For years, Dual Eligible Special Needs Plans (D-SNPs) have been positioned as the industry’s most promising vehicle for coordinating care across Medicare and Medicaid. They were designed around an ambitious ideal: two fundamentally different programs operating as one unified experience for members who need it most.
Yet most health plans, whether they are Medicaid dominant or Medicare dominant, are still chasing this standard. And the gap between vision and operational reality has become the defining challenge of D-SNP execution for health plans.
The Ideal: A Truly Seamless Member Experience
D-SNPs were created with an intention that remains as compelling as it is complex:
- Align Medicare and Medicaid benefits.
- Coordinate care seamlessly across programs with different rules, incentives, and oversight structures.
- Give members and caregivers a single, uncomplicated pathway to services, support, and care coordination.
It is a powerful idea. But fully achieving it requires a level of organizational, operational, and cultural integration that few plans have historically been built for.
Two Starting Points, Two Sets of Strengths, and Blind Spots
Most health plans enter the D-SNP market from one of two directions. Each brings valuable capabilities, but also structural limitations that become visible from the moment D-SNP demands a unified model.
Medicaid Dominant Plans: Deep Community Roots, New Medicare Pressures
Medicaid-based organizations often have strong Aged, Blind, and Disabled (ABD) care management instincts, as well as rich relationships with Community-Based Organizations (CBOs) and an infrastructure built for Long-Term Services and Supports (LTSS).
Despite these skills, their operating model was not designed to overcome organizational challenges like satisfying state contract requirements while simultaneously building Star performance, managing Risk Adjustment Factor (RAF) with discipline, and rigorously complying with Medicare Advantage (MA) requirements.
Put simply, their operating model was not built to serve the dual priorities that D-SNP requires.
Medicare Dominant Plans: MA Expertise with Big Medicaid Gaps
On the other hand, a Medicare-dominant plan brings strengths and blind spots in opposite directions. Risk adjustment and utilization management are core competencies for these plans, while LTSS coordination, CBO relationships, and the level of state oversight accountability that ABD Medicaid demands are not.
In these plans, the Medicaid side is often an afterthought, despite being the heart of the D-SNP promise.
The Defining Challenge: Bridging the Gap Between Vision and Reality
The hard truth is that true seamlessness may not be fully possible given the structural differences between Medicare and Medicaid. They were never designed to fit perfectly together.
But in the D-SNP world, closest-to-seamless is what wins—in member experience, in state relationships, and in competitive positioning.
The plans that succeed acknowledge the gap and tackle it head-on. Not with incremental fixes or isolated initiatives, but with a willingness to rethink how the organization operates across lines of business.
What It Actually Takes to Close the Gap
Achieving the D-SNP standard requires a shift from “coordinated” to integrated. That means
- Organizational Alignment Across Medicare and Medicaid
D-SNP should ideally operate cohesively rather than as a sidecar to two distinct product lines. Plans that strive for seamless integration can better align Medicare and ABD Medicaid under a unified executive framework, fostering shared financial responsibility for the total cost of care. While domain experts continue to offer their valuable expertise, ultimate performance accountability can be elevated above product silos. When governance is in harmony, incentives become aligned, leading to more effective execution.
- A Single Operating Model for Care and Data
It is important to recognize that dual-eligible members experience their coverage as an interconnected whole, and care teams should adopt a similar approach. High-performing D-SNPs are increasingly adopting an interdisciplinary care framework that includes a unified care plan and a comprehensive member data view across programs. By implementing standardized workflows and integrated analytics, we can minimize duplication, identify risks earlier, and improve care transitions, ultimately working toward a more seamless experience for our members.
- Equal Fluency in Medicare and Medicaid
Achieving true integration involves not only structural changes but also a genuine shift in mindset. It is essential for Medicaid-focused plans to apply the same level of discipline to Medicare Stars, RAF integrity, and MA compliance as they do to LTSS and community engagement. Meanwhile, Medicare-focused plans should work towards developing strong competencies in areas like state oversight, ABD complexity, and LTSS coordination. D-SNP operates at the crossroads of both programs, and it is important to recognize that no single team has the entire solution. Plans that thrive are those that are open to sharing authority across different domains and fostering expertise under a collaborative leadership framework.
- Enterprise-Level Recognition of What is at Stake
D-SNP performance is an important consideration that goes beyond being just a growth strategy for Medicare or an extension of Medicaid. It truly impacts the entire enterprise. When executive leadership acknowledges that underperformance in D-SNP could jeopardize both competitiveness in Medicare and the credibility of Medicaid, it opens the door to prioritizing integration strategically. This shared understanding can guide investments, accelerate decision-making, and strengthen accountability throughout the organization.
True integration enhances expertise rather than diminishing it. It brings together different areas of expertise under a unified operating model with a shared commitment to performance. By embracing this approach, we can transition from merely meeting the D-SNP standard to fully embodying it in our operations.
Most Plans Have Not Fully Grappled with the Work Required…Yet
D-SNP remains one of the most consequential opportunities in managed care. But many plans are still early in recognizing what true integration demands, and what it can unlock if done right.
Sellers Dorsey is helping plans across the country take on this challenge, and we are synthesizing the most essential lessons into our upcoming D-SNP Integration Playbook for Health Plans.
The playbook is designed for leaders who are serious about closing the gap and elevating their D-SNP performance.
