Growth of Dual-Eligible Special Needs Plans Following Permanent Authorization

ABSTRACT

Objective: To examine trends in Dual-Eligible Special Needs Plan (D-SNP) offerings and enrollment before and after permanent authorization in 2018.

Study Design: Retrospective descriptive analysis.

Methods: We analyzed publicly available monthly SNP Comprehensive Reports, comparing preauthorization (2010-2018) and postauthorization (2019-2025) periods. We calculated annual totals of D-SNPs and enrollees along with mean annual growth rates for both periods.

Results: The mean annual growth rate of unique D-SNP offerings increased from 10.0% preauthorization to 16.2% post authorization. Enrollment of dually eligible beneficiaries increased from a mean annual growth rate of 0.3% preauthorization to 12.8% post authorization. D-SNP enrollment has steadily increased, more than doubling over the past 5 years. By January 2025, there were 986 D-SNPs with 6,030,665 dual enrollees, representing approximately 44% of total dual enrollees.

Conclusions: The significant acceleration in both D-SNP offerings and enrollment reflects notable changes in the D-SNP market following permanent authorization. As states transitioned plans into D-SNPs through 2025, these specialized Medicare Advantage plans are positioned to play an increasingly vital role in addressing the complex needs of Medicare-Medicaid dual enrollees.

Am J Manag Care. 2026;32(4):e133-e137. https://doi.org/10.37765/ajmc.2026.89926

Takeaway Points

The permanent authorization of Dual-Eligible Special Needs Plans (D-SNPs) in 2018 marked a significant long-term commitment by policy makers to integrate care for enrollees who are eligible for both Medicare and Medicaid, signaling stability and certainty to the market. However, the rising demand for specialized care among dual enrollees requires careful oversight to ensure quality and access to care.

• The mean annual growth rate of plan offerings nearly doubled after permanent authorization, increasing from 10.0% to 16.2%.
• The mean annual growth rate of dual enrollees surged after permanent authorization, increasing from 0.3% to 12.8%.
• By January 2025, there were 986 D-SNPs with approximately 6.03 million Medicare-Medicaid dual enrollees (representing approximately 44% of total dual enrollees).

Dually eligible enrollees (13.6 million in 2022)¹ represent only 20% of Medicare and 13% of Medicaid beneficiaries, yet they account for a disproportionate share of spending in both programs (36% of Medicare expenditures and 27% of Medicaid expenditures).¹ Medicare is the primary payer for most hospital, physician, and prescription drug services, whereas Medicaid often covers cost sharing as the secondary payer and other non–Medicare-covered services (eg, long-term care). This division of coverage can lead to fragmented care and misaligned incentives between the programs.^2,3 The separation of physical health and long-term care coverage between Medicare and Medicaid can create opportunities for cost shifting between programs, and lack of financial alignment hinders meaningful care integration.^2,3

Dual-Eligible Special Needs Plans (D-SNPs), authorized in 2003 and operational since 2006, are specialized Medicare Advantage (MA) SNPs designed to meet the complex needs of dual enrollees. Congressional action was required for SNPs to continue operating; therefore, from 2006 to 2017, the SNP market operated under temporary authorizations lasting 1 to 3 years (eAppendix Figure 1 [eAppendix available at ajmc.com]).^4-10 In 2010, the newly established Medicare-Medicaid Coordination Office aimed to streamline processes and services for dual enrollees, and in 2013, select states began demonstration projects under the Financial Alignment Initiative called Medicare-Medicaid Plans (MMPs)—also known as the dual eligible demonstration.⁶ These are not SNPs, but rather tests of integrated care models to improve care for dual enrollees and reduce program costs by aligning financing and coordinating care.¹¹ As early as 2013, the Medicare Payment Advisory Commission (MedPAC) cautioned Congress against reauthorizing all SNPs (based on evaluation findings) and instead recommended that all institutional SNPs and only highly integrated D-SNPs should be permanently authorized and that chronic SNPs should be limited to a small number of conditions.¹² In 2017, the House of Representatives passed a bill (HR 3168) that permanently authorized institutional SNPs but required reauthorization every 5 years for D-SNPs and chronic SNPs.¹³ During this time, many advocacy organizations urged Congress to permanently authorize all MA SNPs, arguing short-term renewals discouraged health plans from leveraging earlier investments and hindered their ability to commit to large-scale innovations in SNPs.^14,15 They claimed that permanent authorization would provide the stability necessary to spur private-sector investment. Advocates also noted Congressional Budget Office estimates showing permanent authorization would cost only $4 million more than a 5-year SNP reauthorization,¹⁵ representing a more fiscally responsible approach.

On February 9, 2018, the 115th Congress passed the Bipartisan Budget Act of 2018, which permanently authorized all 3 types of SNPs (ie, D-SNPs, chronic SNPs, and institutional SNPs).¹⁶ Permanent authorization of D-SNPs included new requirements for enhanced coordination between states and the federal government, with a focus on unifying appeal and grievance protocols, by 2021.^16-18 Under this act, MedPAC is required to provide a status report—every 2 years from 2022 to 2032 and every 5 years thereafter—to Congress on the performance of Medicare managed care plans with varying integration serving dual eligibles.¹⁹ The permanent authorization of SNPs—a major policy change—provided long-term stability to the D-SNP market, spurring significant growth.

D-SNPs have emerged as the primary care management model for dual enrollees, gaining popularity among state Medicaid agencies. By 2021, 29% of dual eligibles were enrolled in D-SNPs.²⁰ In the 5 years from 2020-2024, growth of D-SNPs ranged from 8% to 16% annually²¹ and outpaced growth of general MA plans (7%).²² Growth rates for both, however, slowed in 2024 and 2025.^21,23 Existing descriptive publications on D-SNPs describe trends and/or the MA landscape, but none have focused on the 2018 permanent authorization.^1,20-24 In this study, we examined the growth trajectory of D-SNPs and enrollment trends over time, with a focus on the 2018 policy change granting permanent authorization of D-SNPs, to observe how plan offerings and enrollment changed afterward.

METHODS

Design

This retrospective descriptive study examined trends in D-SNP offerings and enrollment using publicly available data. The University of Minnesota Institutional Review Board determined that this study was not human participants research.

Data

Plan information for dual enrollees is typically obtained from Medicare Part D prescription drug coverage landscape files; however, these files lack enrollment data. To address this limitation, we used Special Needs Plan Data from CMS.²⁵ The monthly SNP Comprehensive Reports provide data on Medicare and Medicaid health plan enrollment (by state, county, contract, and other variables). Reports from May 2007 to the current month are publicly available from the CMS website.

For this study, we included 2010-2025 data for enrollees residing in all 50 states, the District of Columbia, and Puerto Rico. Any SNP with enrollment of fewer than 11 beneficiaries is suppressed in the data and was not assigned to any state or contract. Any contract with a plan operating in multiple states (ie, more than 1 state for values of “state[s]”) or with missing values was not assigned to any state (4 plans total).

Descriptive Analysis

We examined the growth in the number of D-SNPs and dual-eligible enrollment using cumulative enrollment data at the beginning of each calendar year (ie, January). Calculating annual changes based solely on January enrollment data can be restrictive because dual-eligible beneficiaries can enroll or switch plans during the year; however, our method aligns with previous approaches.²⁶ We excluded data years 2007 to 2009 because there was a moratorium on SNPs for 2 years.⁴ To examine trends in plan offerings and enrollment, we counted the total number of plans and enrollees and calculated annual changes in both. We also calculated the mean annual growth rate before (2010-2018) and after (2019-2025) permanent authorization. We included the year of policy change (ie, 2018) in the “before” category because contracts for 2018 would have been in place before the year began. All analysis were conducted using SAS 9.4 (SAS Institute Inc) and Stata 17.4 (StataCorp LLC).

RESULTS

We present trends in D-SNP offerings and enrollment over time in Figure 1 (A). The growth rate of D-SNPs fluctuated significantly from 2010 to 2016, from a high of 14.3% in 2013 to a negative growth rate of –15.6% in 2010. The highest growth rate (21.4%) was observed in 2019 (the year after permanent authorization). Although plan growth has stayed positive since 2016, it has slowed in recent years. In contrast, the growth rate of D-SNP enrollees has consistently remained positive, with the highest annual growth rate of 22.1% recorded in 2022. However, like plan offerings, the growth in dual enrollees has also slowed in recent years, with a low growth rate (3%) observed in January 2025. These variations in growth trends appear to coincide with the permanent authorization of D-SNPs in 2018 and with sunsetting of MMPs beginning in 2023. The mean annual growth rate of plan offerings substantially increased from 10.0% before permanent authorization to 16.2% afterward (Figure 1 [B]). Enrollment of dual eligibles in D-SNPs surged over the past 7 years (2019-2025), with an mean annual growth rate of 12.8%. This growth is particularly striking compared with the period before permanent authorization, during which the mean annual growth of dual enrollees in D-SNPs was only 0.3%. As a sensitivity analysis, we excluded 2018 from the “before” category and our results were similar.

We display the total number of D-SNPs offered by year in Figure 2 (A). Plan offerings slightly declined between 2013 and 2015 (from 384 to 352 plans), likely due to the introduction of MMPs (eAppendix Figure 1). Since 2018, the number of D-SNPs has steadily increased, reaching 986 plans by January 2025. Florida had the most D-SNPs (n = 114), followed by Texas (n = 79), New York (n = 61), California (n = 43), Georgia (n = 36), and Puerto Rico (n = 36) (eAppendix Figure 2). Similarly, the total number of D-SNP enrollees has been increasing (Figure 2 [B]). Following permanent authorization in 2018, enrollment surged significantly, reaching 6,030,665 dual enrollees as of January 2025 (approximately 44% of estimated total dual enrollees¹).

DISCUSSION

Our analysis offers several new insights about the D-SNP landscape. First, the permanent authorization of SNPs in 2018 coincided with a substantial increase in the rate of D-SNP growth and enrollment. Second, fluctuations in plan offerings and dual enrollees in D-SNPs correspond to key federal policies. Notably, our findings show a subsequent decline in D-SNP growth in 2014 and 2015, coinciding with the launch of the MMP demonstration in 2013, when 15 states began participating. In states with both MMP demonstrations and D-SNPs in the same market, dual enrollees were likely redirected from D-SNPs to MMPs.²⁷ We observed a flat D-SNP enrollee growth rate in 2014, while rates declined in 2015 and 2016. Additionally, the CMS announcement of the 3-year phaseout of MMPs also seems to coincide with decreased growth rates in D-SNP offerings and enrollment, especially in 2025 (last year of transition).

Whereas previous reports have primarily focused on data from the past 5 years or so, our analysis provides a comprehensive view of D-SNPs by presenting their full historical trajectory from 2010 to 2025. This broader perspective allows us to contextualize recent trends within the long-term evolution of D-SNPs, offering a more nuanced understanding of the impact of policy changes on these specialized MA plans. Our study builds on existing literature by examining whether permanent authorization of SNPs in 2018 coincided with a rise in D-SNP offerings and enrollment. To our knowledge, this is the first study to focus on this major policy change. Tracing the evolution of D-SNPs requires understanding notable policy changes, including MA policies, and their impact on plan offerings and enrollment. Before 2010, enrollment in D-SNPs was relatively modest (June 2008: n = 854,877) despite the increase in number of plans (from 42 in 2005 to 439 in 2008).²⁸ Several changes to MA plans since 2019 may have increased their attractiveness to Medicare beneficiaries, such as expanded non-Medicare supplemental benefits (eg, meals, transportation)²⁹ and a new MA open enrollment period for the first 3 months of each calendar year (“try before you buy”).³⁰ MedPAC reported that between 2018 and 2023, the mean number of MA plans available to beneficiaries increased more than 2-fold and acknowledged the entry of new MA insurers.²⁹ Other prior research has also examined plan offerings and enrollment trends in D-SNPs using other publicly reported data (eg, CMS prescription drug coverage, as dual eligibles are automatically enrolled in Medicare Part D) and reported similar growth in plans.^20,21,23 Milliman reported the annual growth of D-SNPs as approximately 14.6% in 2020, 10.7% in 2021, 17.1% in 2022, 12.9% in 2023, 7.8% in 2024, and 6.3% in 2025.^21,23 In our analysis, we also note the declining growth rate of D-SNP offerings after 2022. KFF studies highlight the footprints of large MA organizations by state over time as well as variation in D-SNP enrollment by state.²⁰ Compared with 2018, the number of D-SNPs offered by every major insurer increased in 2024.²⁰

Policy changes, such as the phaseout of MMPs in 2025, are likely to further influence both the national and state D-SNP landscapes. Most states are expected to transition their MMPs to D-SNPs.³¹ California ended MMPs and transitioned to D-SNPs in January 2023.²¹ Recent regulatory requirements for D-SNPs may be impacting another sharp rise in new D-SNP offerings^21,23; however, plan growth rates continued to stay positive in 2025, similar to enrollment of dual eligibles. More research is warranted to understand how state-specific policies affect local D-SNP markets and how plan offerings relate to the number of dual enrollees in each state. As the share of dual enrollees in D-SNPs continues to increase (approximately 44% as of January 2025),¹ policy makers must also consider whether dual enrollees are placed in integrated or nonintegrated D-SNPs. In 2024, coordination-only (nonintegrated) D-SNPs dominated the market (65%) compared with highly integrated D-SNPs (27%) and fully integrated D-SNPs (8%).²³ Dual enrollees are more racially and ethnically diverse and experience complex aging needs and social vulnerabilities at higher levels than those enrolled in Medicare alone.²⁴ Long-standing concerns of poor coordination, challenges in navigating 2 separate programs, and fragmented care underscore the need for integrated D-SNPs.³ Future studies should consider how Medicare-Medicaid integration under D-SNPs is shaped by the permanent authorization enacted in 2018 and the phaseout of integrated MMPs in 2025.

Limitations

This study had several limitations. The primary limitation is that although we found extensive growth in plan offerings and D-SNP enrollment immediately following the 2018 permanent authorization policy change, we cannot conclude that it was causal. Other MA policy changes likely contributed to the change in D-SNP landscape. Additionally, SNP Comprehensive Reports do not include characteristics of beneficiaries, limiting our ability to describe dual enrollees in D-SNPs.

CONCLUSIONS

The permanent authorization of D-SNPs in 2018 marked a significant long-term commitment by policy makers to integrate care for dual enrollees, signaling stability and certainty to the market. Since then, the D-SNP market has experienced accelerated growth in both plan offerings and enrollment. 

Author Affiliations: Division of Health Policy and Management, School of Public Health, University of Minnesota (RD, SN, PJH, HMP), Minneapolis, MN.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RD, HMP); acquisition of data (RD); analysis and interpretation of data (RD, PJH, HMP); drafting of the manuscript (RD, SN, HMP); critical revision of the manuscript for important intellectual content (RD, SN, PJH, HMP); statistical analysis (RD); administrative, technical, or logistic support (SN); and supervision (SN, PJH, HMP).

Address Correspondence to: Roshani Dahal, MPH, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN 55455. Email: daha0007@umn.edu.

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