Dual Eligible Special Needs Plans (D-SNPs) are designed to serve one of the most medically and socially complex populations: individuals eligible for both Medicare and Medicaid. But 2025 and 2026 CMS Final Rules create a wave of new regulatory requirements that significantly reshape how D-SNPs engage, retain, and support their members. These rules — from monthly Special Enrollment Period (SEP) changes to transparency, integration, and supplemental benefit requirements — intensify the need for operational alignment and member-centric strategies.
The Regulatory Landscape: What’s Changing
The 2025 Final Rule marked a significant shift in how D-SNPs manage enrollment. By moving to monthly SEPs for full-benefit dual eligibles and low-income subsidy (LIS) beneficiaries, CMS gave members twelve opportunities each year to adjust their coverage. While this policy expands flexibility and choice for enrollees, it also creates heightened disenrollment risk for plans. Alongside these changes, D-SNPs must now demonstrate greater alignment with state Medicaid programs, requiring stronger collaboration and improved data-sharing processes to minimize confusion and coverage gaps.
Looking ahead to 2026, CMS introduces even more stringent requirements. D-SNPs will be held to higher standards of integration, with a particular emphasis on Medicare–Medicaid data exchange and care coordination. Beneficiary-facing materials must also meet clearer standards for transparency, accessibility, and cultural appropriateness, with a focus on reducing disparities for members with limited English proficiency or limited access to digital platforms. Finally, plans offering supplemental benefits aimed at addressing health-related social needs will face new accountability measures, including the need to track outcomes and demonstrate return on investment. Together, these provisions raise the stakes for D-SNP leaders and amplify the operational complexity of serving dual-eligible populations.
Key Pain Points for D-SNPs
- Enrollment & Retention Pressure. With monthly SEPs, members now have 12 opportunities per year to switch plans. Without consistent engagement and clear communication, disenrollment risk spikes.
- Fragmented Medicare–Medicaid Coordination. Misaligned workflows between Medicare enrollment and state Medicaid processes create member frustration. Under 2026 rules, failure to integrate isn’t just a member experience problem — it’s a compliance risk.
- Communicating with Hard-to-Reach Members. Language barriers, limited digital access, and social instability make it difficult to connect with many D-SNP enrollees. With new CMS requirements for culturally appropriate and accessible materials, the stakes for effective communication are even higher.
- SDOH Reporting Burden. Supplemental benefits must now be tied to measurable outcomes. Plans that cannot capture, analyze, and report these data may face scrutiny while losing an important retention tool.
Why Community Health Workers Are Central to the Solution
Community Health Workers (CHWs) are uniquely suited to help D-SNPs navigate this new regulatory terrain. As trusted, culturally aligned professionals embedded in their communities, CHWs can stabilize enrollment by building relationships and ensuring members understand their coverage options during monthly SEP windows. By proactively engaging members, they reduce confusion, prevent lapses in coverage, and help mitigate disenrollment risk.
CHWs are also natural bridges between Medicare and Medicaid systems. Working in coordination with plan operations, they can serve as real-time navigators during eligibility redeterminations or coverage transitions, smoothing over the gaps that often cause members to fall through the cracks. Their community roots make them particularly effective in communicating CMS-mandated materials in ways that resonate with members. While regulatory language may be technical, CHWs can translate those requirements into plain, culturally relevant explanations that ensure comprehension.
Perhaps most importantly, CHWs can play a central role in strengthening social determinants of health programs. By screening for housing, food, transportation, and other needs, documenting referrals, and following up on outcomes, they not only support member well-being but also provide the data plans need to comply with 2026’s supplemental benefit reporting requirements. In this way, CHWs serve as both frontline problem-solvers and compliance allies.
Final Thought
Regulatory shifts don’t have to mean operational strain or member loss. With the right strategies D-SNP plans can turn regulatory challenges into opportunities for stronger integration, higher retention, and improved member well-being.
Plans need to keep members informed, engaged, and enrolled while operating under tighter timelines and resource constraints.
If you’d like to explore these approaches in more detail, let’s talk.