Understanding Dual Alignment 

Upcoming Changes to Benefit Alignment for Dually Eligible Members

The Centers for Medicare and Medicaid Services (CMS) has finalized federal regulations that will change how Medicare and Medicaid coverage is aligned for individuals who are eligible for both Medicare and Medicaid, commonly referred to as dually eligible. These changes will be phased in between 2027 and 2030 and are intended to improve care coordination by increasing enrollment with Managed Care Organizations (MCO)s that offer fully integrated Dual Eligible Special Needs Plans (D-SNPs), providing both Medicare and Medicaid coverage.

What's Changing?

Beginning in 2027, individuals newly enrolling in a D-SNP will be required to enroll with the same Managed Care Organization (MCO) for both Medicaid and Medicare coverage. Members already enrolled in a D-SNP may continue their current coverage during the transition period.  By 2030, all individuals dually eligible for Medicare and Medicaid will be required to receive both benefits through the same MCO 

How This May Impact Providers 

• Member Enrollment Shifts: Providers may see gradual changes in member MCO enrollment as alignment requirements are implemented through 2030.
• Care Coordination: Increased alignment is expected to improve coordination of Medicare and Medicaid benefits over time.
• Administrative Processes: Providers may experience changes to eligibility verification, authorizations, billing, or other administrative workflows as enrollment patterns evolve.

The CMS regulation in its entirety and CMS FAQs regarding this update can be found at the links below: 

• eCFR :: 42 CFR 422.514 -- Enrollment requirements.
• Frequently Asked Questions (FAQs) and Enrollment Scenarios for §422.514(h) 

Please watch for continued updates, including website updates, FAQs, and webinars. Thank you for your continued partnership and support of our Members in Pennsylvania. 

Thank you for your time and continued partnership in supporting our Members in Pennsylvania. 

How This May Impact Members

Visit our member Understanding DSNP webpage to learn about how these changes may affect members. Help members learn what a Dual-Eligible Special Needs Plan (D-SNP) and the importance of these regulation changes.