Dual Eligible & State Implementation on Syam Adusumilli

Medicaid Work Requirements

Sun, 15 Mar 2026 00:00:00 +0000

The One Big Beautiful Bill Act made Medicaid work requirements federal law. Starting January 1, 2027, all states must condition eligibility for the ACA expansion population on 80 hours per month of work, education, community service, or caregiving, with exemptions for populations that include the elderly, disabled, pregnant, medically frail, and caregivers of children under 14. The Congressional Budget Office estimates the provision will reduce federal Medicaid spending by more than $300 billion over ten years, primarily through coverage losses. By 2034, CBO projects 5.2 million fewer adults will have Medicaid coverage, and 4.8 million more people will be uninsured.

Summary: Medicaid Work Requirements

Sun, 15 Mar 2026 00:00:00 +0000

The One Big Beautiful Bill Act made Medicaid work requirements federal law. Starting January 1, 2027, all states must condition eligibility for the ACA expansion population on 80 hours per month of work, education, community service, or caregiving. The Congressional Budget Office estimates the provision will reduce federal Medicaid spending by more than $300 billion over ten years, primarily through coverage losses. By 2034, CBO projects 5.2 million fewer adults will have Medicaid and 4.8 million more will be uninsured. The dual eligible population, approximately 12 million people receiving both Medicare and Medicaid, sits at the intersection of these requirements in ways the legislative debate largely ignored.

The FAI Is Dead

Sun, 15 Mar 2026 00:00:00 +0000

The Financial Alignment Initiative ended on December 31, 2025, after more than a decade of testing whether integrated Medicare-Medicaid financing could improve care and reduce costs for dual eligible beneficiaries. Authorized under Section 3021 of the Affordable Care Act and administered through CMMI, the FAI launched in 2013 as the federal government’s most ambitious attempt to solve the structural problem at the center of dual eligible care: two separate programs, two separate payment streams, two separate regulatory frameworks, and no single entity accountable for the whole person.

Summary: The FAI Is Dead

Sun, 15 Mar 2026 00:00:00 +0000

The Financial Alignment Initiative ended December 31, 2025, after more than a decade of testing whether integrated Medicare-Medicaid financing could improve care and reduce costs for dual eligible beneficiaries. Thirteen states participated at the demonstration’s peak. Ten tested a capitated model through Medicare-Medicaid Plans operating under three-way contracts among CMS, the state Medicaid agency, and the health plan. At enrollment height, approximately 470,000 beneficiaries participated. The FAI was never certified for expansion under CMMI’s statutory standard. The population it served remains, and FIDE SNPs are now the primary vehicle expected to carry integration forward.

Dual Eligible Integration

Sun, 15 Mar 2026 00:00:00 +0000

Three tiers of D-SNP integration now exist in the Medicare Advantage market, and CMS is systematically pushing the entire landscape upward toward the highest tier. Coordination-only D-SNPs, the baseline category that dominated the market for years, are being phased into irrelevance through enrollment restrictions and regulatory tightening. Highly Integrated D-SNPs and Fully Integrated D-SNPs, together with the Applicable Integrated Plan designation, represent the regulatory future. Between 2025 and 2027, a series of rulemaking actions will fundamentally restructure which plans can enroll dual eligibles, how enrollment flows between Medicare and Medicaid managed care, and which organizations have the operational capacity to compete in this market.

Summary: Dual Eligible Integration

Sun, 15 Mar 2026 00:00:00 +0000

Three tiers of D-SNP integration now exist in the Medicare Advantage market, and CMS is systematically pushing the entire structure upward toward the highest tier. Coordination-only D-SNPs, the baseline category that dominated for years, are being phased into irrelevance. HIDE SNPs and FIDE SNPs, together with the Applicable Integrated Plan designation, represent the regulatory future. Between 2025 and 2027, a series of rulemaking actions will restructure which plans can enroll dual eligibles, how enrollment flows between Medicare and Medicaid managed care, and which organizations have the operational capacity to compete.

State-by-State Analysis

Sun, 15 Mar 2026 00:00:00 +0000

This is the companion to MCR-02.06, the state-by-state rate impact analysis. Where that article covers the rate and risk adjustment environment across the top 20 Medicare markets, this article covers the dual eligible landscape, state Medicaid policy, and integration infrastructure for the same 20 states. Together, the two state-by-state articles provide the geographic reference framework for the series. The 20 states profiled here account for the vast majority of the nation’s approximately 12.8 million dual eligible beneficiaries and the overwhelming share of D-SNP enrollment.

Summary: State-by-State Analysis

Sun, 15 Mar 2026 00:00:00 +0000

The 20 states profiled in this analysis account for the vast majority of the nation’s approximately 12.8 million dual eligible beneficiaries and the overwhelming share of D-SNP enrollment. A dual eligible in New York has access to FIDE SNPs, AHEAD-participating hospitals, and a mature Medicaid managed care system. A dual eligible in rural Texas may have access to a single coordination-only D-SNP, no PACE program, and a state that has not expanded Medicaid. Both are dual eligibles. Their integration options bear no resemblance to each other. The variation is primarily a function of state Medicaid agency decisions rather than federal requirements.

Medicare Savings Programs

Sun, 15 Mar 2026 00:00:00 +0000

Medicare Savings Programs pay some or all of a beneficiary’s Medicare premiums and cost-sharing. Enrollment in an MSP automatically qualifies the beneficiary for the Part D Low Income Subsidy. Together, the Medicare Rights Center estimates that MSP and LIS enrollment saves each individual at least $8,400 annually in out-of-pocket health care costs. Enrollment has never exceeded 60 percent of the eligible population. Millions of Medicare beneficiaries who qualify for these programs do not receive them, and the legislation that was designed to fix the enrollment problem has been frozen for a decade.

Summary: Medicare Savings Programs

Sun, 15 Mar 2026 00:00:00 +0000

Medicare Savings Programs pay some or all of a beneficiary’s Medicare premiums and cost-sharing. MSP enrollment automatically qualifies the beneficiary for the Part D Low Income Subsidy. Together, the Medicare Rights Center estimates that MSP and LIS enrollment saves each individual at least $8,400 annually. Enrollment has never exceeded 60 percent of the eligible population. Millions who qualify do not receive these benefits, and the legislation designed to fix the enrollment problem has been frozen for a decade.

PACE at a Crossroads

Sun, 15 Mar 2026 00:00:00 +0000

PACE is the only model that fully integrates Medicare and Medicaid financing under a single capitation for community-dwelling, nursing-home-eligible adults. As of the end of 2025, approximately 90,580 participants were enrolled across 194 organizations operating more than 376 centers in 32 states. Enrollment grew 12 percent in 2025 alone, with existing programs accounting for 91 percent of that growth. The program has been “about to scale” for twenty years. The end of the FAI, the FIDE SNP build-out, and MA market volatility may have finally created the conditions for meaningful expansion. The structural barriers that have constrained PACE for decades have not disappeared.

Summary: PACE at a Crossroads

Sun, 15 Mar 2026 00:00:00 +0000

PACE is the only model that fully integrates Medicare and Medicaid financing under a single capitation for community-dwelling, nursing-home-eligible adults. As of late 2025, approximately 90,580 participants were enrolled across 194 organizations operating more than 376 centers in 32 states. Enrollment grew 12 percent in 2025, with existing programs accounting for 91 percent of that growth. The program has been “about to scale” for twenty years. The end of the Financial Alignment Initiative, the FIDE SNP build-out, and MA market volatility may have created the conditions for meaningful expansion. The structural barriers that have constrained PACE for decades have not disappeared.