D-SNP integration: SMACs, EAEs, and what changed

The move toward more integrated D-SNPs

A Dual Eligible Special Needs Plan (D-SNP) is a type of Medicare Advantage plan for people enrolled in both Medicare and Medicaid. Because these members get coverage from two programs with different rules, benefits, and appeals systems, care is easily fragmented. The policy goal behind integration is to stitch the two programs together so that, from the member's point of view, there is one plan, one card, one set of benefits, and one process for problems.

CMS classifies D-SNPs along a spectrum of integration. At one end are coordination-only (CO) D-SNPs, which coordinate Medicaid benefits but do not cover them directly. In the middle are Highly Integrated Dual Eligible SNPs (HIDE SNPs), and at the integrated end are Fully Integrated Dual Eligible SNPs (FIDE SNPs), which cover Medicare and Medicaid benefits, including long-term services and supports, through the same organization. The direction of travel across recent rulemaking is unmistakable: CMS wants more plans further along that spectrum, and it is using contract requirements, enrollment rules, and unified processes to get them there.

State Medicaid Agency Contracts (SMACs)

Every D-SNP must have an executed contract with the state Medicaid agency in each state it operates. This is the State Medicaid Agency Contract, the SMAC, sometimes called the MIPPA contract after the statute that requires it. Without a SMAC, a plan cannot operate as a D-SNP. It is the foundational document of the whole arrangement.

The SMAC is where integration gets real, because it is the instrument states and CMS use to raise the bar. SMACs must meet Medicare-Medicaid integration requirements, and for certain D-SNPs they must include unified appeals and grievance processes. States use the SMAC to define the plan's Medicaid responsibilities, the populations it serves, care coordination expectations, data-sharing obligations, and increasingly the integration standards the plan must meet to keep operating. Because the SMAC is negotiated state by state on an annual cycle, a plan operating in multiple states is managing multiple contracts, each with its own requirements and its own renewal timeline. For a new entrant, securing the SMAC is not a formality to complete after the network is built; it is a gating relationship that shapes what the network has to include.

Exclusively Aligned Enrollment (EAE)

Exclusively Aligned Enrollment (EAE) is the mechanism that ties a member's Medicare and Medicaid coverage to the same parent organization. Under EAE, a D-SNP only enrolls members who are also enrolled in an affiliated Medicaid managed care plan operated by the same organization. The member's Medicare and Medicaid live under one roof, which is what makes true integration, one care team, one set of benefits, one process, possible.

EAE is central to the strongest form of integration. Beginning in plan year 2025, all FIDE SNPs are required to have exclusively aligned enrollment, which in turn makes every FIDE SNP an Applicable Integrated Plan. To support members moving into integrated coverage, CMS also established an Integrated Care Special Enrollment Period effective January 2025, which lets full-benefit dually eligible individuals elect an integrated D-SNP to align their coverage. EAE is powerful but demanding: it only works if you actually operate the affiliated Medicaid plan, which means the Medicare and Medicaid sides of your organization have to be built and aligned together, not bolted on afterward.

Applicable integrated plans and unified processes

An Applicable Integrated Plan (AIP) is a D-SNP that is integrated enough to be held to unified member-facing processes, most importantly a unified appeals and grievance process that spans Medicare and Medicaid. Instead of a member facing two separate appeals tracks with different rules and deadlines when a service is denied, an AIP runs one integrated process. From the member's side, there is a single way to raise a problem and a single way it gets resolved.

AIP status carries concrete obligations that shape day-to-day operations.

• Unified appeals and grievances: one integrated process covering both Medicare and Medicaid benefits, with aligned notices, timeframes, and continuation-of-benefits rules.
• Integrated member materials: CMS and certain states jointly develop integrated model materials for use by AIP D-SNPs, so member communications present the two programs as one.
• Aligned enrollment foundation: because all FIDE SNPs became AIPs with exclusively aligned enrollment in 2025, AIP status generally presumes the enrollment and organizational alignment underneath it.
• Cross-program coordination: care coordination, prior authorization, and benefit determinations have to work across the Medicare-Medicaid line rather than in two silos.

What the recent CMS rules require

The Contract Year 2025 Medicare Advantage and Part D final rule is the pivot point. It advanced several provisions aimed at simplifying options for dually eligible members and pushing D-SNPs and Medicaid managed care organizations into closer alignment. Two changes stand out for planning purposes.

First, from plan year 2025, all FIDE SNPs must operate with exclusively aligned enrollment and therefore function as applicable integrated plans, cementing full integration at the top of the spectrum. Second, the rule adopted enrollment provisions at Section 422.514(h) that, effective beginning in 2027, limit enrollment in certain D-SNPs to individuals who are also enrolled in an affiliated Medicaid managed care organization, and cap the number of D-SNP plan benefit packages an organization can offer in the same service area as its affiliated Medicaid plan. The practical effect is a market that rewards organizations operating both the Medicare and Medicaid sides in a service area and constrains those running a D-SNP without the aligned Medicaid plan behind it. If you are entering the D-SNP market now, you are entering a landscape that is being reshaped to favor integration, and building to the old coordination-only model risks being out of step with where the rules are taking the program.

Network and operational implications

Integration is not just a compliance filing; it changes what your plan has to be able to do. On the network side, a genuinely integrated D-SNP has to cover Medicaid-domain services that a coordination-only plan could largely leave to the state, most notably long-term services and supports and, in integrated arrangements, behavioral health. That means contracting nursing facilities, home and community-based services providers, personal care agencies, and behavioral health organizations, provider types a Medicare-only network build simply does not include. Your network adequacy work now spans two programs' worth of provider types and standards.

Operationally, the demands run just as deep. Exclusively aligned enrollment only functions if your Medicare and Medicaid membership systems, care management, and provider data are aligned so that a member is recognized as the same person on both sides. Unified appeals and grievances require processes, notices, and staff trained to handle a single integrated track rather than two parallel ones. The SMAC in each state adds its own reporting, data-sharing, and care-coordination obligations that have to be operationalized, not just signed. And because SMACs and integration requirements evolve annually and vary by state, this is a program you have to actively maintain, not stand up once.

This is where we work with D-SNP plans and new entrants. We map the integration requirements that apply to your specific footprint, build the LTSS and behavioral health network that integrated status demands, align the enrollment and appeals operations that EAE and AIP status require, and structure the state relationship behind the SMAC so it holds up year over year. The plans that treat integration as a structural build, done early and done deliberately, are the ones positioned to thrive as CMS keeps tightening the standard. The plans that treat it as paperwork are the ones scrambling when the next rule lands.