By Marc Gilman
Questions? Call (800) 927-9326 or email
Key Takeaways
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A new monthly enrollment window opened January 1, 2026 for certain full-benefit dual eligibles, letting them switch into an integrated D-SNP once a month — separate from, and in addition to, the usual Medicare enrollment periods.
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CMS has been steadily tightening the definition of a “D-SNP look-alike.” The threshold for non-SNP Medicare Advantage plans serving dual eligibles dropped from 80% to 70% in 2025, and to 60% for 2026 and beyond — making it harder for a plan to informally function like a D-SNP without meeting the actual integration requirements.
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Starting in 2027, certain D-SNPs will require “aligned enrollment” — meaning a member’s Medicare D-SNP and Medicaid managed care plan must come from the same company in some markets, along with integrated member ID cards and coordinated health risk assessments.
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State-level integration expanded sharply between 2025 and 2026. Statewide exclusively aligned enrollment is now in 16 states, up from 9 the year before; Applicable Integrated Plans exist in 22 states, up from 14.
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Massachusetts is directly part of this shift. It’s one of several states (along with Illinois, Ohio, and Rhode Island) that wound down its old Financial Alignment Initiative demonstration at the end of 2025 and transitioned those members into more highly integrated D-SNPs (FIDE-SNPs) starting January 1, 2026.
The federal push: making D-SNPs actually mean something
For years, some Medicare Advantage plans that weren’t formally structured as Dual Eligible Special Needs Plans (D-SNPs) still ended up serving a very high share of dual-eligible members, without being required to meet the coordination standards an actual D-SNP has to meet. CMS has been closing that gap through what’s called the “look-alike” threshold: a non-SNP plan whose enrollment crosses a certain percentage of dual eligibles gets flagged, and CMS won’t contract or renew with it. That threshold has dropped fast — from 80% down to 70% for plan year 2025, and down again to 60% for 2026 and beyond. The practical effect is fewer plans able to informally serve large dual-eligible populations without the integration requirements that come with being a true D-SNP.
Beginning in 2027, the requirements tighten further. Certain D-SNPs will be limited to members who are also enrolled in an affiliated Medicaid managed care organization — “aligned enrollment” — with the number of separate benefit packages a plan can offer alongside that arrangement also capped. Integrated member ID cards and integrated health risk assessments become required as well, replacing the separate Medicare and Medicaid paperwork many dual-eligible members currently juggle.
The detail that’s easy to miss: a new monthly enrollment window
Here’s something worth knowing that doesn’t get as much attention as the bigger structural changes: as of January 1, 2026, CMS created a new Special Enrollment Period specifically for certain full-benefit dual-eligible individuals. Once per month, eligible members can enroll into certain integrated D-SNPs that coordinate their Medicare and Medicaid coverage under one plan. This is separate from — and in addition to — the standard enrollment windows (Initial Enrollment Period, Annual Enrollment Period, Medicare Advantage Open Enrollment Period).
There’s an important limit on this window worth knowing: it can only be used to move into an integrated D-SNP. It can’t be used to enroll in or switch between non-D-SNP Medicare Advantage plans. But for someone who qualifies and hasn’t yet aligned their Medicare and Medicaid coverage under a single integrated plan, this monthly opportunity — rather than waiting for the Annual Enrollment Period — is a meaningful, underused tool.
What’s happening at the state level
States have wide latitude in how they structure Medicare-Medicaid coordination, using levers like enrollment rules, managed care procurement, and contracting structures — and 2026 shows a clear acceleration compared to the year before. Statewide “exclusively aligned enrollment” — where a state limits D-SNP enrollment to members whose Medicaid coverage comes from the same company — now exists in 16 states, up from 9 in 2025. Applicable Integrated Plans, a more advanced integration structure, are now present in 22 states, up from 14. Default enrollment processes that automatically align a member’s Medicare and Medicaid coverage are in place in 21 states, up from 16.
Nationally, the 2026 inventory shows just over 6 million total D-SNP enrollees, including roughly 1.98 million in Highly Integrated D-SNPs (HIDE-SNPs) and about 744,000 in Fully Integrated D-SNPs (FIDE-SNPs) — the most tightly coordinated structure currently available.
This is directly relevant close to home. Massachusetts is one of several states — along with Illinois, Ohio, and Rhode Island — that operated a Medicare-Medicaid Plan (MMP) under the federal Financial Alignment Initiative demonstration, which wound down at the end of 2025. Those states transitioned their MMP members into FIDE-SNPs starting January 1, 2026, meaning Massachusetts entered this year with a meaningfully expanded FIDE-SNP presence tied directly to that legacy transition. Anyone with a client who was previously in an MMP-style plan in Massachusetts should expect their coverage structure to have shifted this year, even if the practical experience of care feels similar.
How Medicare and Medicaid actually coordinate day to day
For anyone dually eligible, the basic payment order doesn’t change regardless of how integrated the plans are: Medicare is always the primary payer for services both programs cover, and Medicaid acts as secondary, covering Medicare’s deductibles, copays, and coinsurance, plus additional benefits like vision or dental where the state allows it.
The Medicare-Medicaid Coordination Office (MMCO), part of CMS, oversees D-SNPs at the federal level and works with states to support compliance with enrollment and integration requirements, alongside efforts toward unified grievance and appeals processes so members aren’t navigating two entirely separate systems when something goes wrong.
Why this still isn’t seamless
None of this means coordination is fully solved. Administrative complexity — enrollment steps, appeals processes, claims handling — can still create real gaps in care, even in a well-integrated plan. Funding pressure is a separate, live concern: Medicaid budget constraints at the state level can affect coverage and enrollment capacity for dual eligibles independent of how well-designed the federal integration rules are. And because states have so much discretion in how they implement these requirements, the actual experience of being a dual-eligible Medicare beneficiary still varies significantly depending on which state — sometimes even which county — someone lives in.
Questions worth asking
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Is a client currently in a D-SNP, and if so, is it an integrated plan (HIDE-SNP or FIDE-SNP) or a lower-integration structure?
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If a client was previously in a Medicare-Medicaid Plan under the Financial Alignment Initiative, has their transition to a FIDE-SNP been confirmed and understood?
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Could the new monthly integrated SEP be useful for a full-benefit dual-eligible client who hasn’t yet aligned their coverage?
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Is a client currently enrolled in a plan that could be affected by the tightening D-SNP look-alike threshold?
What To Do Next
If you’re a dual-eligible Medicare beneficiary — or helping someone who is — and want to understand how these changes affect your specific coverage, reach out and we’ll walk through it together.
Questions? Call (800) 927-9326 or email
This article is for general educational purposes and is not a recommendation regarding any specific Medicare or Medicaid plan. Rules, thresholds, and state programs described here are subject to change and vary by state. Consult Medicare.gov, your state Medicaid agency, or a licensed advisor to review your specific situation.
