[{"data":1,"prerenderedAt":155},["ShallowReactive",2],{"article-dsnp-integration-operations":3},{"id":4,"title":5,"author":6,"body":7,"category":136,"date":137,"description":138,"extension":139,"featured":140,"image":141,"imageAlt":142,"meta":143,"navigation":144,"path":145,"seo":146,"stem":147,"tags":148,"__hash__":154},"articles\u002Farticles\u002Fdsnp-integration-operations.md","D-SNP Integration Operations: Running Medicare and Medicaid on One Spine","Ayin Health Solutions",{"type":8,"value":9,"toc":127},"minimark",[10,14,17,22,25,28,31,34,37,41,44,47,50,53,56,60,63,66,69,73,76,79,82,85,88,92,95,98,101,104,107],[11,12,13],"p",{},"More than 6 million people are enrolled in Dual Eligible Special Needs Plans. That number grew from 2.2 million in 2018, and CMS is not done expanding the program's scope. What has changed faster than enrollment is the regulatory obligation attached to every one of those members.",[11,15,16],{},"If your plan runs Medicare and Medicaid administration on separate platforms connected by a middleware bridge or a batch-file handshake, you already have a compliance problem. CMS has made the direction of travel clear: integration is not aspirational — it is now a contract requirement, with hard deadlines attached.",[18,19,21],"h2",{"id":20},"what-cms-actually-requires-now","What CMS Actually Requires Now",[11,23,24],{},"The Bipartisan Budget Act of 2018 permanently authorized D-SNPs and directed CMS to unify Medicare and Medicaid appeals and grievance procedures. That directive has been landing in State Medicaid Agency Contract (SMAC) requirements and final rules ever since.",[11,26,27],{},"For contract year 2025, applicable integrated plans — D-SNPs affiliated with a Medicaid MCO in the same service area — must operate unified appeals and grievance procedures under 42 CFR §§ 422.629–422.634. That means a single intake point, a single tracking system, and a single acknowledgment to the member regardless of which program the issue touches. As of January 1, 2025, enrollees have 65 calendar days from the date on a coverage decision letter to file an integrated reconsideration. Both clocks run on one track.",[11,29,30],{},"FIDE-SNPs face the highest bar. Starting January 2025, fully integrated plans must operate with exclusively aligned enrollment — meaning they can no longer enroll partial-benefit dual-eligible individuals. A FIDE-SNP holds capitated contracts covering essentially all Medicaid services, including long-term services and supports. The administrative footprint is substantial.",[11,32,33],{},"HIDE-SNPs occupy the middle tier. They carry a Medicaid managed care contract but may not cover the full Medicaid benefit. CMS still requires them to meet unified grievance procedures and integrated care coordination standards where the SMAC mandates it.",[11,35,36],{},"The 2027 mandate, codified at § 422.514(h) in the CY2025 final rule, closes the biggest remaining gap. Where an MA organization — or its parent, or any entity sharing that parent — also holds a Medicaid MCO contract in the same service area, enrollment must be exclusively aligned by 2027. By 2030, the D-SNP can only enroll individuals already in, or actively enrolling in, the affiliated Medicaid plan. Plans that have been treating their MA and Medicaid lines as separate businesses are now on a countdown.",[18,38,40],{"id":39},"where-two-systems-break-down","Where Two Systems Break Down",[11,42,43],{},"The operational failure mode is predictable. A member has a hospital admission. The Medicare claim adjudicates under your MA platform. The Medicaid cost-sharing liability goes to a separate Medicaid system. The crossover claim moves sequentially: Medicare adjudicates first, generates an EOB, and that EOB becomes the input for Medicaid secondary adjudication — often via batch file, often overnight, sometimes via manual re-entry.",[11,45,46],{},"At every handoff, things go wrong.",[11,48,49],{},"Cost-sharing is miscalculated because the Medicaid system did not receive the updated Medicare payment in time for the adjudication window. A prior authorization approved on the Medicare side is not visible to the care manager working in the Medicaid platform. The member's care plan in the MA system reflects a primary care provider who changed three months ago on the Medicaid side. The health risk assessment completed in January sits in one system; the social determinants screening required under the 2024 D-SNP rule — housing, transportation, food security — lives in another.",[11,51,52],{},"Each of these is not just an operational nuisance. Each is a compliance exposure. CMS requires D-SNPs to maintain procedures for care coordination activities following HRAs. OIG has an active work plan project — OEI-03-25-00211, opened June 2025 — specifically examining D-SNP compliance with care coordination requirements, with particular attention to whether plans are using HRAs to generate risk-adjustment revenue without fulfilling the corresponding care coordination obligations.",[11,54,55],{},"Quality measures compound the problem. HEDIS and Star Rating measures that span both Medicare and Medicaid — HbA1c control, medication adherence, follow-up after hospitalization — require data from both systems to score accurately. Plans running two systems often cannot produce a clean denominator for dual-eligible members. They reconcile manually at the end of the measurement year, which introduces both error and delay.",[18,57,59],{"id":58},"what-states-are-adding-on-top","What States Are Adding on Top",[11,61,62],{},"Federal floors are not the ceiling. California's Department of Health Care Services now limits new D-SNP enrollment in all counties to plans affiliated with a Medi-Cal managed care plan. If your D-SNP does not have an affiliated Medi-Cal contract, you cannot grow your California book. The state has effectively made integration a market-access requirement, not just a compliance requirement.",[11,64,65],{},"New York's 2026 SMAC introduced specific provisions for MLTCP-aligned HIDE-SNP plans and clarified the path for plans converting between D-SNP types. The state's requirements around care coordination documentation, network adequacy for long-term services and supports, and Medicaid-side grievance tracking are written into the SMAC — which means CMS and the state can both audit against them.",[11,67,68],{},"Plans with members in multiple states are navigating a patchwork of SMAC terms that vary in integration depth, grievance timelines, and care management documentation standards. A two-system architecture cannot accommodate that variation without a proliferation of custom interfaces that each carry their own maintenance burden and failure risk.",[18,70,72],{"id":71},"what-a-single-member-spine-looks-like","What a Single Member Spine Looks Like",[11,74,75],{},"A genuinely integrated D-SNP administration model does not mean a single technology vendor owns everything. It means a single authoritative member record that both the MA and Medicaid functions read from and write to in real time.",[11,77,78],{},"On the eligibility side, that record reflects the member's dual-eligible status, their Medicaid aid category, their Medicare entitlement type, and their enrollment in both plans — updated on the same cycle. When CMS processes a Low Income Subsidy status change or a state Medicaid agency updates a member's LTSS authorization, that change propagates to the care management team and the claims adjudication engine without a batch delay.",[11,80,81],{},"On the claims side, crossover processing should not require a separate system handshake. The adjudication engine knows the member is dual-eligible, knows the Medicare payment, and calculates the Medicaid cost-sharing liability in a single pass or in a tight, same-day sequential process with a shared claim record — not a batch EOB export to a disconnected platform.",[11,83,84],{},"On the care management side, the care manager sees a single longitudinal record: the HRA, the care plan, the social determinants screening, the open authorizations on both sides, the recent claims regardless of program, and the open grievances regardless of which intake channel received them. There is no \"Medicare care manager\" and \"Medicaid care manager\" working from different records for the same member.",[11,86,87],{},"On grievances and appeals, a single intake queue routes and tracks everything. The integrated reconsideration timeline — 65 days from the coverage decision letter — is system-enforced, not calendar-managed by a compliance analyst.",[18,89,91],{"id":90},"the-operational-debt-calculation","The Operational Debt Calculation",[11,93,94],{},"The honest question for a COO is not \"can we pass the next audit with our current architecture?\" It is \"what does it cost us per year to maintain the seam, and what does it cost us if the seam fails at audit?\"",[11,96,97],{},"The maintenance cost is real: custom interfaces, reconciliation staff, parallel data quality reviews, manual quality measure reconciliation, duplicate training curricula for teams working two systems. The compliance cost of failure is also real: CMS has authority to impose civil monetary penalties, suspend enrollment, and terminate contracts for D-SNPs that cannot demonstrate integrated care coordination. OIG's new audit project signals that care coordination documentation will receive scrutiny, not just claims accuracy.",[11,99,100],{},"The 2027 exclusively aligned enrollment requirement makes the stakes concrete. If your Medicare enrollment system and your Medicaid enrollment system cannot confirm, in real time, that a prospective D-SNP enrollee is also enrolled in the affiliated Medicaid plan, you will either enroll ineligible members or turn away eligible ones. Neither outcome is acceptable at scale.",[11,102,103],{},"Plans that start the architecture work now — before the 2027 deadline, before the next SMAC cycle, before the OIG audit findings publish — will spend that investment once. Plans that wait will spend it under pressure, on a compressed timeline, while simultaneously managing member disruption and regulatory scrutiny.",[105,106],"hr",{},[11,108,109],{},[110,111,112,113,120,121,126],"em",{},"To learn how Ayin Health Solutions supports D-SNP integration at the operational level, visit ",[114,115,119],"a",{"href":116,"rel":117},"https:\u002F\u002Fayin.com\u002Fsolutions\u002Fdual-eligible",[118],"nofollow","ayin.com\u002Fsolutions\u002Fdual-eligible"," or ",[114,122,125],{"href":123,"rel":124},"https:\u002F\u002Fayin.com\u002Fcontact",[118],"contact our team",".",{"title":128,"searchDepth":129,"depth":129,"links":130},"",2,[131,132,133,134,135],{"id":20,"depth":129,"text":21},{"id":39,"depth":129,"text":40},{"id":58,"depth":129,"text":59},{"id":71,"depth":129,"text":72},{"id":90,"depth":129,"text":91},"Compliance","2026-04-29","CMS is tightening FIDE-SNP and HIDE-SNP requirements every contract year. Plans still running dual-eligible populations across two separate systems are accumulating operational debt they will eventually have to repay — here is what integrated D-SNP administration actually requires at the workflow level.","md",false,"\u002Fphotography\u002FAyin_still_5.png","Healthcare operations and coordination",{},true,"\u002Farticles\u002Fdsnp-integration-operations",{"title":5,"description":138},"articles\u002Fdsnp-integration-operations",[149,150,151,152,153],"Dual-Eligible","D-SNP","Medicaid","Medicare Advantage","Operations","ezmkq1pOyowfWH_Ty2f-BW6NSWOgt3HRWtbT__ai5nM",1790973089557]