those benefits.^[67] CMS has recently made improvements to Medicare Plan Finder that include more detail on the supplemental benefits available in each Medicare Advantage plan. CMS also recently issued a new regulation that will require Medicare Advantage plans to be more transparent about whether an individual is eligible for Special Supplemental Benefits for the Chronically Ill (one type of supplemental benefit); plans will be required to list eligibility criteria on plan websites.^[68] A few years ago, CMS finalized a rule requiring plans to provide a mid-year notification to enrollees about unused supplemental benefits available to them. However, this rule was paused before going into effect and rescinded in April 2026.^[69]

Some D-SNPs Must Offer Integrated Appeals at the Plan Level

CMS requires that all D-SNPs with an AIP designation use unified, integrated appeal processes.[71] In other words, if a service might be covered by Medicare or Medicaid, the plan must review the request, apply all applicable Medicare and Medicaid coverage criteria, and send a single notice addressing coverage under both programs.^[72] If a plan member appeals a denial, the plan must also undertake an integrated review and issue an integrated reconsideration notice.

CMS encourages plans that are not AIPs to integrate their appeal processes as much as possible. At a minimum, D-SNPs are expected to assist members in filing Medicaid appeals.^[73] CMS also expects D-SNPs to assist in gathering medical documentation from providers in support of a Medicaid appeal.^[74]

Looking Ahead

D-SNPs are here to stay and their enrollment continues to grow. For advocates, understanding D-SNPs is important both for assisting clients and for policy advocacy. Advocates need to be aware of the levers available to states and federal agencies to affect D-SNP design and to engage as stakeholders, particularly at the state level. Advocacy can help ensure that requirements for plans and their actual operations work effectively to meet the complex needs of dually eligible individuals and promote health equity in the delivery of services.

Because dually eligible individuals are more likely than Medicare-only enrollees to be people of color and have disabilities and chronic conditions, the ability of D-SNPs to address equity in health care access should get particular attention. For example, there is a need to assess how effective a D-SNP’s care coordination and coordination of benefits practices are at improving enrollee experience and access to services, and how disruptive D-SNP prior authorization and network restrictions are to enrollee care.

This advocacy starts with an understanding of the extent of D-SNP penetration in the state, the state’s D-SNP enrollment rules, and the scope of D-SNP services, both to assist clients with enrollment choices, and to help them navigate issues that arise with the delivery of services. We encourage advocates to explore and understand the D-SNP landscape in their state and the policies the state has implemented with D-SNPs. See Appendix B for a list of resources to get started.

This area of advocacy is complicated. A growing number of organizations and experts are turning to D-SNP policy to help shape a better health care landscape for older adults and people with disabilities. Justice in Aging is engaging in an educational campaign on D-SNPs. Learn more and get involved.

Appendix A

Categories of D-SNPs

Source for enrollment numbers and states: CMS, Comprehensive Data for May 2026. For requirements, see 42 C.F.R. 422.2 (definitions of FIDE SNP and HIDE SNP) and 42 C.F.R. 422.561 (definition of Applicable Integrated Plan)

Appendix B

Sources for Mapping the D-SNP Landscape in a State or Local Area

This Appendix lists resources for advocates wishing to get more information on D-SNPs in their area.

Types of D-SNPs In an Area

High-level Medicare Advantage data by state. KFF offers a number of tables that give basic information by state on the type of Medicare Advantage plans available by state.

Detailed D-SNP data by state. CMS offers a monthly spreadsheet detailing D-SNP plans by name, state, type, and enrollment.

County and local level data. The list of SNPs in the back of the Medicare & You Handbook for the local area (the list immediately follows the list of regular Medicare Advantage plans) or the Plan Compare feature at the Medicare.gov website are good starting points for county information on D-SNP availability.^[76] Local State Health Insurance Assistance Programs (SHIPs) also are a resource on D-SNP availability. CMS offers monthly spreadsheets with enrollment by county for all Medicare Advantage plans, but the data may be difficult to tie to D-SNP plans.

Requirements That D-SNPs Must Follow

Justice in Aging has published a SMAC toolkit that includes different state approaches to D-SNP requirements. The Integrated Care Resource Center (ICRC) has also published sample SMAC language that includes some SMAC language by state.

Advocates can ask their state for a copy of the current SMACs and for information on what, if any, additional provisions are in the contracts beyond the minimum federal requirements. Justice in Aging’s D-SNP Frequently Asked Questions document lists publicly available SMACs.

Endnotes

1. KFF, A Closer Look at the Growing Role of Special Needs Plans in Medicare Advantage (Sept. 25, 2025). ↑

2. This is expected to continue, especially with the discontinuation of another approach to integrating care for dually eligible individuals, the Financial Alignment Initiative. See MACPAC, Medicare-Medicaid Plan Demonstration Transition Updates and Monitoring, slide 7 (Dec. 2022). ↑

3. 42 U.S.C. § 1395w-28(b)(6)) (Section 1859(b)(6)) of the Social Security Act). ↑

4. Bipartisan Budget Act of 2018 (P.L. 115-123). ↑

5. Author analysis of CMS, SNP Comprehensive Data (May 2026). ↑

6. KFF, Medicare Advantage Enrollment Grew by About 1 Million People, Mainly Due to Special Needs Plans (Feb. 23, 2026. Author analysis of May 2021 and May 2026 data in CMS, SNP Comprehensive Data. ↑

7. Author analysis of May 2021 and May 2026 data in CMS, SNP Comprehensive Data. ↑

8. Author analysis of May 2026 data in CMS, SNP Comprehensive Data. ↑

9. KFF, 10 Things to Know About Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) (Feb. 2024). ↑

10. KFF, A Profile of Medicare-Medicaid Enrollees (Jan. 31, 2023). ↑

11. Dually eligible individuals account for 36% percent of Medicare spending while only making up 20% of Medicare enrollees and account for 27% of Medicaid spending while only comprising 13% of the total Medicaid population. MACPAC, Data book: Beneficiaries dually eligible for Medicare and Medicaid, p. 18 (Dec. 2025). ↑

12. See, e.g., 42 U.S.C. § 1395w-28(b)(6), 42 C.F.R. § 422.101(f), and Medicare Managed Care Manual, Ch. 16(b). ↑

13. 42 U.S.C. § 1395w-28(f)(5)(A) and (7) (§ 1895(f)(5)(A) and (7) of the Social Security Act); see also CMS, Model of Care. See also NCQA, What is a Model of Care?. See also Justice in Aging, Care Coordination for D-SNP State Medicaid Agency Contracts (Aug. 19, 2025). ↑

14. 42 C.F.R. § 422.101(f)(1)(i); 422.107; and 422.562(a)(5). See also ICRC, Definitions of Different Medicare Advantage Dual Eligible Special Need Plan (D-SNP) Types in 2023 and 2025 (Dec. 2022). ↑

15. 42 C.F.R. §422.107(f)(1). ↑

16. 42 U.S.C. § 1395w-28(f)(3) (Section 1859(f)(3) of the Social Security Act). ↑

17. 42 C.F.R. §422.107. SMACs have eight minimum requirements: the MA organization’s responsibilities to provide or arrange for Medicaid benefits; categories of eligibility for dually eligible beneficiaries to be enrolled under the D-SNP, including the targeting of specific groups; Medicaid benefits covered under the D-SNP; cost-sharing protections covered under the D-SNP; information about Medicaid provider participation and how that information is to be shared; verification process of an enrollee’s eligibility for both Medicare and Medicaid; service area covered under the SNP; and the period of the contract (MACPAC, Improving Integration, footnote 12). ↑

18. 42 U.S.C. § 1395w-28(f)(3)(D); 42 C.F.R. §422.107. For most plans, the minimum requirements are very limited, requiring D-SNPs generally to coordinate the delivery of Medicaid benefits, and specifically to notify the state Medicaid agency when a member of a subgroup designated in the contract is admitted to a hospital or skilled nursing facility. The Integrated Care Resource Center (ICRC) has developed model language for plans to implement both basic elements to meet federal requirements and optional elements to further regulate D-SNPs. See ICRC, Sample Language for State Medicaid Agency Contracts (SMACs) with Dual Eligible Special Needs Plans (2024). ↑

19. Justice in Aging, Consumer Protections: Member Rights for D-SNP State Medicaid Agency Contracts (Nov. 2025) ↑

20. 42 C.F.R. § 422.50. ↑

21. 42 U.S.C. § 1859(f)(3) (Section 1859(f)(3) of the Social Security Act). ↑

22. MACPAC, Improving Integration for Dually Eligible Beneficiaries: Strategies for State Contracts with Dual Eligible Special Needs Plans, p.224 (June, 2021) (“MACPAC, Improving Integration”). ↑

23. D-SNPs limiting membership to dually eligible individuals in institutional settings are rare but a small number exist including, for example, a few in Southern California. Note that these D-SNPs are distinct from Institutional SNPS (I-SNPs), which serve individuals in institutions but do not limit their enrollment to dually eligible individuals. ↑

24. Specifically, when the Medicaid MCO contract is between the state and the D-SNP’s Medicaid organization; between the state and the D-SNP’s parent organization; or between the state and an entity that is owned and controlled by the D-SNP’s parent organization. ↑

25. 42 C.F.R. § 422.2. ↑

26. Id. ↑

27. ICRC, Definitions of Different Medicare Advantage Dual Eligible Special Need Plan (D-SNP) Types in 2023 and 2025, (Dec. 2022). ↑

28. 42 C.F.R. § 422.2. See also CMS, Guidance for States Seeking to Leverage New Opportunities for Integrated Care Programs, p.2 (Aug. 2022). ↑

29. Author analysis of CMS SNP data from May 2026, counting the number of states with D-SNPs that are Applicable Integrated Plans. One requirement for a D-SNP to be an Applicable Integrated Plan is to have exclusively aligned enrollment. CMS, SNP Comprehensive Data (Jan. 2024). ↑

30. For federal rules requiring exclusively aligned enrollment and limiting the number of D-SNP contracts in certain circumstances, see 42 C.F.R. § 422.514(h) and the definition of FIDE SNP in 42 C.F.R. § 422.2. For sample contract language for limiting enrollment categories, see ICRC, “Sample Language for State Medicaid Agency Contracts (SMACs) with Dual Eligible Special Needs Plans” (2024). Note that, since partial benefit dually eligible individuals (a term referring to individuals enrolled in a Medicare Savings Program but not full Medicaid) are not enrolled in Medicaid MCOs, policies that require exclusively aligned enrollment means that partial benefit dually eligible individuals would not be allowed to enroll in the D-SNP. ↑

31. MACPAC, Improving Integration, p. 212. ↑

32. California Department of Health Care Services, 2026 Exclusively Aligned Enrollment State Medicaid Agency Contract Boilerplate, p. 1 (2026). ↑

33. 42 C.F.R. §422.66(c)(2); CMS, Default Enrollment Policy and Data on Approved Medicare Advantage Plans, (April 15, 2026). Note that default enrollment is not limited to individuals in aligned Medicaid MCOs. Default enrollment may also occur if an individual is in an aligned Medicaid Prepaid Ambulatory Health Plan (PAHP) or perhaps a Medicaid Prepaid Inpatient Health Plan (PIHP). Other policies around exclusive alignment, including the definition of FIDE SNP in 42 C.F.R. § 422.2, the contracting restrictions in 42 C.F.R. § 422.514(h), and the Special Enrollment Period described in 42 C.F.R. § 423.38(c)(35) all refer only to aligned enrollment with Medicaid MCOs (and not PAHPs or PIHPs). ↑

34. 42 C.F.R. § 422.66(c)(2); CMS, Default Enrollment Policy and Data on Approved Medicare Advantage Plans, (April 15, 2026). States must ask CMS permission to allow default enrollment in the state. ↑

35. CMS, Default Enrollment Policy and Data on Approved Medicare Advantage Plans, (April 15, 2026). ↑

36. Id. ↑

37. 42 C.F.R. § 422.66(c)(4) ↑

38. Justice in Aging, Eligibility, Enrollment, and Supplemental Benefits for D-SNP State Medicaid Agency Contracts (May 2025) ↑

39. Currently, dually eligible individuals have a Special Enrollment Period that allows them to drop plans once per month. See CMS, Special Enrollment Periods, for this and other opportunities to join, drop, or switch Medicare Advantage Plans. ↑

40. Justice in Aging, Eligibility, Enrollment, and Supplemental Benefits for D-SNP State Medicaid Agency Contracts (May 2025). ↑

41. Author analysis of CMS SNP data. CMS, SNP Comprehensive Data (May 2026). ↑

42. 42 C.F.R. § 422.2 (Definition of FIDE SNP) ↑

43. 42 C.F.R. § 422.2 (Definition of HIDE SNP). In Oregon, the contracting works a little different, as described in subsection (1)(iii) of the definition of HIDE SNP in 42 C.F.R. § 422.2. ↑

44. 42 C.F.R. § 422.2 (Definition of HIDE SNP). ↑

45. 42 C.F.R. § 422.562(a)(5). D-SNPs are required to assist enrollees in finding appropriate Medicaid contacts, assist with filling out Medicaid forms, assist with obtaining documentation for filing a Medicaid appeal and the like. See 84 Fed. Reg. 15680, 15702. (April 16, 2019). See also Justice in Aging, CMS Regulations Set Ground Rules for D-SNPs (2019). ↑

46. This subset is decided by the CO D-SNP, and should be described in the Model of Care. The Model of Care is not publicly available. ↑

47. 42 C.F.R § 422.107(d). ↑

48. 42 C.F.R. §422.107(c)(9); 42 C.F.R. § 422.629. ↑

49. 42 C.F.R. § 422.561. ↑

50. ICRC, Definitions of Different Medicare Advantage Dual Eligible Special Need Plan (D-SNP) Types in 2023 and 2025 (Dec. 2022). ↑

51. See Justice in Aging, SMAC Toolkit. ↑

52. KFF, Dual-Eligible Enrollment in Medicaid Managed Care, by Plan Type ↑

53. For example, a state that offers managed care to its dually enrolled population, but offers behavioral health outside of managed care through fee for service, is said to have a behavioral health carve out. ↑

54. States with Medicaid fee-for-service enrollees can use SMACs to improve access to Medicare and Medicaid benefits. ↑

55. For details on the Financial Alignment Initiative, see CMS, Financial Alignment Initiative. The states with Financial Alignment Initiative models that ended in December 2025 are Illinois, Massachusetts, Minnesota, New York, Ohio, Rhode Island, South Carolina, and Texas. Washington State’s model was a managed fee-for-service model. California’s demonstration transitioned in 2022, and Colorado’s demonstration ended in 2017. ↑

56. MACPAC, Medicare-Medicaid Plan Transition. ↑

57. 85 Fed. Reg. 9,002, 9,019 (Feb. 18, 2020). ↑

58. MedPAC, Report to the Congress: Medicare and the Health Care Delivery System (June 2019), p. 442. ↑

59. 42 C.F.R. § 422.514(d). This was decreased from 80% in recent years. ↑

60. 42 C.F.R. § 422.514(e). ↑

61. For a discussion of the statutory and regulatory authority for different types of supplemental benefits, see ATI Advisory, Nonmedical Supplemental Benefits in Medicare Advantage in 2024, p. 5, and ATI Advisory, Advancing Non-Medical Supplemental Benefits in Medicare Advantage: Considerations and Opportunities for Policymakers, pp. 4-5. ↑

62. CMS, Frequently Asked Questions on Coordinating Medicaid Benefits and Dual Eligible Special Needs Plans Supplemental Benefits (May 27, 2021). ↑

63. Id. ↑

64. Julie Carter and Rachel Gershon, Clearer Choices: Why Medicare Advantage Enrollees Need Better Information on Supplemental Benefits, Health Affairs (2025). ↑

65. ATI Advisory, Delivering on the Promise of the CHRONIC Care Act: Progress in Implementing Non-Medical Supplemental Benefits (2021), pp. 11-12. ↑

66. See CMS, Part C Reporting Requirements. ↑

67. Julie Carter and Rachel Gershon, Clearer Choices: Why Medicare Advantage Enrollees Need Better Information on Supplemental Benefits, Health Affairs (2025) ↑

68. 42 C.F.R. § 422.111(b)(6). CMS, Letter to All Current and Prospective Medicare Advantage, Prescription Drug Plan, and Section 1876 Cost Organizations, Medicare Plan Finder Enhancements for Contract Year 2027 (May 15, 2026). Available in the HPMS memo archive. ↑

69. 91 FR 17384, 17549 ↑

70. Commonwealth Medicine, What do Medicare Enrollees Value about their Coverage? (Feb. 2024) (“Seven in 10 people (69%) in MA plans indicated they had used one or more of their plan’s supplemental benefits in the past year. Dental care, vision care, and an allowance for over-the-counter medications were the benefits most often used. Of the three in 10 who said they did not use any supplemental benefits in the past year, 63 percent said they hadn’t needed the benefits, 24 percent said they did not know what benefits their plan offers, 9 percent said the benefits are hard to use, and 4 percent said it costs too much to use the benefits; 6 percent cited additional reasons.”) ↑

71. 42 C.F.R. § 422.630. For an in-depth discussion of the integrated appeals regulations and suggestions to states for implementing their requirements, see ICRC, Integrated Appeal and Grievance Processes for Integrated D-SNPs with “Exclusively Aligned Enrollment” (June, 2020). ↑

72. 42 C.F.R. § 422.561. For specific requirements see 42 C.F.R. §§ 422.629, 422.631-422.634. These regulations implement the statutory mandate found at 42 U.S.C. § 1395w-28(f)(8)(B). For a CMS memo explaining how supplemental benefits are subject to appeal regulations, see CMS, Implementing Supplemental Benefits for Chronically Ill Enrollees (April 24, 2019). ↑

73. 42 C.F.R § 422.562(a)(5). ↑

74. 42 C.F.R. § 422.562(a)(5)(i)(C). ↑

75. CMS, D-SNPs: Integration & Unified Appeals & Grievance Requirements. ↑

76. The county/region inserts in the Medicare & You Handbook are not available on-line but a paper copy can be requested from 1-800-Medicare. The Plan Compare feature is available at Medicare.gov. ↑