We all know that handling one health insurance company can be a headache. Now, imagine juggling two at the same time. This is the reality for nearly 13 million older adults and people with disabilities who are enrolled in both Medicare and Medicaid. Insufficient coordination of Medicare and Medicaid benefits contributes to confusion and roadblocks in getting needed care. From obtaining primary care and accessing needed equipment like wheelchairs, to setting up at-home care, dually eligible individuals face significant hurdles in getting the care and supports they need. And this is on top of the life complexities experienced by this population, such as managing multiple chronic conditions and grappling with daily life factors impacting their health, such as unstable housing, food insecurity, limited transportation, and discrimination.

Enter the Dual-Eligible Special Needs Plan (D-SNPs), a special type of Medicare Advantage plan intended to address the barriers that the dual eligible population faces.¹ However, a critical question looms—do D-SNPs truly deliver on their promise? Reports suggest that enrollees in these plans may not experience significantly different health outcomes or care quality compared to other Medicare enrollment options.² Even more alarming, research suggests that where enrollees do report receiving better care in D-SNPs, dually eligible enrollees of color do not report the same outcomes.³ At the same time, research shows across the board, the health insurance companies that administer Medicare Advantage plans are being overpaid by billions while also denying access to care through narrow networks and arduous prior authorization processes.⁴

A critical question looms—do D-SNPs truly deliver on their promise?

Nonetheless, D-SNPs are proliferating nationwide, with enrollment doubling from 2020 through 2023, reaching nearly 6 million individuals. The number of D-SNPs operating has increased from 551 four years ago to 823 plans today with all but four states - Illinois, New Hampshire, North Dakota, and Vermont – operating D-SNPs⁵. Some states have witnessed staggering growth, with enrollment in at least 7 states more than tripling within a span of four years. Montana’s growth quadrupled while Oklahoma saw an astounding 605% increase in D-SNP enrollment in four years (see state snapshot). In five states – Arizona, Florida, Hawaii, Rhode Island, and Tennessee – 40% or more of individuals dually eligible are enrolled in a D-SNP.⁶ Enrollment growth has been highest among Black, Hispanic, and Asian/Pacific Islander individuals.⁷

Enrollment in D-SNPs as more than tripled in at least 8 states within a span of just four years.

This surge demands our attention, especially given the profound impact D-SNP enrollment can have on low-income older adults and people with disabilities, and underscores the need for scrutiny and advocacy to ensure that enrollees experience improved health outcomes.

State Snapshot of D-SNP Enrollment where Growth More than Tripled⁸

Several factors have contributed to the spike in D-SNP enrollment. Federal policy changes, such as the 2018 Chronic Care Act allowing Medicare Advantage plans to offer new types of supplemental benefits, play a significant role. States are also increasingly shifting to managed care for their Medicaid population, further driving D-SNP growth.

This surge in D-SNP enrollment demands our attention.

Meanwhile, states that operate Medicare and Medicaid plans, like California, Illinois, Ohio, and Massachusetts, Rhode Island, South Carolina, and Texas, are transitioning individuals enrolled in their Medicare and Medicaid plans into D-SNPs with the conclusion of the Financial Alignment Initiative in 2025.⁹

In this dynamic federal and state policy landscape, advocacy is a necessity. While D-SNPs have the potential to better coordinate care for dually eligible individuals, advocates must hold federal and state policymakers accountable so that D-SNPs deliver on their promise. And without advocates for enrollees intervening, individuals can experience significant harm from care delays and inaccurate denials of life saving care, which contribute to unnecessary institutionalization and hospitalization.

If you’re working on behalf of dually enrolled individuals, the call to action is clear. Join Justice in Aging as we launch a new integrated care education project, providing resources and opportunities to get informed and engaged.

• Sign up for our Medicare & Medicaid Integration Workgroup listserv to connect with advocates nationwide and learn about future education and advocacy opportunities.
• Register for our D-SNPs Basics webinar on February 27, 2024.

Your involvement can shape the trajectory of health care policy for older adults and people with disabilities and pave the way for a future that is more equitable.

We are thankful to Arnold Ventures for their support of this project.

1. Justice in Aging, Dual Eligible Special Needs Plans (D-SNPs): What Advocates Need to Know (Jan. 2022) ↩︎
2. Haviland, A. et al., Do dual eligible beneficiaries experience better health care in special needs? (Jun. 2021); Roberts, E.T. & Mellor, J.M., Differences in care between Special Needs Plans and other Medicare coverage for dual-eligibles (Sept. 2022); Meyers, D.J., et al., Medicare and Medicaid Dual-Eligible Special Needs Plan Enrollment and Beneficiary-Reported Experiences With Care (Sept. 2023). ↩︎
3. Roberts, E.T. & Mellor, J.M., Differences in care between Special Needs Plans and other Medicare coverage for dual-eligibles (Sept. 2022). ↩︎
4. MedPAC, The Medicare Advantage program: status report (Jan. 2024); KFF, Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021 (Feb. 2023). ↩︎
5. MACPAC, Integrating Care for Dually Eligible Beneficiaries: Different Delivery Mechanisms Provide Varying Levels of Integration (Jun. 2023). ↩︎
6. KFF, How Dual Eligible Individuals Get their Medicare Coverage (Jul. 2023). ↩︎
7. KFF, How Dual Eligible Individuals Get their Medicare Coverage (Jul. 2023); Meyers, D.G., et al., Growth In Medicare Advantage Greatest Among Black And Hispanic Enrollees (Jun. 2021). ↩︎
8. CMS, Special Needs Plan (SNP) Data, comparing SNP Comprehensive Report period 2023-12 and SNP Comprehensive Report period 2020-01. Data Note: Author did not include D-SNP enrollment for states that participate(d) in the Financial Alignment Initiative and transitioned enrollment from their Medicare Medicaid Plans to D-SNPs in the time period of 2020-2024. Limitations in the Data: The January 2020 report combined enrollment across states in plans with regional enrollment. To account for this, authors divided enrollment equally among states where regional D-SNP enrollment was presented. For example, Arkansas, Maryland, North Carolina, and West Virginia have also seen big growth in D-SNP enrollment; all appear to have more than tripled enrollment in four years. These states are included in multi-state D-SNP plans that do not provide enrollment numbers broken out by state so are excluded from the table. ↩︎
9. National Center on Law & Elder Rights, Integrated Care for Dually Eligible Individuals (Nov. 2022). ↩︎