Strengthening Medicare-Medicaid Integration: NAMD’s Recommendations on Proposed CMS Duals Policies

This snapshot provides a high-level overview of NAMD’s comments on CMS’ proposed rule addressing Medicare Advantage and Part D policy changes that affect individuals dually eligible for Medicare and Medicaid. For a more detailed analysis, read NAMD’s full comments here.

Background: Why These Policies Matter

Individuals who are dually eligible for Medicare and Medicaid must navigate two separate programs with different rules, benefits, and administrative structures, which can contribute to fragmented care and inconsistent access to services. To help address these challenges, Congress created Special Needs Plans (SNPs) in the Medicare Advantage program, including Dual Eligible Special Needs Plans (D-SNPs), to better coordinate care, benefits, and enrollment for high-needs populations. Over time, CMS has strengthened D-SNP requirements to promote better Medicare–Medicaid alignment and ensure meaningful state oversight of these plans through state Medicaid agency contracts (SMACs). Integrated SNPs are generally operated by the same umbrella organization that also runs a Medicaid managed care plan, allowing for closer coordination across Medicare and Medicaid benefits for a beneficiary served by both programs, while non-integrated SNPs do not have this same level of alignment.

NAMD’s Policy Perspective

The proposed rule builds on CMS’ prior efforts to strengthen Medicare–Medicaid integration by:

• updating administrative processes,
• addressing potential enrollment disruptions, and
• examining trends in the growth of non-integrated special needs plans serving dually eligible individuals.

NAMD supports many of the policies proposed in this rule, including changes to Model of Care submission timing and targeted updates to passive enrollment and alignment policies, which reflect CMS’ continued focus on improving care coordination for dually eligible individuals. States and territories have made substantial investments in D-SNPs to reduce fragmented care, improve coordination across Medicare and Medicaid benefits, and promote aligned enrollment.

At the same time, Medicaid agencies operate in diverse delivery system environments, with variation in managed care structures, provider capacity, and levels of integration. In particular, Medicaid programs that operate in managed fee-for-service environments do not have access to the same set of levers to integrate care for dually eligible individuals. As CMS considers these policies, NAMD encourages flexibility to ensure they can be implemented across a wide range of state and territorial contexts and tailored to local program structures and member needs.

Overview of Key Proposed Policies and NAMD Feedback

Model of Care (MOC) Off Cycle Submission Timing: CMS proposes replacing the current MOC off-cycle submission window with two defined submission periods per contract year. NAMD and Medicaid agencies support this change, noting that it would reduce administrative overlap between initial, renewal, and off-cycle submissions while preserving sufficient time for plans to update care coordination approaches.

Passive Enrollment Policies: CMS proposes changes to passive enrollment requirements intended to make this authority more operational when integrated plans exit a market. NAMD supports CMS’ goal of preventing gaps in coverage for dually eligible individuals during these transitions. Some Medicaid agencies expressed concerns that removing the “substantially similar” network requirement, which currently helps ensure that receiving plans include a comparable set of providers, combined with a 120-day continuity-of-care period, could affect access to care for individuals with complex needs. NAMD encourages CMS to preserve flexibility for Medicaid agencies to address network adequacy and continuity-of-care considerations based on local delivery system conditions.

Continuity of D-SNP Enrollment in Medicaid Fee-for-Service States and Territories: CMS proposes adjustments to prior alignment policies to avoid unintended disruptions in states with voluntary Medicaid managed care and in the territories. NAMD appreciates CMS’ consideration of the unique Medicaid and Medicare program structures and financing arrangements in the territories, including the proposed exemptions for these jurisdictions.

D-SNP Contract Termination Authority: CMS proposes clarifying its authority to immediately terminate a D-SNP’s Medicare contract when the required state Medicaid agency contract ends. NAMD does not have concerns with this proposal and supports CMS’ aim of protecting members and maintaining program integrity when state Medicaid contracts are no longer in place, though we recommend CMS align Medicare contract termination dates with SMAC contract termination dates.

Request for Information: C-SNPs and I-SNPs: CMS seeks input on the growth of Chronic Condition Special Needs Plans (C-SNPs) and Institutional Special Needs Plans (I-SNPs) enrolling dually eligible individuals. Medicaid agencies support CMS’ interest in strengthening oversight of non-integrated products and better understanding how these plans interact with state integration strategies. At the same time, Medicaid agencies emphasize the importance of approaches that advance integration while reflecting variation in state capacity, delivery systems, and existing oversight structures.

Moving Forward

NAMD appreciates CMS’ continued partnership and commitment to improving care for dually eligible individuals. As CMS finalizes these policies, Medicaid agencies look forward to continued collaboration to advance integrated care while preserving the flexibility needed to reflect diverse state and territorial contexts.