This FAQ document answers common questions from advisors and advocates who are assisting individuals enrolled in both Medicare and Medicaid (“dually eligible individuals”) who are considering their health plan options.
It is a companion to Justice in Aging’s brief Dual-Eligible Special Needs Plans: What Advocates Need to Know (“D-SNP basics brief”) and webinar.
Table of Contents
D-SNP Basics
What is a D-SNP?
Dual-Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage health plan designed to serve dually eligible individuals.
Like all Medicare Advantage plans, D-SNPs are run by private insurance companies who contract with the Centers for Medicare & Medicaid Services (CMS) to provide Medicare (and sometimes Medicaid) benefits through managed care.
All D-SNPs are required to coordinate an enrollee’s Medicare benefits with their Medicaid benefits to some level.
Are D-SNPs available in every state?
At the time of this document’s publishing, D-SNPs are available in 46 states and the District of Columbia.
D-SNPs are not currently available in Alaska, Illinois,[1] New Hampshire, or Vermont. D-SNP availability depends in part on a person’s county or zip code.
Individuals can see the D-SNPs available in their area by accessing the Medicare Plan Finder.
What is a State Medicaid Agency Contract and where can it be found?
D-SNPs are required to have a contract with their state Medicaid agency known as a State Medicaid Agency Contract (SMAC).
While the federal government specifies minimum requirements for SMACs, states can add additional requirements to ensure that plans meet the integration needs of their dual populations. This makes SMACs a powerful policy lever for advancing integration and improving care for people dually eligible.
While some states make their SMACs publicly available online, many do not. Advocates should engage with their state Medicaid agencies to request more transparency and access to SMACs.
Additionally, advocates can also request their states allow for public comment periods where advocates, dually eligible enrollees, their caregivers and other members of the public can provide feedback to the state on the SMAC(s) before the contract period begins.
This document includes a list of publicly available SMACs in the Appendix. For more information on SMACs, see Justice in Aging’s D-SNP basics brief and State Medicaid Agency (SMAC) Toolkit Series.
What is a D-SNP Model of Care, and how can I access it?
Each D-SNP must develop an evidence-based Model of Care (MOC), a comprehensive document that explains how the plan will deliver and coordinate care for the dually eligible population it serves. The MOC must be reviewed and approved by the National Committee for Quality Assurance (NCQA) before the plan can operate.
Unfortunately, these documents are generally not publicly available, as most plans consider their MOC documents to be proprietary. At a minimum, MOCs must include information on how the plan will conduct health risk assessments, develop comprehensive individualized care plans, utilize interdisciplinary care teams, coordinate the delivery of the member’s care, and manage care transitions.
H.R. 1’s Impact on D-SNPs and People Dually Eligible (The One Big Beautiful Bill Act)
How does H.R. 1 affect D-SNPs?
H.R. 1 does not make any changes to D-SNPs. However, there are a number of ways people dually eligible for Medicare and Medicaid, and their caregivers will be both directly and indirectly impacted by H.R. 1. For more information on H.R. 1 and its impact on older adults and people with disabilities, see Justice in Aging’s Medicaid Defense materials and MSP Brief.
H.R. 1 requires states to make significant administrative changes to the Medicaid expansion program for adults under 65 who are not enrolled in Medicare. These changes will necessitate a substantial reallocation of state resources, which may hinder states’ capacity to advance integration and provide effective oversight of D-SNPs.
Moreover, H.R. 1’s significant cuts to Medicaid funding will limit states’ options for balancing their budgets. To cover the shortfall, states may be forced to reduce optional benefits, such as home and community-based services (HCBS), dental, vision, and hearing benefits—many of which D-SNPs are responsible for coordinating. In this context, D-SNPs could potentially play an important role in maintaining access to these benefits, depending on the states’ capacity to focus on D-SNPs.
Additionally, because H.R. 1 introduces new eligibility requirements for a portion of the Medicaid population (the expansion population), there is a risk that dually eligible individuals could lose coverage due to misinformation or confusion. D-SNPs could help prevent such errors and ensure that eligible individuals retain their coverage.
Are dually eligible enrollees subject to work requirements under H.R. 1?
No, people dually eligible are not subject to the law’s new work requirements, more frequent redetermination requirements, or the law’s cost sharing requirements.
These requirements apply specifically to the expansion population (adults 19-64 not enrolled in Medicare); people dually eligible are categorically excluded from these requirements. For more information on H.R. 1 and its impact on older adults and people with disabilities, see Justice in Aging’s Medicaid Defense materials and MSP Brief.
That said, because of system strain and confusion, it’s still possible that people dually eligible could be incorrectly impacted by these provisions. Advocates should work closely with their states to ensure that these individuals are protected and not negatively affected by the changes. For more, see Justice in Aging’s Toolkit on Mitigating the Harms of Medicaid Work Requirements for Older Adults.
Enrolling in a D-SNP
Are dually eligible individuals required to join a D-SNP?
No. Dually eligible individuals can choose between Original Medicare (also often called traditional or fee-for-service Medicare), Medicare Advantage health plans, and (in most states) the Program of All-Inclusive Care for the Elderly (PACE).
Some states automatically enroll dually eligible individuals into D-SNPs when they become Medicare eligible, but the right to opt out or disenroll remains. For more information on enrollment and eligibility requirements for D-SNPs, including when default enrollment is allowed, see the Justice in Aging State Medicaid Agency Contract (SMAC) template toolkit section on Enrollment and Eligibility.
Should a dually eligible person join a D-SNP?
The decision to join a D-SNP is an individual one based on a person’s health care needs and provider preferences, the D-SNP's network of contracted providers, prescription drug availability, and other considerations. This can be a complicated choice.
Speaking with a free, unbiased State Health Insurance Program (SHIP) counselor, reviewing plan materials, and using the Medicare Plan Finder are ways to help your client review their options and make the enrollment choice that is best for them.
Can a partial-benefit dually eligible person join a D-SNP?
A partial-benefit dually eligible individual is a person who is enrolled in a Medicare Savings Program (e.g., Qualified Medicare Beneficiary, Specified Low Income Medicare Beneficiary, or Qualified Individual) only and are not also enrolled in full Medicaid.
Medicare Savings Programs are a type of Medicaid program that provides financial assistance by paying Medicare out-of-pocket costs including premiums, co-pays, and co-insurance. They do not provide the full range of Medicaid benefits, such as doctor visits, hospital stays, personal care services, nursing facility services, or other benefits.
A full-benefit dually eligible individual is a person who is enrolled in Medicare and full Medicaid, whether or not they are also enrolled in a Medicare Savings Program.
Most states allow partial-benefit dually eligible individuals to enroll in some D-SNPs, and in some of those states, separate D-SNPs are offered just for partial-benefit dually eligible individuals.[2]
As discussed previously, each D-SNP is required to enter into a SMAC, which is sometimes public. A SMAC will contain information on which populations are eligible to enroll in a D-SNP. You can also contact your client’s state Medicaid agency or the D-SNP to get clarity on D-SNP eligibility for partial-benefit dually eligible individuals.
How will a dually eligible individual know if they are a full or partial dual?
Dually eligible individuals who have full Medicaid benefits should receive state Medicaid agency documents including a notice of award or approval and a Medicaid card with important information such as their state Medicaid member number.[3]
Some states also issue cards identifying an individual as being enrolled in the Qualified Medicare Beneficiary program. For people who are only enrolled in a Medicare Savings Program, without full Medicaid coverage, some states do not issue any cards.
Advocates can support their dually eligible clients and confirm their dual eligibility status by contacting their state Medicaid agency. In addition, 1-800-Medicare is available to confirm Qualified Medicare Beneficiary program enrollment and whether the dually eligible individual has secondary health insurance benefit such as full Medicaid benefits.
Can a person in “spend-down” or “share of cost” Medicaid join a D-SNP?
States determine which Medicaid enrollees are eligible for enrollment in a D-SNP. This includes whether a person who is medically needy (also known as “spend-down” or “share of cost”) is eligible for enrollment in a D-SNP. Information about populations eligible for D-SNP enrollment can be found in the plan’s SMAC. Advocates can find out more by contacting their client’s state Medicaid agency or the D-SNP.
If a person loses their Medicaid coverage and is assessed as spend-down or share of cost, they will no longer be eligible for their D-SNP if full Medicaid is required for enrollment. D-SNPs in some states may have “deeming periods” that act as a short grace period keeping individuals enrolled in the D-SNP. This deeming period provides time for the individual to attempt to fix or restore their Medicaid eligibility. For more information, see the discussion on deeming below.
Are people automatically enrolled into a D-SNP? What protections are available?
A person can be automatically enrolled in a D-SNP in some circumstances through “default enrollment.” People on Medicaid who become newly eligible for Medicare, either by age or disability, can be enrolled in D-SNPs through default enrollment.
Default enrollment – or automatic enrollment – into a D-SNP is limited to circumstances in which a person is already enrolled in a Medicaid managed care plan when they become eligible for Medicare. These individuals may be automatically enrolled into the D-SNP that is affiliated with their Medicaid managed care plan.
Plans must send written notice before automatic enrollment takes place. The individual retains the right to opt out of default enrollment. In order to opt out, your client must make the affirmative choice to cancel the default enrollment before it is effective.
To use default enrollment, a D-SNP must receive approval from both the state and the Centers for Medicare & Medicaid Services (CMS). Not all D-SNPs or states have default enrollment in place.[4] For more information on default enrollment, see Justice in Aging’s D-SNP basics brief.
Accessing Information about D-SNP Integration and Responsibilities
How can a person find out what level of integration a D-SNP has?
Different types of D-SNPs have different levels of responsibilities when it comes to integrating Medicare and Medicaid benefits, including care coordination, communications, and grievances and appeals. D-SNP categories are Fully Integrated (FIDE), Highly Integrated (HIDE), or coordination-only (CO D-SNP). Each of these categories can also have an Applicable Integrated Plan (AIP) designation.
It is helpful to know what type of D-SNP a person is enrolled in to understand what responsibilities and coordination the D-SNP is obligated to provide to its enrollees. More information on these integration designations is available in Justice in Aging’s D-SNP basics brief.
It is not always easy to figure out a D-SNP’s integration level. Sometimes FIDE and HIDE designations are included in the plan’s name on Medicare Plan Finder or on the plan’s website materials (though often, these materials do not specify the D-SNP’s integration level). You might consider calling the plan and asking about the plan’s integration level.
CMS also releases Special Needs Plan (SNP) monthly data on Special Needs Plans. It is available as an excel document, and includes each plan’s name, the state it is in, and whether it’s a FIDE, HIDE, or CO D-SNP. Note that it may be hard to match the information from Medicare Plan Finder to the SNP monthly data.
How does an individual experience the various levels of integration provided by different D-SNPs?
At a minimum, all D-SNPs are required to coordinate Medicaid benefits. However, certain types of D-SNPs must go further. For example, HIDE and FIDE-SNPs are required to cover some or all Medicaid services in addition to coordinating them.
D-SNPs range from CO D-SNPs, which offer the lowest level of integration, to FIDE-SNPs, which have the most financial integration. Generally, the higher the level of integration, the more seamless the enrollee’s experience; services are more likely to be communicated, coordinated, and delivered as though they come from a single plan. For example, more integrated plans provide their members with a single set of plan materials and a single ID card.
That said, because each state sets its own contract requirements for D-SNPs through their State Medicaid Agency Contract (SMAC), an enrollee’s experience can vary significantly depending on where they live.
How can a person find state requirements for D-SNPs?
A state’s SMAC can contain a wealth of information, including eligibility criteria for enrollment into the D-SNP, extra care coordination requirements, and expectations around member communications. Some states publicly post their SMAC’s online, but most do not.
Accessing a state’s SMAC can be difficult. We’ve listed some examples of public SMACs in the Appendix. Advocates can try asking their Medicaid agency for a copy of their state SMACs. For more information on SMACs, see Justice in Aging’s D-SNP basics brief and SMAC Toolkit.
D-SNP Benefits, Provider Networks, and Costs
What benefits do D-SNPs offer?
D-SNPs are required to offer Medicare Part A (hospital/inpatient), B (outpatient), and D (prescription drug) benefits. D-SNPs often offer supplemental benefits that are not offered under Original Medicare, including vision, dental, hearing, transportation, and flex cards.
Please note that Medicaid often covers many items that are also offered as supplemental services by a D-SNP. D-SNPs plan materials, including the Evidence of Coverage, will list the services offered by the D-SNP.
One thing to look out for is whether the client’s provider or supplier is enrolled in the D-SNP, which can affect whether Medicare or Medicaid will cover the service.
What care coordination will a D-SNP offer?
D-SNPs must follow their Model of Care (MOC), which must include a description of how the D-SNP will coordinate care for enrollees.[5]
A state’s SMAC may include additional care coordination requirements, including requirements for the D-SNP to engage in discharge planning from a hospital or nursing facility stay, and to incorporate additional elements in its health risk assessment for the individual. For more information, see Justice in Aging’s SMAC template toolkit section on Care Coordination.
Plan materials (including the Evidence of Coverage) may, but do not always, contain information on the care coordination offered by a plan. Advocates can try contacting their client’s state Medicaid agency to obtain additional information about care coordination offered by D-SNPs.
What costs are associated with a D-SNP?
In general, a dually eligible person should not be charged premiums, co-pays, or co-insurance, in Original Medicare or in a D-SNP. In certain circumstances, a D-SNP may charge a premium for offering additional services. If an individual accesses non-covered services or goes to a provider that is not enrolled in Medicare or Medicaid, there may also be associated costs.
Providers sometimes charge dually eligible individuals for services improperly. For more information, see Justice in Aging’s Improper Billing Toolkit.
Does your client have to get prior authorization from a D-SNP?
Yes, your client may need to get prior authorization, depending on the service they seek. Prior authorization, or prior approval, is an element of a D-SNP. Members must get prior authorization from D-SNPs for many health services before treatment is provided. A plan’s Evidence of Coverage can include information on which services may be subject to prior authorization.
What health care providers are available in a D-SNP?
One key difference between Original Medicare and a D-SNP is that enrollees are required to see providers that are contracted with the health plan or agree to accept payment from the plan. The D-SNP provider directory will include the list of providers members can see for their care. The directory is also available on the plan’s website or in print.
While Medicare will incorporate Medicare Advantage provider network information in Medicare Plan Finder, concerns over accuracy persist.[6] For providers that are important to a client, prior to enrollment, advocates and their clients should contact the plan, confirm whether providers are in network, and document the call (including the date, time and plan representative name or identification number).
What medications does a D-SNP cover?
Medicare Plan Finder includes a tool which allows individuals to enter in the medications that they would like their plan to cover and will list the utilization management restrictions for covered medications (e.g., prior authorization, step therapy, and quantity limits). They can then search D-SNPs to find their medications and network pharmacies.
A D-SNP’s Part D formulary is also listed online. 1-800 Medicare and SHIP counselors are also a good resource to determine which D-SNPs include coverage for their prescription drugs.
How will enrolling in a D-SNP affect a person’s Medicaid benefits?
A person will continue to keep their Medicaid benefits while enrolled in a D-SNP. Some D-SNPs, such as FIDE SNPs, may include coverage and delivery of Medicaid benefits. All D-SNPs are required, at some level, to coordinate their enrollee’s Medicaid benefits.
Appendix B of Justice in Aging’s D-SNP basics brief provides a table explaining how different kinds of D-SNPs are required to offer different types of Medicaid benefits.
One thing to look out for when considering a client’s enrollment into a D-SNP is when a client is enrolled in a 1915(c) home and community-based services (HCBS) waiver. Some states and D-SNPs restrict enrollment for people who are enrolled in 1915(c) HCBS waivers.
Advocates should confirm with the D-SNP or state so that their clients do not inadvertently jeopardize their 1915(c) services by joining a D-SNP.
D-SNP Enrollment and Disenrollment
When can a dually eligible person disenroll from a D-SNP?
There are many times of year that a dually eligible individual can leave a D-SNP:
- All Medicare enrollees can make changes to their Medicare coverage during the Medicare Open Enrollment Period starting October 15 through December 7 of every year. Changes made during the Open Enrollment Period are effective January 1 of the following year.
- All Medicare enrollees can leave a Medicare Advantage plan, including a D-SNP, from January through March each year. This is known as the Medicare Advantage Open Enrollment Period.
- Effective in January 2025, dually eligible individuals can utilize two new special enrollment periods (SEPs) to disenroll from their D-SNPs. The Monthly and the Integrated Care SEPs are explained in more detail below.
- Since D SNPs are a type of Medicare Advantage plan, other Special Enrollment Periods around disenrolling from or switching Medicare Advantage plans can apply.
What special enrollment periods (SEPs) apply to dually eligible individuals?
The SEPs available to all Medicare enrollees in specific situations outlined in Medicare.gov are for the purposes of making changes to their Medicare coverage. Effective January 1, 2025, dually eligible individuals also have two additional SEPs, the Monthly and the Integrated Care SEPs.
- The Monthly SEP allows dually eligible individuals and Low-Income Subsidy (LIS) (also called Extra Help) enrollees the ability to switch to a different standalone prescription drug plan or disenroll from a Medicare Advantage plan into Original Medicare and enroll in a standalone prescription drug plan. While eligible enrollees can use this SEP to return to Original Medicare and enroll in a standalone Prescription Drug Plan on a monthly basis, the SEP cannot be used to enroll into another Medicare Advantage plan.
- The new Integrated Care SEP allows full-benefit dually eligible individuals to enroll into, or switch between, integrated D-SNPs on a monthly basis. This new integrated SEP is limited and can only be used by full-benefit dually eligible individuals to enroll into integrated plans that align enrollment between their Medicare and Medicaid plans.
For more information on the SEPs available to dually eligible individuals, see this Justice in Aging fact sheet.
Are their situations where a person loses membership in a D-SNP? What protections are available?
A person can be disenrolled from the D-SNP if they no longer meet the enrollment criteria. This includes moving to a service area not covered by the D-SNP or if Medicaid benefits are discontinued. Some D-SNPs offer a “deeming period,” which maintains D-SNP enrollment if a person loses full Medicaid.
A person is “deemed” eligible for a temporary period of time. Deeming periods can last thirty days to six months, depending on the plan. Deeming provides continued access to D-SNP providers and D-SNP provided care. If a person restores their Medicaid eligibility before the deeming periods ends, they will not be disenrolled.
Deeming is optional and not all states or D-SNPs have deeming periods. To find out if deeming is offered, enrollees can ask their D-SNP if they offer a deeming period and for how long. The State SMAC, if publicly available, will also contain this information if a D-SNP offers deeming, and whether the D-SNP covers Medicaid benefits during this period.
For more information on the deeming protections, see the Justice in Aging SMAC toolkit section on Consumer Protections: Member Rights.
Appendix: Examples of Public State Medicaid Agency Contracts
Each D-SNP sponsor must enter into a contract with the state in which the D-SNP operates. These contracts are called State Medicaid Agency Contracts (SMACs). Below is a sample of SMACs that are public. Note, the SMACs listed below may not be the most up to date versions available.
Arizona
Arizona Health Care Cost Containment System Medicare Advantage Organization Agreement.
California
California Department of Health Care Services Exclusively Aligned Enrollment D-SNP Contract.
Georgia
Georgia Department of Community Health Medicare Advantage Health Plan Agreement.
Indiana
Iowa
Contract between Iowa Department of Human Services and Amerigroup Iowa, Inc.
Massachusetts
MassHealth Senior Care Options Contract, available at: https://www.mass.gov/lists/senior-care-organization-sco-contracts.
Michigan
Michigan Department of Health and Human Services D-SNP Template Contract.
Minnesota
New Jersey
New Jersey Model MIPPA Contract.
New York
New York State Department of Health SMAC Contract.
Ohio
Pennsylvania
Rhode Island
State of Rhode Island Executive Office of Health and Human Services D-SNP SMACs.
Tennessee
Washington State
Washington State Health Care Authority Amended and Restated State Medicaid Agency Contract.
Wisconsin
Contract between State of Wisconsin Department of Health Services and D-SNP Provider.
Endnotes
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The state of Illinois announced that FIDE SNPs will be available to dually eligible individuals starting January 1, 2026. For more information, see Fully Integrated Dual Eligible Special Needs Plans in Illinois. ↑
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According to the CMS SNP Comprehensive Report September 2025, twenty-nine states (AL, CT, DC, DE, FL, GA, IA, ID, IN, KY, MD, MI, MS, NC, NY, OH, TN, VA, WA, WI) offer certain D-SNP plans that only enrolls partial-benefit dually eligible individuals. D-SNPs operating with exclusively aligned enrollment limit enrollment to only full-benefit dually eligible individuals who receive coverage of Medicaid benefits through the D-SNP or a Medicaid managed care plan owned and operated by the same parent company as the D-SNP. Starting in January 2025, FIDE SNPs will be required to operate with exclusively aligned enrollment and will thus be unable to enroll partial-benefit dually eligible individuals. For more information, see Lakhmani Weir, Erin, “Definitions of Different Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Types in 2023 and 2025,” Integrated Care Resource Center (December 2022) (Accessed October 29, 2025). ↑
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42 CFR 435.917 ↑
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As of March 2025, CMS had approved 76 plans in 15 states and Puerto Rico for default enrollment. CMS, “Default Enrollment: Policy and Data on Approved Medicare Advantage Plans,” (May 2025). ↑
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In addition, CO D-SNPs are subject to federal requirements to, for at least one subset of dually enrolled individuals, provide notice to the state when a member is admitted to a hospital or skilled nursing facilities. 42 CFR 422.107(d). ↑
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See CMS, “Updates to the Contract Year 2026 Medicare Plan Finder and Medicare.gov,” (Accessed October 28, 2025). ↑
