Samantha Morales: Hello everyone, and welcome to today’s webinar presentation entitled Dual Eligible Special Needs Plans Updates: What California Advocates Need to Know. I’m Samantha Morales, Senior Policy Advocate on the Health Team at Justice in Aging. Today I’m joined by my colleague, Tiffany Huyenh-Cho, Director, California Medicare and Medicaid Advocacy. Next slide, please.
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A little bit about Justice in Aging. As many of you may know, we are a national organization that uses the power of law to fight senior poverty by securing access to affordable healthcare, economic security, and the courts, for older adults with limited resources. Since our founding in 1972, our efforts have focused on fighting for people who have been historically marginalized and excluded from justice, such as women, people of color, LGBTQ+ individuals, and people with limited English proficiency. Next slide, please.
Justice in Aging is committed to advancing equity for low-income older adults in economic security, healthcare, housing, and elder justice initiatives. We strive to address the enduring harms and inequities caused by systematic racism and other forms of discrimination that uniquely impact low-income older adults in marginalized communities. Next slide, please.
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Tiffany Huyenh-Cho: All right. Thank you, Sam, for being here with us and moderating our presentation and helping with today’s webinar. Thank you all for joining today’s webinar and taking time out of your day. We’re happy to be here and provide some updates about what is happening in dual eligible special needs plan landscape in California. Our agenda today is packed, we’re going to get through it, but we will cover what Dual Eligible Special Needs Plans or D-SNPs are, the different types that exist, who can enroll, what requirements that these plans have, and how these plans integrate or coordinate with Medi-Cal. We will also discuss at a high level the impact of H.R.1 on state and federal budget changes for people that are dually eligible for Medicare and Medi-Cal and identify advocacy opportunities.
Some key points I want to share to frame our conversation first. Nearly 50% of people that are dually eligible for Medicare and Medicaid in the nation receive their care from a D-SNP or Dual Eligible Special Needs Plan. Because of this, it’s important that advocates understand these plans to help individuals make informed decisions, as well as to hold plans accountable to regulatory requirements and to shape policies at the state and federal levels. Dual eligibles, or also known as dually eligible people for Medicare and Medicaid navigate two health insurance programs, Medicare and Medi-Cal, and this means navigating different medical criteria under both. Medicare covers the majority of care for dual eligibles, but this group are also heavy Medi-Cal utilizers. Medi-Cal is an important source of other types of care not typically covered by Medicare, things like in home personal care services or transportation or long-term care in a nursing facility.
D-SNPs can streamline care and benefits, but enrollment is always a personal decision. It is influenced by individual needs and preferences. If your preferred provider is not in a D-SNP, it may not be wise to join a D-SNP because you could lose access to your provider. It is very important that people are informed about the benefits of D-SNPs, but also the limitations that come with joining a D-SNP.
What are D-SNPs exactly? They are Medicare managed care plans. They are a subset or a type of Medicare Advantage, but D-SNPs are unique in that they are meant for people that are dually eligible for Medicare and Medicaid only. Only dual eligibles can join a D-SNP. D-SNPs administer Medicare benefits, and members of these plans must get prior authorizations for services, and they’re also limited to the D-SNP plan’s specific network of contracted providers. D-SNPs are unique in that fact because they only enroll dually eligible people, and they are tailored to meet this group. They are designed with the goal of improving the quality of care and health outcomes for this group, as well as to coordinate the delivery of Medicare and Medi-Cal benefits. And to do that, D-SNPs have some core elements that don’t exist in other Medicare Advantage plans. Every D-SNP, in order to operate, they must sign a contract with the state Medicaid agency to operate in that state.
These contracts are called state Medicaid agency contracts or SMACs. These are used to hold the D-SNP to higher standards and responsibilities, including oversight from both CMS and the federal government and the state Medicaid agency. And state Medicaid agencies have an interest in these D-SNP plans because the plans enroll a large number of their Medicaid population. States can use the power of these state contracts to impose additional requirements on the D-SNP, things like improving care delivery or providing assistance with Medicaid annual renewals. And lastly, D-SNPs are required to coordinate or provide some level of coordination with Medicaid benefits. This is a requirement that makes D-SNPs unique, and we’ll get more into what care coordination means in a D-SNP.
But here on this chart, you can see that there are several different types of Medicare Advantage plans. It is a big landscape nationwide and in California alone. On the left side, you’ll see the big umbrella from Medicare Advantage and all the different type of Medicare Advantage plan that are available. D-SNPs fall under the special needs plans category, and we’ll be discussing only the D-SNPs today.
D-SNP enrollment has grown rapidly, both in California and across the US. There are 1.8 million people dually eligible for Medicare and Medi-Cal today living in California, and 26% of them are enrolled in a D-SNP, and about 50% are in original Medicare or traditional fee-for-service Medicare. Dual eligibles as a group have some common characteristics. In California, they are more likely to be Latino, Asian, Black, and have at least one chronic medical condition. Dual eligibles also make up more than 75% of In-Home Supportive Services recipients or IHSS, and 80% of residents in Medi-Cal skilled nursing facilities. Because of their health needs, dual eligibles use healthcare more, and this leads to higher spending. Nationally, this group makes up 16% of Medicare enrollees, but 31% of Medicare spending. And on the Medicaid side, dual eligibles are 14% of all Medicaid enrollees, but 29% of Medicaid spending. And partly because of the disproportionate spending for this group compared to their population size, there has been increased attention to the D-SNPs to improve care and health outcomes as well as reduced spending.
All D-SNPs provide Medicare Part A and B benefits as well as prescription coverage. It’s all provided within the plan. People enrolled in the D-SNPs will receive the majority of their Medicare services from the D-SNPs. D-SNPs often also cover supplemental benefits. These are typically items and services not covered under traditional Medicare. As you know, Medicare has some gaps. It does not traditionally include dental, for example, but dental as a supplemental benefit is common, as well as hearing or respite hours for caregivers or other things like over-the-counter items like first aid supplies and vitamins. In California, 91% of all of the D-SNPs offer dental care through supplemental benefits, but only 2% offered caregiver respite hours. You can see there can be some variation in what supplemental benefits are offered, and D-SNPs and all Medicare Advantage plans can choose what supplemental benefits to offer and whether or not to offer them at all, really.
And as you know, in California, dual eligibles are required to join Medi-Cal Managed Care so D-SNP members in California typically have two plan memberships D-SNP for the Medicare benefits and a Medi-Cal plan for Medi-Cal managed care. Enrollees will also still receive non-Medi-Cal managed care benefits through fee-for-service like in home supportive services or IHSS and other home and community-based programs.
Who regulates D-SNPs exactly? They are Medicare plans, so they are regulated by the federal government, the Center for Medicare and Medicaid Services or CMS. CMS sets the minimum ground rules that all D-SNPs must comply with. And CMS also requires D-SNPs to report on all sorts of measures like performance to evaluate and compare the quality of healthcare services that are provided. California State Medicaid Agency, the Department of Healthcare Services, or DHCS, also has oversight over D-SNPs through the state contracts that D-SNP sign with the state Medicaid agency. Again, these state Medicaid contracts or SMACs are required. In order to operate in California, a D-SNP must have signed one with DHCS.
States can also use these state contracts to impose additional requirements that are higher than the federal minimum. For example, in California, our D-SNPs are required to also report the number of referrals that the D-SNP makes to Medi-Cal-based programs like IHSS or community-based adult services, and dual eligibles are still entitled to the full spectrum of their Medicare and Medi-Cal benefits, so connecting members to the appropriate services must be a priority. This requirement to document the number of referrals can be really helpful in determining whether the D-SNPs are doing just that. These state contracts are key and can give states discretion in how D-SNPs operate in their state.
Okay. Let’s talk about who can enroll in a D-SNP. Generally, anyone with full Medicare and Medi-Cal benefits, this means both Part A and Part B, as well as full scope Medi-Cal. People with a Medi-Cal share cost in California cannot join a D-SNP because you cannot join a Medi-Cal managed care plan with a share of cost. You also must be 21 years of age or older to join a D-SNP. States can choose to set higher enrollment criteria if they want to through that SMAC. In California, we have that requirement that all members also be a part of Medi-Cal managed care.
And as always, D-SNPs are voluntary to join. Dually eligible individuals have freedom of choice when it comes to choosing how they receive their Medicare benefits, so all Medicare enrollees, including dual eligibles, have options to choose from. They can remain in traditional or original Medicare, or they can pick a managed care option like a D-SNP or a non D-SNP Medicare advantage plan. PACE or the Program of All-Inclusive Care also remains an option for dual eligibles. It is not required that dual eligibles join a D-SNP or any other program. They can remain in original Medicare if they would like.
While D-SNPs are voluntary to join, I do want to highlight a form of automatic enrollment that can be used. This type of automatic enrollment is called default enrollment, and here, a dual eligible is automatically or default enrolled into a D-SNP when they first become Medicare eligible. This could be through turning 65 or through disability or through disability after reaching the 24 months waiting period for social security disability benefits. I do want to be clear that the vast majority of D-SNPs do not use this default enrollment process. D-SNPs must first meet certain criteria and quality standards and have to get approval from both the state and federal government to use default enrollment. In California right now, only three plans in two counties use that process. That’s in San Diego and in San Mateo County. In San Diego, it’s Community Health Group. In San Mateo, it’s Kaiser and the Health Plan of San Mateo.
Outside of that, default enrollment does not exist. It is, again, very limited. Before a plan can use default enrollment, they must send notice at least three months in advance, and they must send at least two notices so that folks are aware that this is happening. People can always cancel or opt out of default enrollment before it takes place. Or if you are enrolled, you can later disenroll from the D-SNP. California can expand default enrollment to other plans or counties, but right now it is very limited. If the state wants to expand it further, plans will need to meet certain standards first.
People can also choose to enroll or disenroll in D-SNPs through different periods of the year. Fall Medicare open enrollment is open right now actually, until December 7th. Choices are effective this January 1st, 2026, and Medicare enrollees can choose to join a D-SNP or another Medicare Advantage plan, or disenroll from these plans and return to original Medicare. There are also two new special enrollment periods that went into effect earlier this year. There is the monthly special enrollment period or integrated special enrollment period. These special enrollment periods can be used to disenroll from a D-SNP once every month and return to original Medicare, or it can be used to enroll into certain D-SNPs throughout the year. We did create a fact sheet on how these new special enrollment periods work, it’s linked on the page.
I also want to highlight that navigating Medicare enrollment is complicated. This is where the state health insurance assistance programs can be incredibly important for help in navigating this enrollment process. In California, we have HICAPs. They are a great resource. They are free, and provide objective counseling on enrollment options and Medicare benefits.
Okay. We talked a little bit about what D-SNPs are, who can enroll, but now we’ll get into the types of D-SNPs that exist in California and what the important differences are between them. D-SNP is an umbrella term. There are subcategories underneath.
In California, we have three types. For the most part, the different types dictate what level of integration or coordination between Medicare and Medi-Cal the plan is responsible for. I’m highlighting these categories so folks understand that not all D-SNPs are created alike. Some plans do more to coordinate Medi-Cal benefits, and some do less. California’s Medicaid agency chooses which type of D-SNPs can operate in the state. So first, we have the fully integrated dual eligible special needs plan or FIDE-SNP. In this plan, the D-SNP is responsible for providing both Medicare and Medicaid benefits within one plan. The FIDE-SNP is the highest level of integration possible because one plan is covering all benefits. We only have one FIDE plan in California. It is SCAN Connections, and concentrated in Southern California.
We also have Coordination-Only D-SNPs. These plans offer the least amount of integration and coordination between Medicare and Medi-Cal benefits. These D-SNPs are not responsible for directly providing Medi-Cal services. They provide Medicare benefits and Medicaid is provided through other entities. A lot of the plans in California are these Coordination-Only D-SNPs.
And lastly, we have Applicable Integrated Plans or AIPs. This is a designation given to D-SNPs who have aligned enrollment and do cover at least some Medicaid benefits like primary and acute care and other Medi-Cal services like home health, medical equipment, or nursing facility care. And these Medi-Cal benefits are provided through the Medi-Cal plan. The D-SNP and Medi-Cal plan in a applicable integrated model must be operated by the same parent company. In California, only the existing Medi-Cal insurance companies operate are Applicable Integrated Plans. Because the same insurance company operates both the D-SNP and Medi-Cal plan, there is administrative simplicity as well as a financial incentive for these plans to perform better. Both a FIDE-SNP and coordination only D-SNP can be an AIP if they meet certain requirements. I know this was complicated, so I do encourage people to read our dual eligible special needs plan resource guide for more details.
In California, this is roughly what dual eligible enrollment looks like here this year. Roughly 50% of our dual eligibles are in original Medicare, and the rest are in some sort of Medicare advantage or PACE. You can see we have about only 1% in that FIDE-SNP that I mentioned. 18% are in a regular Medicare Advantage plan and roughly 26% are in some sort of D-SNP itself.
Let’s dig in a little bit more. In the Coordination-Only D-SNP, these plans only have to comply with the basic federal minimum requirements unless the state has imposed additional requirements through their state contracts. Otherwise, these D-SNPs have limited responsibility to provide care coordination between Medicare and Medicaid. One specific requirement they do have is that the plan must notify the state Medicaid agency when a member is admitted into a hospital or nursing facility, or when they are discharged. This is so the Medicaid agency is aware of the admission or discharge and can take steps to coordinate transitions between care settings. And as mentioned before, an applicable integrated plan is a D-SNP with additional integration requirements because members are enrolled in a D-SNP and Medi-Cal plan operated by the same insurance company. The structure ensures that members receive both their Medicare and Medi-Cal benefits through the same parent insurance company.
The Applicable Integrated Plans that we have in California are called Medicare Medi-Cal plans or Medi Medi plans. They started in 2023 and replaced our Cal MediConnect demonstration. They are available in some counties, but not all quite yet.
The Medicare Medi-Cal plans, again, still D-SNPs, but they are a term used to distinguish them from other D-SNPs that are available in the state. These plans, the Medi Medi or Medicare Medi-Cal plans can only be operated by the existing Medi-Cal insurance companies. And when you enroll in one of these plans, you are enrolling in both the D-SNP and the Medi-Cal plan operated by the same company. That is called aligned enrollment. For example, Kaiser has both D-SNPs and Medi-Cal plans. If you’re in Kaiser’s Medi Medi plan, you are enrolled in both Kaiser’s D-SNP and their Medi-Cal plan. The D-SNP and Medi-Cal plan match. And because both Medicare and Medi-Cal benefits are provided through the same insurance company, these plans have single plan materials, so members of the plan have one health plan ID card and a single provider directory that references both Medicare and Medi-Cal providers instead of two separate plan directories.
The plans also used unified appeals. This is something where requests for services must be considered under both Medicare and Medi-Cal standards, not just one. This aligned enrollment structure creates streamlined communications, and it makes it seem like someone is enrolled in one plan as opposed to two separate Medicare and Medi-Cal plans. The MMPs are available in 12 counties today. They are expanding this January 2026, so it’s important that folks know that these plans are now also available for enrollment starting January 2026. There is no automatic enrollment in the MMPs outside of those two counties that I mentioned earlier, so these are voluntary to join. And in the new counties where these plans are expanding, folks can choose to join those plans.
And as you know, it is pretty challenging for counselors and individuals to figure out what category of D-SNP a plan is, either online or through print materials. The term MMP is used to distinguish these D-SNPs, it’s used by the Department of Healthcare Services, but each insurance company still uses their own branding and name. It is helpful to look at that link we have posted on the slide to see the official list of MMP plans available, which ones are available, and in each county as well.
Okay, so now let’s talk a bit about the requirements that all D-SNPs have. If there’s anything specific to the Medicare, Medi-Cal plans, the MMP plans, I’m going to note it, but a lot of this is specific to all D-SNPs.
We’ve covered the types of D-SNPs. All D-SNPs are subject to minimum federal requirements. These requirements even extend beyond the basic requirements that all Medicare Advantage organizations are subject to. Because these plans are specifically designed for dual eligibles, the federal government has put additional standards for them. At a minimum, all D-SNPs must create a model of care. This is a document that explains how the plans will meet the needs of their members. D-SNPs are also required to at least generally coordinate Medicaid benefits, including those in fee for service. Care coordination is a spectrum, but it can involve helping contact the Medicaid side to arrange for Medicaid covered transportation or facilitating facilitating a call or helping with medical records needed to support a Medicaid appeal.
D-SNPs also must screen members for housing stability, food security through assessments. The results of this assessment are then addressed in each member’s individualized care plan that all D-SNPs must create. And lastly, all D-SNPs must have an enrollee advisory committee to garner feedback from plan members. These committees must reflect the plan population for the service area and plans must solicit member input on many different things, including improving access to services, coordination of services, as well as health equity for underserved populations. These are the minimums, but as previously noted, some of the different D-SNP types do have additional requirements that go above and beyond these baseline requirements.
And as noted, D-SNPs must coordinate Medi-Cal services for its members. Care coordination is really the substance behind D-SNPs. It’s meant to address the gaps that dual eligibles face because they navigate two different sources of care. This means all D-SNPs, regardless of type must develop individualized care plans that reflect the member’s needs and use interdisciplinary care teams to provide care and support to manage their member’s care and actualize their care plan. Care teams must be interdisciplinary and have demonstrated expertise and training in order to provide care to a wide variety of needs. This also means that some subset of members may need more specialized care such as people with dementia or Alzheimer’s. Plans also use health risk assessments to identify risk factors, those medical, functional, cognitive, and social needs like food insecurity or transportation that I mentioned earlier.
And in California, most of you know that our Medi-Cal plans offer Enhanced Care Management under CalAIM. Enhanced Care Management is the highest form of care management available to Medi-Cal enrollees, and it is for people with high needs. For people enrolled in a D-SNP, they are not eligible for Enhanced Care Management because it would be contradictory and conflict with the care management that’s already required by the D-SNP plan. It would be very confusing to have a care manager with ECM and then also have a care manager with the D-SNP. We want to make sure that there’s one care manager and one person responsible for coordinating care across the different spectrum of needs.
But to ensure that dual eligibles also receive equivalent care management, all D-SNPs still must provide a similar level of care for certain groups. It is called ECM-like care management right now. In 2026, this type of care management is being renamed to California Integrated Care Management or CICM. Again, it’s meant for people with high needs and that meet certain populations of focus or certain groups. Another distinction between the care management provided in the D-SNP versus the Medi-Cal Enhanced Care Management is that there is less emphasis on in person engagement compared to ECM within a D-SNP.
One other difference though is that in the D-SNP, in 2026, D-SNPs must also provide this higher level of care management to additional group, adults with documented dementia needs. This is only for the D-SNPs. It does not exist in the Medi-Cal only plans. This chronic integrated care management, again, it’s the new term being used in 2026. There are some differences with how care management is provided today. A lot of it does have to do with that in person care management and what entity is providing the care management, whether it be through community-based services or within the plan itself.
D-SNPs also often offer supplemental benefits like we mentioned. These are, again, those benefits not traditionally covered under original Medicare. Common benefits are vision or dental, and most D-SNPs offer supplemental benefits, but there is concern whether members are actually accessing and utilizing these benefits. To combat this, there has been rulemaking to enhance oversight over the use and marketing of supplemental benefits. Plans now must stabilize eligibility criteria, meaning that they cannot change the eligibility criteria mid-year, and there are also new restrictions on how these benefits can be advertised in hopes of improving informed decision-making around D-SNP enrollment.
There was a provision that required a mid-year notification to members of supplemental benefits that people were eligible for but had not used. This was paused indefinitely by CMS. It is disappointing because it could have helped members use all of the benefits their Medicare Advantage or D-SNP plan might have offered. There can still be advocacy in this area. There’s a need for information about these benefits, especially when supplemental benefits duplicate Medi-Cal. Medi-Cal in California is comprehensive, so supplemental benefits often duplicate Medi-Cal benefits as well, like dental, and that can be confusing to navigate, so clear information is needed on how to navigate overlapping benefits.
Another tip is to watch out and make sure that supplemental benefits are not being used to impact Medi-Cal eligibility. The flex cards or prepaid debit cards that some D-SNPs offer as supplemental benefits cannot be counted as income for Medi-Cal eligibility purposes. The money on those prepaid cards are solely for supplemental benefits. It cannot be counted as income for Medi-Cal purposes. And in fact, the state actually just released clear guidance confirming this earlier this week. I haven’t heard of problem cases where these flex cards are used to impact eligibility, but if you are seeing this, let me know.
Another key feature of the Medicare Medi-Cal plans I mentioned before was unified appeals. Unified appeals means the D-SNP must consider both Medicare and Medical standards when they’re reviewing requests for coverage. So typically, Medicare Advantage plans do not consider a person’s Medi-Cal benefits when they decide whether to grant or service or appeal. But in the integrated plans like the MMPs, the plan must consider both Medicare and Medi-Cal standards when deciding medical necessity requests. This unified process is done at the initial decision that a plan makes and at the first level of appeal. The plan must consider both Medicare and Medi-Cal criteria in their determinations and send a single notice to the member. If the member wants to appeal at the plan level, they only have to manage one appeal process as opposed to two separate appeals.
One thing to note though is that after the first level appeal within the plan, the higher levels are not integrated, so you would then pursue separate Medicare and Medi-Cal pass. This unified appeal process is only present in the Medi Medi plans. Other types of D-SNPs or regular Medicare Advantage plans do not have a unified integrated appeal process. People in those plans still navigate separate Medicare and Medi-Cal appeal pathways and separate determinations. Unified appeals can be really helpful for dual eligibles because it ensures that the plan is actually thinking about both your Medicare and Medi-Cal entitlement and not just one.
Let’s go through an example. Medicare and Medi-Cal often cover the same benefits, but have different standards. Durable medical equipment is one common example like a wheelchair. Medicare covers durable medical equipment for use in the home only, but Medi-Cal will cover durable medical equipment if it’s used for the home and outside the home, such as the community. Medicare will not cover durable medical equipment if part of the use is meant to help someone in the community. As an example, Maria is a dual eligible. She lives in San Diego. She’s enrolled in Medi Medi Plan A. She fell a few months ago and now has difficulty walking for long periods of time. Before her fall, Maria frequently visited family that lived near her home. Her physician has recommended a wheelchair and submits a request to Maria’s Medi Medi plan. The plan denies the request on the grounds that Medicare does not cover the wheelchair for use outside of the home. So what went wrong?
First, the plan didn’t even consider whether Maria would qualify for the wheelchair under Medi-Cal standards. They didn’t reference Medi-Cal in their decision to her. Her Medi-Cal benefits would cover the wheelchair even if she needed to use it outside the home. The plan should have considered both Medicare and Medi-Cal standards and issue one single notice that clearly demonstrated that they had considered both Medicare and Medi-Cal criteria. Maria’s rights at this point is to file an appeal at the plan and she can file a single appeal. We have gotten a few examples of Medi Medi plans not following this unified appeal process where instead of one single decision letter, folks are sent two, or the plan is not considering both Medicare and Medi-Cal standards, so if you have seen appeals in these new Medi Medi plans, please reach out to me. We want to make sure that these plans are following this unified appeal process, as it is a requirement.
There are some protections that all D-SNPs have that are outlined in the state contract. All D-SNPs in California offer a three-month minimum deeming period for enrolled members that experience a break in Medi-Cal eligibility. Deeming acts like a grace period and keeps someone enrolled even in the D-SNP, even if the Medi-Cal eligibility is terminated for whatever reason. For example, if someone is assessed a share of cost or if an annual renewal is not completed. Deeming prevents immediate disruption to care and members can continue using D-SNP Medicare services. Dual eligibles can use this three-month period to restore or fix eligibility while still enrolled. And some plans even have longer periods than three months. We’ve seen six months even. The link on the page does detail the deeming period by each individual plan. And lastly, all dual eligible individuals are protected from improper billing and Medicare Advantage, whether it be in a D-SNP or regular Medicare Advantage plan.
Providers that contract with a Medicare Advantage plan must accept all members of the Medicare Advantage plan and cannot bill a dual eligible. They have protections under both state and federal law. Another protection specific to the Medi Medi plans is a 12-month continuity of care period for new members. If you join a Medi Medi plan and your existing provider is not contracted with the new plan, you can still continue seeing that prior provider for 12 months. The plan must grant this request, and it does cover both primary and specialty providers.
And as I mentioned, these Medi Medi plans are expanding to 29 new counties. The counties are listed on the map. Again, these are voluntary to join, but they are an option now so folks can choose whether or not they are appropriate for them and if they like them. I’ll note that some counties will not have a Medi Medi plan in 2026. These are primarily in more rural counties. Partnership HealthPlan is the plan that’s not operating this Medi Medi plan in 2026. We do expect that the additional counties that don’t have a MMP plan will be ready in 2027, but the link on the slide will show you more details of each plan by county.
To sum up, in 2026, dual eligibles have four enrollment options. They can join these integrated plans, original Medicare. I’ll note that enrollment into other D-SNPs that aren’t considered aligned is closed, and that is under state law. The only D-SNPs that are open for enrollment now are the Medi Medi plans and SCAN Connections FIDE-SNP. New enrollment into other D-SNPs is closed. These are the D-SNPs that are not considered integrated. They’re not operated by the Medi-Cal plans. Current members of these other D-SNPs can remain in the plans, but they can remain. They will not be asked to disenroll, but new members cannot join. We expect that these plans will eventually peter out or close as enrollment numbers decrease.
Okay. Next, let’s just cover briefly some advocacy areas. One thing to remember is that dual eligibles and D-SNPs are still entitled to Medi-Cal services, even those under CalAIM or fee-for-service, this includes the community supports offered by Medi-Cal managed care plans. Members in a D-SNP should still be getting screened for community supports and the individuals, their family members or caregivers can also request community supports on their behalf. And as we covered before, improper billing is still a issue area we see often. Dual eligible should not be billed for medical services. And if advocates are seeing this, there are ample resources to fight these instances, so please contact me or visit our website for more information.
Another advocacy area is when Medicare Advantage supplemental benefits overlap with benefits also covered under Medi-Cal, like dental. We often hear confusion about navigating this process either due to difficulty using both coverages or not knowing that they even had dental benefits available to them through the Medicare Advantage or D-SNP plan. We also hear of cases where a dual eligible is improperly billed for dental services by their Medicare dental provider, even when those services would’ve been covered under Medi-Cal. So encouraging plans to proactively help members navigate these benefits is important as well as written communication about benefits in the least. So if you are seeing some issues in these areas, please let us know, we have some tips on how to navigate.
And lastly, a very rich advocacy area right now is education around the multitude of state and federal changes coming to the Medi-Cal and Medicare program. These changes were passed over the summer during the budget process. I won’t cover them in detail for time, but wanted to highlight it so folks know this is coming and are prepared. One, the Medi-Cal asset limit, which right now is eliminated, is coming back. It will be returning for older adults and people with disabilities. It is reinstated at 130,000 for a single person and is effective January 2026. This only applies to people over 65 dual eligibles or people on disability-based Medi-Cal programs like the aged and disabled. We will also be releasing a fact sheet on this soon.
There are also some eligibility changes for some immigrant groups in 2026 too. First, people that are undocumented and over age 19 cannot enroll in full scope Medi-Cal after January 2026. Right now in 2025, Medi-Cal is open to anyone income eligible regardless of immigration status, but enrollment for undocumented individuals will be capped or blocked after January 1st, 2026, so new enrollment is capped. People already on Medi-Cal right now can remain, but new people that want to apply after January are only going to get restricted or emergency Medi-Cal.
There’s also some changes on the federal level from H.R.1. There’s been a lot of resources on this, but H.R.1 makes sweeping changes to Medicare and Medicaid, including what groups of immigrants qualify for Medicare and Medicaid. It also imposes work requirements as a condition of eligibility for younger populations in the expansion categories. So older adults and dual eligibles are not subject to work requirements directly, but we want to make sure they won’t be swept up in work requirements or fear that they’re subject to work requirements when they are not. This is where clear and accurate information is really needed.
You can see on our slide we have a resource on the Budget Reconciliation Act that covers these provisions. And then lastly, we have a lot of resources. These are about D-SNPs, the different changes, how to improve care. And then some of the other changes that were mentioned, the MMP plans as well as the state and federal budget changes are also listed on this slide. And with that, I think we have time for questions.
Samantha Morales: Yes. Thank you so much, Tiffany, for your expertise. We have quite a few questions, and so I went through and tried to uplift a few themes that stood out to me. The first sets of questions that stood out were about levels of integrated care, for example, that I know you went over in the beginning of the webinar. For example, how can advocates find out what level of integration a D-SNP has?
Tiffany Huyenh-Cho: Yeah, thanks for raising that question. We get that every time we do a webinar and in conversation. It is difficult. It is very, very difficult. The levels of integration is not really listed on a D-SNP’s member materials, it just says D-SNP. It often doesn’t say if it’s a FIDE-SNP or coordination only, or the MMP D-SNP. For the MMPs, DHCS has listed that website where they specifically say which D-SNPs are MMPs in each county. Some counties there’s more than one. Some counties there’s only one. You can call your D-SNP plan, they should be able to tell you.
You can also look at, CMS has a monthly spreadsheet that they put out of D-SNP enrollment, and it does list it by integration level. Obviously, that is very technical and you have to go through the Excel spreadsheets, but that is another way. I know that the HICAPs do create their own lists as well to determine which D-SNPs are which types of D-SNPs are available. But I know that they too also have difficulties in finding out that information. There’s been a lot of push from advocates to CMS to make it more clear the levels of integration D-SNPs have. So right now, it is imperfect, but there are some strategies for it for figuring that out.
Samantha Morales:Thank you, Tiffany. And another question in this category is, what is exclusively aligned enrollment or EAE?
Tiffany Huyenh- Cho: Exclusively aligned enrollment is the requirement that when you join certain D-SNPs, the Medi Medi plans are the perfect example. You are enrolled in the D-SNP and you’re required to join that D-SNP’s matching Medi-Cal plan. All of the Medi Medi plans are operated by the existing Medi-Cal insurance companies, Kaiser, Community Health Group, L.A. Care, there’s a lot of them. They are creating D-SNPs, that’s what the MMPs are in 2026. So when you join that plan, you are joining both the D-SNP and the Medi-Cal plan. You cannot have misaligned enrollment. You can’t be in CalOptima D-SNP and Kaiser Medi-Cal plan, you need them to match. That is what exclusively aligned enrollment is. Everyone is enrolled in the same D-SNP and matching Medi-Cal plan.
Samantha Morales: Great. And another set of questions has to do with eligibility criteria for D-SNP enrollment. For example, is the ZIP code still part of the criteria for enrollment in a D-SNP?
Tiffany Huyenh- Cho: It can. They’re going to be available only in certain areas, and each D-SNP is allowed to operate in certain service areas, and that is going to be dictated by your ZIP code. So yes, that can still be a criteria for enrollment.
Samantha Morales: And an additional question around eligibility criteria for D-SNP enrollment, are enrollees with a share of cost or, for example, skilled nursing facility residents mandated to join a Medi-Cal managed care plan?
Tiffany Huyenh- Cho: That’s a great question because it is a little bit confusing. We have different rules about who must join Medi-Cal managed care in California. If you have a share of cost and live in the community and that you are not a resident of a skilled nursing facility, you cannot join a Medi-Cal managed care plan. There, you are prohibited from enrolling into a Medi-Cal managed care plan. But if you are part of a skilled nursing facility and have a shared cost, as most do in these skilled nursing facilities, you are required to join a Medi-Cal managed care plan. Long-term care became a benefit of Medi-Cal managed care plan, I think two years ago, so we’ve moved the long-term care benefit. It is now the responsibility of the Medi-Cal managed care plans. So people in skilled nursing facilities with the share of cost are required to join the Medi-Cal managed care plans for their long-term care or skilled nursing facility benefits.
Samantha Morales: Thank you, Tiffany. And since we have a few more minutes, there are a few more questions in that eligibility criteria group of questions. Can a member be enrolled in a D-SNP receive ECM or community support services?
Tiffany Huyenh- Cho: Yes and no. That, also a very good question and I think really highlights the confusing landscape that we have, but ECM or Enhanced Care Management is care management provided by Medi-Cal plans, but we don’t want duals that are in D-SNPs to get conflicting or contradictory care management by the Medi-Cal plan and by the D-SNP, because again, D-SNPs themselves already provide care management. Someone in a D-SNP is not eligible for Enhanced Care Management, because care management is being provided by the D-SNP. It’s a similar level. It’s not fully identical, but it is supposed to be equivalent level of care management. The D-SNP care management is supposed to be equivalent to Enhanced Care Management. Duals in a D-SNP are still entitled to care management, but it’s not called Enhanced Care Management. And that is going to be that new name, the California Integrated Care Management starting in 2026.
Community supports, yes, you are still entitled to those. That is provided by the Medi-Cal plan itself. And if you’re in a D-SNP, you should still be getting screened by the plan for community supports. If you feel you are not getting the community supports that you need, you can also reach out and ask the plan to screen you for them as well. But enrolling in a D-SNP should not be a barrier to getting community supports, the difference is really the Enhanced Care Management because it can be contradictory to the care management in the D-SNP itself.
Samantha Morales: Thank you, Tiffany. And just in one minute before we wrap up, and that’s a related question is, can members who are enrolled in a D-SNP also be enrolled in the Multipurpose Senior Services Program or MSSP, or would this be a duplication of services?
Tiffany Huyenh- Cho: Good one. It doesn’t bar you from being enrolled because the only criteria we have right now is around your age, your full scope, but it could potentially be considered contradictory, so there will be balancing of the MSSP and the Enhanced Care Management. And I think in the Medi-Cal only world too, MSSP is considered duplicative of Enhanced Care Management. So there is quite a bit of detail on that, and I can follow up on some of the more specifics. Fortunately, I don’t have that off the top of my head.
Samantha Morales: Thank you so much, Tiffany. And with that, I think we only have time for that last question. Thank you again for all of you for joining us today. And thank you to Tiffany, our presenter, your wealth of knowledge. And as a reminder, any questions that went unanswered today will be followed up via email and feel free to reach out to Tiffany with any additional questions if you have more questions later. Don’t forget to complete the post-webinar survey. Your feedback on these programs is important to us and have a great rest of your day. Thank you so much.
