Changes for Low-Income, Medicare-Eligible Members
Changes for Low-Income, Medicare-Eligible Members
By Rachel Brammeier
Over the next few years, low-income, Medicare-eligible members may see changes to services and care models. The government’s goal is to ensure that dual-eligible members receive both their Medicare and Medicaid benefits from a single organization, creating a more seamless, coordinated care experience through exclusively aligned enrollment (EAE).
Timeline of Events
In 2025, the government rolled out a monthly Dual Special Needs election for full dual eligible members, replacing the previous quarterly election. Clients with Medicare and Medicaid can also enroll during the initial enrollment period, when they are first eligible for Medicare; the Annual Enrollment Period (AEP) from October 15 through December 7; and the Medicare Advantage Open Enrollment Period (OEP) from January 1 through March 31.
Starting in 2026, the government will be ending Value-Based Insurance Design (VBID). This program allowed Medicare Advantage (MA) plans to offer extra benefits. These extra benefits include a $0 copay on all covered Part D prescriptions, cards to purchase healthy foods, transportation, and utilities; based on extra help or Low-Income Subsidy (LIS) eligibility. Members eligible for extra help or LIS will pay their plans for Part D cost share amount or the standard LIS copay, whichever is less.
Many plans will rely on Special Supplemental Benefits for the Chronically Ill (SSBCI) to offer extra benefits like Part D and those mentioned previously. Those who are eligible for VBID may get to keep those extra benefits with proof of a chronic condition, such as high blood pressure, diabetes, or cardiovascular disease. Verification from a Primary Care Physician (PCP) may be required on such health conditions, but some are verifying their current clients in advance. In some states, the client simply needs to attest to their chronic condition to pass this requirement. Others may be required to participate in case or care management programs to receive the extra benefits.
Once 2027 begins, all integrated Dual Special Needs Plans (D-SNPs) with an affiliated Medicaid Managed Care Organization (MCO) must have exclusive aligned enrollment (EAE). A MCO is a private health insurance company that contracts with the state to provide healthcare services to Medicaid beneficiaries. The state pays MCOs a fixed monthly rate for each Medicaid member’s care. Integrated D-SNPs will also be required to issue one integrated ID card for both Medicare and Medicaid, and perform a single Health Risk Assessment (HRA) that covers both Medicare and Medicaid services.
Medicaid and D-SNP
Covered Medicaid categories can include the following:
- Qualified Medicare Beneficiary (QMB or QMB+)
- Specified Low Income Beneficiary (SLMB or SLMB+)
- Qualified Individual (QI)
- Qualified Disabled Working Individual (QDWI)
- Full Benefit Dual Eligible (FBDE)
D-SNP Types
Fully Integrated Dual Eligible (FIDE) Special Needs Plans:
- Fully integrated, coordinating all Medicare and Medicaid benefits in one plan.
- Required to have exclusively aligned enrollment (EAE) and provide nearly ALL Medicaid services, including:
- Long-term Services and Supports (LTSS)
- Behavioral Health Services
- Home Health
- Durable Medical Equipment (DME)
Highly Integrated Dual Eligible (HIDE) Special Needs Plans:
- Required to cover EITHER long-term services and support (LTSS) or behavioral services.
- May exclude additional Medicaid services from their coverage.
Coordination Only (CO) Dual Eligible Special Needs Plans:
- Lowest level of integration.
- Meets certain minimum coordination standards, but are not required to provide a broad range of medical benefits.
Applicable Integrated Plans (AIPs):
- An AIP is a subtype of D-SNP that has more requirements for integrating care and services, including integrated appeals and grievances (all FIDE SNPs are AIPs).
Future Trends
As we continue to see a shift towards coordinated care of the dual-eligible population with a focus on FIDE and HIDE SNPs, we will see some additional market trends.
- Growth of Chronic Special Needs Plans
- Since chronic plans are not subject to the same integrated requirements, carriers may choose to focus on chronic plans to provide similar additional benefits.
- Requires a primary care physician to verify the patient has the chronic condition within a set time frame.
- A large portion of patients have a chronic condition, but it is even more prevalent in those who are 65 and above. According to the Centers for Disease Control and Prevention (CDC, 2025a), 90% of the nation’s $4.9 trillion in annual health care expenditures are for people with chronic and mental health conditions. In a separate study conducted from 2013 to 2023 by CDC (2025b), 9 in 10 older US adults (age 65 and above) reported 1 or more chronic conditions.
- Since chronic plans are not subject to the same integrated requirements, carriers may choose to focus on chronic plans to provide similar additional benefits.
- State level transitions
- States will begin efforts to transition their older population from previous state programs to integrated D-SNPs.
- Innovative care
- Artificial intelligence (AI), telehealth, and other innovative solutions will continue to immerge, with hopes to streamline and enhance healthcare and coordinated care.
Additional Resources
From the Government
CMS – Contract Year 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F)
CMS – Implementing Supplemental Benefits for Chronically Ill Enrollees
Code of Federal Regulations – Title 42, Section 422.102 Supplemental benefits
From Carriers
Aetna – From VBID to SSBCI, What you need to know
United Healthcare – 2026 Dual Special Needs plan (D-SNP) updates
Wellcare – Dual Plans and Enrollment Options
Wellcare – Frequently Asked Questions, Special Supplemental Benefit for the Chronically Ill, 2026
References
Centers for Disease Control and Prevention. (2025a). Chronic disease facts and statistics. U.S. Department of Health and Human Services. https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html
Watson, K.B., Wiltz, J.L., Nhim, K., Kaufmann, R.B., Thomas, C. W., & Greenlund, K. J. (2025b). Trends in multiple chronic conditions among US adults, by life stage, Behavioral Risk Factor Surveillance System, 2013-2023. Preventing Chronic Disease, 22, Article 240539. https://www.cdc.gov/pcd/issues/2025/24_0539.htm
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