ACOs & Programs

D-SNP (Dual Eligible Special Needs Plan)

~10 min readBy Pelica Health teamPublished August 28, 2026Updated August 28, 2026Reviewed by Catherine Zhao

Short answer

A D-SNP is a Medicare Advantage plan that enrolls only people who have both Medicare and Medicaid. It coordinates benefits across the two programs, holds a contract with the state Medicaid agency, and has to run a Model of Care that NCQA scores before CMS lets it operate. D-SNPs hold 78% of the 8.2 million people enrolled in Special Needs Plans in 2026. They are categorized by how much Medicaid risk they take: coordination-only, highly integrated (HIDE), or fully integrated (FIDE).

What a D-SNP is

A Dual Eligible Special Needs Plan is a Medicare Advantage plan that enrolls only people who have both Medicare and Medicaid. It coordinates benefits across the two programs, holds a contract with the state Medicaid agency under 42 CFR 422.107, and runs a Model of Care that NCQA scores before CMS will let it operate.

Special Needs Plans came out of the Medicare Modernization Act of 2003 and first sold coverage in 2006. Congress renewed the authority six times before the Bipartisan Budget Act of 2018 made SNPs a permanent part of Medicare Advantage. 42 CFR 422.2 carries the definitions that matter operationally.

The plan is still a Medicare Advantage coordinated care plan. It has a network, a benefit package, and Part D. The difference is that everyone in it is dually eligible, and the plan has obligations no general MA plan carries.

Why D-SNP membership is growing

Special Needs Plans are where Medicare Advantage growth is happening. In 2026 about 8.2 million people are enrolled in a SNP, an increase of more than 900,000 in a year, and SNPs accounted for 85% of the net increase in Medicare Advantage enrollment. D-SNPs hold 78% of that.

8.2M

People in Special Needs Plans in 2026, 23% of all Medicare Advantage enrollment.

78%

Share of SNP enrollment that sits in a D-SNP. C-SNPs hold 20%, I-SNPs 2%.

90 days

Window to complete the initial health risk assessment on every new enrollee, before or after the effective date.

Who counts as dual eligible

Dual eligibility is not one status. CMS recognizes several Medicaid eligibility categories, and the split between full-benefit and partial-benefit duals drives both what the plan covers and which enrollment rules apply.

Full-benefit duals get the full state Medicaid benefit package: QMB Plus, SLMB Plus, and full-benefit dual eligible (FBDE).
Partial-benefit duals get Medicaid help with Medicare premiums and sometimes cost sharing, but no full Medicaid benefit: QMB Only, SLMB Only, Qualifying Individual (QI), and Qualified Disabled and Working Individual (QDWI).

Full-benefit duals and members in the QMB, SLMB, and QI categories are automatically deemed into the Part D low-income subsidy, which removes the deductible and drops copays to a few dollars. States vary in how they define their categories, so the same label does not always mean the same coverage across state lines.

D-SNP vs C-SNP vs I-SNP

There are exactly three types of Special Needs Plan, and they are defined by who is allowed to enroll.

Requirement	D-SNP	C-SNP	I-SNP
Who can enroll	People entitled to both Medicare and Medicaid	People with one or more CMS-designated severe or disabling chronic conditions	People who are institutionalized or institutionalized-equivalent
Eligibility verified by	State Medicaid eligibility data	A physician attestation of the qualifying condition	A level-of-care assessment
Contract with the state Medicaid agency	Required	Not required	Not required
Model of Care approval period	1, 2, or 3 years by score	1 year, regardless of score	1, 2, or 3 years by score
Share of 2026 SNP enrollment	78%	20%	2%

The C-SNP condition list is set in regulation and covers 15 condition groups, including chronic heart failure, diabetes, dementia, chronic kidney disease, cancer, and severe mental illness. C-SNP enrollment jumped 45% between 2025 and 2026, faster than any other SNP type, though from a much smaller base.

How integrated the plan is: coordination-only, HIDE, FIDE

Every D-SNP coordinates Medicare and Medicaid. How much Medicaid money it actually holds is what separates the categories, and it determines the member's experience of appeals, notices, and care management.

Coordination-only D-SNP. Holds a state Medicaid agency contract that sets minimum coordination duties. It does not take on Medicaid risk.
HIDE SNP. A capitated contract covers either long-term services and supports or behavioral health. From plan year 2025 that contract has to cover the plan's entire service area.
FIDE SNP. A single entity holds both the Medicare Advantage contract and the Medicaid managed care contract. From plan year 2025 the Medicaid contract has to cover primary and acute care including Medicare cost sharing, long-term services and supports with at least 180 days of nursing facility coverage, behavioral health, home health, and medical supplies and equipment.

Layered on top is the applicable integrated plan designation. An AIP is a FIDE or HIDE SNP with exclusively aligned enrollment paired with the Medicaid managed care organization covering the same members, or a D-SNP whose enrollment a state limits to members of an affiliated Medicaid plan. AIPs run unified appeals and grievances across both programs, and beginning no later than contract year 2027 they have to conduct a single integrated health risk assessment that satisfies Medicare and Medicaid requirements at once.

The Model of Care, and why it is scored

Every SNP must have a Model of Care recommended for approval by NCQA under sections 1859(f)(5) and (f)(7) of the Social Security Act. It is submitted through HPMS with the plan's application or renewal, and it is graded.

The MOC Matrix has four standards: description of the SNP population, care coordination, provider network, and quality measurement and performance improvement. Those break into 15 elements worth 60 points. A plan needs at least 70% overall and at least 50% on every single element. Miss either threshold and the plan gets one chance to fix and resubmit, and a cured MOC is only approved for a year.

Aggregate MOC score	Approval period for a D-SNP or I-SNP
85% or higher	3 years
75% to 84%	2 years
70% to 74%	1 year
Below 70%, or any element below 50%	Failing; one cure opportunity, then 1 year at most

A three-year approval is worth real money in staff time, because it takes the submission and the surveyor cycle off the calendar for two years. C-SNPs cannot earn one; BBA 2018 caps them at a single year no matter what they score.

What the Model of Care actually obligates you to do

The MOC narrative is a document. The requirements behind it at 42 CFR 422.101(f) are a workflow, and they are specific about timing and about what counts as trying.

A comprehensive initial health risk assessment within 90 days before or after the enrollment effective date, and a comprehensive HRA every year after that.
The assessment tool has to cover physical, psychosocial, and functional needs, and include at least one question from a CMS-specified screening instrument on housing stability, food security, and access to transportation.
At least three attempts to reach the member to schedule the HRA, on different days and at different times of day, and automated calls do not count. If the member still has not responded, a follow-up letter goes out. Non-response and refusals have to be documented.
An individualized care plan within 90 days of the initial HRA or 90 days after the enrollment effective date, whichever is later, developed through an interdisciplinary care team with the member participating where feasible.
At least one face-to-face encounter a year, starting within the first 12 months of enrollment, in person or by real-time interactive telehealth.

These obligations are also measured. SNP Care Management is a Star Ratings measure scoring the share of members who got an initial HRA and an annual reassessment on time. The 2026 Star Ratings national average was 76%, which means roughly one in four assessments across the industry is late or missing.

Why D-SNP populations change quality and adherence work

The measure specifications are identical across plan types. What differs is the population, and the gap shows up in the same five places every year.

Dual and LIS status predicts lower measure performance within the same plan. CMS built the Categorical Adjustment Index specifically for this: it adds to or subtracts from a contract's Overall and Summary Star Ratings to correct for the average within-contract gap between LIS or dual members and everyone else, and between disabled and non-disabled members. The size of the adjustment scales with how much of the contract is LIS, dual, or disabled.
Low copays do not produce high adherence. Full-benefit duals pay a few dollars a fill, and D-SNP PDC performance still trails. The barriers are transportation, housing instability, health literacy, and losing track of a refill during a move or a hospitalization, none of which a $0 copay solves.
Coverage churn breaks continuity. Medicaid eligibility gets redetermined and can lapse. A member who loses full-benefit status changes what the plan covers and, if the lapse persists, whether they can stay enrolled at all.
Survey measures are case-mix adjusted for it. Dual eligibility status and the low-income subsidy indicator are both adjusters in CAHPS scoring, alongside age, education, health status, and proxy use.
Documentation runs thinner. Care spread across safety-net clinics, emergency departments, and multiple pharmacies leaves a fragmented record, which hits both gap closure and risk documentation.

The enrollment rules that changed in 2025

Two changes took effect January 1, 2025 and reshaped how duals move between plans.

The quarterly dual and LIS special enrollment period was retired. In its place, a monthly dual/LIS SEP lets full-benefit duals, partial-benefit duals, and LIS-only members move to Original Medicare with a standalone Part D plan, or switch between standalone Part D plans. A separate monthly integrated care SEP lets full-benefit duals only move into a FIDE SNP, a HIDE SNP, or an applicable integrated plan, and it has to be used to align Medicare and Medicaid enrollment. Neither SEP can be used to join a non-D-SNP Medicare Advantage plan.

Separately, CMS tightened the D-SNP look-alike rule. A look-alike is a Medicare Advantage plan that is not a SNP but carries a high concentration of dually eligible members. The threshold dropped from 80% to 70% for 2025 and to 60% for 2026, which forces more of those plans either to become real D-SNPs with the integration obligations that come with it, or to stop enrolling that population.

Where D-SNP operations break

What goes wrong	Consequence
Initial HRA started at day 60 and never completed	The 90-day clock is regulatory, and the miss shows up in SNP Care Management
Two automated calls logged as outreach attempts	Automated calls do not count toward the three required attempts
HRA completed but never reflected in the care plan	The regulation requires HRA results to be addressed in the individualized care plan
Bad phone numbers and addresses never reconciled against Medicaid data	Unreachable members are the single largest driver of missed assessments in this population
Quality and care management running off separate member lists	The same member gets called three times for three programs, or not at all
Loss of full-benefit status noticed at renewal	Eligibility changes affect coverage, SEP rights, and continued enrollment

How Pelica handles D-SNP work

Most of a D-SNP's compliance burden is reaching people. The assessment, the care plan, the annual face-to-face, the refill, and the gap closure all depend on making contact with members who move often, screen unknown numbers, and are already being called by four other programs.

Pelica keeps one live record per member across claims, EHR, pharmacy, lab, and ADT, so the HRA clock, the care plan due date, the open quality gaps, and the next refill sit in one place instead of four systems. The Care Management copilot works the outreach queue, documents every attempt against the three-attempt requirement, and escalates to a coordinator when a person is genuinely needed. Customers hold 96%+ adherence, improve gap closure by 41%, and go live in 2 weeks.

Related terms

CAHPS and HOS are the two member surveys that carry heavy Star weight in this population. PDC is the calculation behind the Part D adherence measures where duals tend to lag, and triple-weighted measures explains why those three adherence measures matter more than anything else on the scorecard.

Sources

Frequently asked questions

Common questions about dual eligibility, the three SNP types, integration categories, and the Model of Care.

What is a D-SNP?

A Dual Eligible Special Needs Plan is a Medicare Advantage coordinated care plan that enrolls only people entitled to both Medicare and Medicaid. It coordinates benefits across both programs, holds a contract with the state Medicaid agency under 42 CFR 422.107, and must operate a Model of Care that NCQA scores and approves. Special Needs Plans were created by the Medicare Modernization Act of 2003 and made permanent by the Bipartisan Budget Act of 2018.

What is the difference between a D-SNP and a C-SNP?

Eligibility. A D-SNP enrolls people who have both Medicare and Medicaid, verified through state Medicaid eligibility data, and it must hold a contract with the state Medicaid agency. A C-SNP enrolls people with one or more severe or disabling chronic conditions from a list CMS sets in regulation, verified by a physician attestation, and it has no Medicaid contract. A C-SNP's Model of Care is also capped at a one-year approval regardless of its score, while a D-SNP can earn up to three years.

What are FIDE, HIDE, and coordination-only D-SNPs?

They describe how much Medicaid risk the plan carries. A coordination-only D-SNP holds a state Medicaid agency contract setting minimum coordination duties but takes no Medicaid risk. A HIDE SNP has a capitated Medicaid contract covering either long-term services and supports or behavioral health across its full service area. A FIDE SNP holds both the Medicare Advantage contract and the Medicaid managed care contract under one entity, covering primary and acute care, long-term services and supports, behavioral health, home health, and medical supplies.

What is a SNP Model of Care and who approves it?

The Model of Care is the plan's documented care management structure, required under sections 1859(f)(5) and (f)(7) of the Social Security Act. NCQA scores it against four standards broken into 15 elements worth 60 points. A plan needs at least 70% overall and at least 50% on every element. D-SNPs and I-SNPs scoring 85% or higher get a three-year approval, 75% to 84% gets two years, and 70% to 74% gets one year.

When must a D-SNP complete a health risk assessment?

Within 90 days before or after the enrollment effective date for every new enrollee, and once a year after that. The plan must make at least three attempts to reach the member on different days and at different times, and automated calls do not count. If the member still has not responded, a follow-up letter is required, and non-response or refusal has to be documented. The individualized care plan is due within 90 days of the initial assessment or 90 days after the effective date, whichever is later.

Can a dual eligible member switch plans every month?

Since January 1, 2025 there are two monthly special enrollment periods, and neither allows a move into a non-D-SNP Medicare Advantage plan. The dual/LIS SEP lets full-benefit duals, partial-benefit duals, and Extra Help-only members move to Original Medicare with a standalone Part D plan or switch between standalone Part D plans. The integrated care SEP is limited to full-benefit duals and can only be used to enroll in a FIDE SNP, HIDE SNP, or applicable integrated plan, aligning Medicare and Medicaid coverage. The old quarterly dual/LIS SEP no longer exists.

Why do D-SNP populations score differently on Star Ratings measures?

The measure specifications are identical; the population is not. CMS built the Categorical Adjustment Index specifically to correct Overall and Summary Star Ratings for the average within-contract performance gap between low-income subsidy or dual members and everyone else, and between disabled and non-disabled members. CAHPS scores are separately case-mix adjusted for dual status and the low-income subsidy indicator. In practice the drivers are transportation, housing instability, Medicaid coverage churn, and fragmented documentation, not cost sharing, since full-benefit duals already pay a few dollars per prescription fill.

The 90-day assessment clock starts before most plans have a working phone number.

Pelica keeps one live record per member across claims, EHR, pharmacy, lab, and ADT, and runs AI copilots that work the outreach queue, document every attempt, and escalate only when a person is needed. Customers hold 96%+ adherence, improve gap closure by 41%, and go live in 2 weeks.

Book a Demo → See the Care Management copilot