State-by-State Analysis

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.

Analytic Framework

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Each state profile addresses the same set of questions. What is the size of the dual eligible population relative to total Medicare enrollment? What integration tier do the state’s D-SNPs operate at, and is FIDE or HIDE SNP infrastructure available? Has the state expanded Medicaid under the ACA, and how does OBBBA’s FMAP reduction for expansion populations affect fiscal sustainability? What is the state’s posture on work requirement implementation, including whether it is pursuing early implementation through a Section 1115 waiver or relying on the January 2027 federal deadline? Is the state an AHEAD participant? Does PACE operate in the state, and at what scale? And finally, what is the state Medicaid managed care landscape, meaning which organizations hold D-SNP contracts and how concentrated or fragmented is the MCO market?

The answers vary enough across these 20 states to produce fundamentally different operating environments for plans, providers, and beneficiaries. A dual eligible in New York has access to FIDE SNPs, AHEAD-participating hospitals, and a robust Medicaid managed care system. A dual eligible in rural Texas may have access to a single CO D-SNP, no PACE program, and a state that has not expanded Medicaid. Both are dual eligibles. Their care integration options bear no resemblance to each other.

Tier 1: Largest Dual Eligible Markets

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Florida leads the nation in D-SNP enrollment and has one of the most competitive MA markets in the country. The state has not expanded Medicaid, which limits its dual eligible population to those qualifying through aged or disability pathways. Despite the non-expansion status, Florida’s dual eligible population exceeds 800,000 and supports a D-SNP market dominated by Humana, UnitedHealthcare, and Aetna alongside regional players. The state’s Medicaid managed care landscape is fragmented across multiple managed care regions with different MCO assignments, which complicates exclusively aligned enrollment. Florida automatically aligns Medicaid MCO enrollment to match D-SNP selection, a policy that facilitates integration but does not guarantee FIDE-level coordination. HIDE and AIP D-SNPs are available in multiple counties, though CO D-SNPs remain the majority of plans. Florida has no AHEAD participation and limited PACE availability relative to its population. Work requirements will apply to the expansion population under OBBBA; because Florida has not expanded Medicaid, the direct work requirement impact falls on a narrower population than in expansion states, but the six-month renewal cycle applies to all Medicaid enrollees.

California operates the most complex dual eligible integration landscape in the country. CalAIM, the state’s 2022 Medicaid transformation, restructured Medi-Cal managed care around population health, behavioral health integration, and community supports. California’s dual eligible population exceeds 1.5 million, the largest in the nation. The state participated in the FAI through Cal MediConnect, which ended in 2023, earlier than most other FAI states. The successor D-SNP model uses aligned enrollment between Medi-Cal managed care plans and D-SNPs, with several counties now offering plans that integrate Medicare and Medi-Cal benefits under a single parent organization. PACE operates in California at larger scale than in most states, with multiple PACE organizations across the state. California expanded Medicaid and extended Medi-Cal coverage to all income-eligible adults regardless of immigration status through 2025, though OBBBA’s provisions restrict new enrollment by undocumented individuals starting in 2026. The state is not pursuing early work requirement implementation.

Texas has the third-largest dual eligible population nationally, exceeding 600,000, and a Medicare market shaped by its non-expansion status, vast rural geography, and WISeR state designation under CMMI’s prior authorization model. Texas transitioned its FAI Medicare-Medicaid Plans into HIDE SNPs at the end of 2025. The state’s Medicaid managed care system operates through STAR+PLUS, which covers acute and LTSS for aged and disabled populations. D-SNP availability is concentrated in urban counties, with significant gaps in rural West Texas, the Panhandle, and the Rio Grande Valley. Texas automatically aligns Medicaid MCO assignment with D-SNP enrollment. The state’s non-expansion status and large uninsured population mean that many low-income Texans who would be dual eligible in expansion states are instead uninsured or covered only through limited state programs. PACE operates in a small number of Texas markets. Texas submitted an early work requirement waiver application in 2025 and is positioned for implementation ahead of the federal deadline.

New York has the most established FIDE SNP infrastructure of any state. The state’s dual eligible population exceeds 875,000, and its Medicaid managed care system has operated at scale for decades. New York participated in the FAI through two demonstrations: FIDA, which ended in 2019, and FIDA-IDD for individuals with intellectual and developmental disabilities, which continued through the demonstration’s end. The successor FIDE SNPs build on that infrastructure. Multiple New York counties participate in AHEAD, creating an overlapping accountability structure where AHEAD hospitals bear total cost of care risk for attributed Medicare beneficiaries who may also be enrolled in FIDE SNPs. The state’s Medicaid managed care landscape includes major plans like UnitedHealthcare, Fidelis Care, Healthfirst, and MetroPlus, several of which operate aligned D-SNPs. New York expanded Medicaid, eliminated the MSP asset test, and set income limits for Medicare Savings Programs above the federal minimum. PACE operates in New York but at modest scale relative to the dual eligible population. The state is not pursuing early work requirement implementation.

Pennsylvania presents a payvider case study. UPMC, operating as both insurer and provider, has significant D-SNP presence through its Community HealthChoices Medicaid managed care contracts and affiliated Medicare Advantage plans. The state’s Medicaid managed care consolidation through Community HealthChoices reshaped the LTSS landscape, and the aligned D-SNPs use the integrated care SEP to promote enrollment. Pennsylvania lost its FIDE SNP designation in 2025 because the state’s behavioral health carve-out conflicted with the updated FIDE definition requiring behavioral health coverage within the plan. This means Pennsylvania’s D-SNPs operate at the HIDE or AIP level, but not FIDE, until the state addresses the behavioral health carve-out. Rural dual eligible access remains a challenge in the state’s northern and western counties. AHEAD participation includes several hospital systems. PACE operates through multiple organizations including LIFE programs in urban areas.

Tier 2: Mid-Tier Markets

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Ohio participated in the FAI through MyCare Ohio and transitioned those plans into FIDE SNPs at the demonstration’s end. The state is a WISeR participant and submitted an early work requirement waiver. Ohio’s dual eligible population is substantial, and its Medicaid managed care landscape includes CareSource, Molina, UnitedHealthcare, and Anthem. The transition from MyCare Ohio MMPs to FIDE SNPs preserved enrollment relationships and care coordination protocols built over a decade of demonstration experience. Ohio is among the best-positioned states for post-FAI integration.

North Carolina transformed its Medicaid program in 2023 through the Healthy Opportunities transition to managed care, after decades of operating a primary care case management model. The state expanded Medicaid in December 2023. D-SNP infrastructure is still developing; the managed care transition means that MCO-D-SNP alignment is a new capability being built rather than an established one. The state’s dual eligible population faces a simultaneous managed care transition and work requirement implementation.

Michigan participated in the FAI through MI Health Link and transitioned its plans into HIDE SNPs. The state expanded Medicaid and has a Medicaid managed care landscape that includes Meridian Health Plan (now part of Centene), Molina, and UnitedHealthcare. Rural dual eligible access is a persistent challenge in the Upper Peninsula and northern Lower Peninsula. PACE operates in several Michigan markets.

Illinois transitioned its FAI Medicare-Medicaid Alignment Initiative plans into FIDE SNPs starting January 2026, making it one of the newest FIDE SNP states. The state expanded Medicaid and operates a complex Medicaid managed care system across multiple regions. The FIDE SNP launch represents a significant integration upgrade for Illinois dual eligibles who were previously in coordination-only arrangements.

Georgia is the cautionary example. As the only state that fully implemented a Medicaid work requirement before OBBBA, Georgia’s Pathways to Coverage program enrolled fewer than 8,100 people out of 300,000 eligible while spending $54 million on administration. The state has not expanded Medicaid. Its D-SNP market is growing but operates primarily at the CO level. Georgia’s simultaneous experience implementing work requirements and building D-SNP infrastructure illustrates the resource competition that many states will face starting in 2027.

Arizona operates the Arizona Long-Term Care System, a unique managed LTSS model that has been in place since the 1980s and predates most other state managed care programs. ALTCS provides comprehensive managed care for individuals who meet an institutional level of care, including many dual eligibles. Arizona is a WISeR state, submitted an early work requirement waiver, and has HIDE SNP availability through its ALTCS-aligned plans. The ALTCS model gives Arizona a dual eligible integration infrastructure that most states lack, though it is structurally distinct from the D-SNP framework.

New Jersey expanded Medicaid and operates a Medicaid managed care system with D-SNP options from multiple carriers. FIDE and HIDE SNP availability exists in some counties. The state is building integration infrastructure but is not among the post-FAI states and does not have demonstration-era experience to build from.

Tier 3: Growth Markets

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Virginia has FIDE SNP availability and implemented mandatory agent training requirements for agents selling FIDE D-SNPs, an unusually specific state-level broker regulation. The state expanded Medicaid in 2019 and has an active D-SNP market with aligned enrollment through Aetna and Molina, among others. Virginia’s approach to agent regulation may serve as a model for other states concerned about broker-driven churn in the dual eligible market.

Minnesota has a distinctive cooperative health plan tradition built around HealthPartners and UCare, both nonprofit organizations with deep roots in the state’s healthcare system. Minnesota participated in the FAI through an alternative model that aligned administrative processes within its existing Minnesota Senior Health Options program rather than testing a new capitated structure. The state’s guaranteed-issue Medigap provision, effective August 2026, will give Minnesota beneficiaries a new pathway to Original Medicare supplemental coverage that does not exist in most states. PACE operates in Minnesota through several programs.

Tennessee operates TennCare, one of the oldest and most distinctive Medicaid managed care programs in the country. The state’s dual eligible population is significant, and the TennCare infrastructure provides a managed care foundation for D-SNP integration. Tennessee has not been a leader in FIDE SNP development, and its D-SNPs operate primarily at the CO level.

Missouri has a large dual eligible population relative to its Medicare enrollment. Over 85 percent of the state’s full-benefit dual eligibles qualify through SSI pathways, one of the highest concentrations in the country. Missouri expanded Medicaid through a 2020 ballot initiative over legislative opposition, and implementation was contentious. The D-SNP market is developing but is not at the FIDE level.

Indiana operates HIDE and AIP D-SNPs and automatically aligns Medicaid MCO enrollment with D-SNP selection. The state expanded Medicaid through a waiver program (HIP 2.0) that includes cost-sharing and health savings account requirements. Indiana raised its QI program income limit to 200 percent of FPL, making it one of the most generous Medicare Savings Program states for the Qualifying Individual benefit.

Wisconsin has FIDE SNP availability and a managed care landscape that includes multiple carriers operating aligned D-SNPs. The state’s Family Care managed LTSS program provides a foundation for D-SNP integration. PACE operates through the PACE Partnership in several Wisconsin markets.

Colorado participated in the FAI through a managed fee-for-service model that ended in 2017, making it one of the earliest FAI exits. The state expanded Medicaid, eliminated the MSP asset test, and has been active in Medicaid modernization. D-SNP integration is developing but not at the FIDE level. SelectQuote and regional carriers operate D-SNPs along the Front Range, but rural western Colorado has limited D-SNP availability. PACE does not operate at scale in Colorado despite the state having one of the highest PACE enrollment rates per capita nationally, concentrated in the Denver metro. Colorado’s dual eligible population is modest in absolute terms but growing, and the state’s progressive Medicaid policy environment positions it as a potential FIDE SNP builder if the Medicaid agency prioritizes integration.

Washington is a WISeR state with progressive Medicaid integration policies and one of the most supportive state-level environments for dual eligible coordination. The state participated in the FAI through a managed fee-for-service model and has HIDE SNP availability through Molina and UnitedHealthcare. Washington automatically aligns Medicaid enrollment with D-SNP selection, which facilitates integration without requiring FIDE-level infrastructure. The state’s Medicaid managed care system integrates behavioral health and LTSS under managed care, removing the carve-out barriers that block FIDE SNP development in other states. PACE operates in several Washington markets. Eastern Washington’s rural dual eligible population faces access gaps that mirror rural Idaho and Montana, with provider scarcity compounding the limited plan competition. Washington is among the states most likely to pursue FIDE SNP development in the near term, and its policy infrastructure could make it a model for the other Pacific Northwest states.

Pacific Northwest and Mountain West

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Oregon operates a Medicaid system structurally distinct from any other state. The Coordinated Care Organization model, launched in 2012, delivers Medicaid services through locally governed, global-budget entities that integrate physical health, behavioral health, and dental care under a single capitated payment. Approximately 90 percent of Oregon’s 1.1 million Medicaid enrollees receive care through CCOs. For dual eligible integration, this means the Medicaid side of the equation operates through entities that already accept full risk and coordinate across service categories. Oregon’s D-SNPs, including CareOregon Advantage Plus and Providence Medicare Dual Plus, align with CCOs to coordinate Medicare and Medicaid benefits. The alignment is operational in the Portland metro and Willamette Valley, where CCO and D-SNP service areas overlap and the same parent organizations operate on both sides. Rural and eastern Oregon dual eligibles face a thinner landscape. Several eastern Oregon counties lack any MA plan, and CCO-D-SNP alignment requires plan presence that does not exist in the most remote markets. Oregon released a PACE RFP in 2023, with new programs expected to begin operations between 2025 and 2026, expanding PACE availability beyond its current limited footprint. The state has eliminated the MSP asset test, reducing one barrier to benefit access for low-income seniors. Oregon’s CCO model gives it a Medicaid integration foundation that most states lack, but translating that foundation into FIDE-level D-SNP integration requires building the Medicare side of the relationship to match the Medicaid infrastructure already in place.

Idaho expanded Medicaid through a 2018 ballot initiative that voters approved over legislative opposition. The state’s dual eligible population is small in absolute terms but significant relative to Idaho’s total Medicare enrollment of approximately 393,000 beneficiaries. Idaho’s D-SNP market is thin: six SNP plans (D-SNP, C-SNP, and I-SNP combined) operated in the state as of 2026. The Medicare Medicaid Coordinated Plan and the Idaho Medicaid Plus Program represent the state’s dual eligible coordination infrastructure, but neither operates at FIDE or HIDE SNP levels. Saint Alphonsus Health Plan, affiliated with Trinity Health, functions as the closest thing to a payvider in the Boise market. Rural Idaho, particularly the central mountain counties and the eastern border, faces compound challenges: limited plan availability, provider scarcity, and a Medicaid program that was implemented reluctantly and remains politically contested. Idaho has not pursued early work requirement implementation, but its small Medicaid agency will face the same capacity constraints as larger states when the January 2027 deadline arrives. For dual eligible integration, Idaho is at the starting line, not the middle of the race.

Utah expanded Medicaid through a 2018 ballot initiative that the legislature subsequently narrowed through a waiver, covering fewer adults than the voters intended. The state’s dual eligible population is smaller relative to total Medicare enrollment than in most profiled states, reflecting Utah’s younger demographic profile. D-SNP availability is limited. SelectHealth, the Intermountain Health-affiliated plan, operates as the dominant payvider with integrated delivery capacity across the Wasatch Front. Utah’s Medicaid managed care system operates through Accountable Care Organizations, and the D-SNP landscape is primarily coordination-only. Utah withdrew a work requirement waiver application in 2025, signaling some uncertainty about implementation strategy. PACE does not operate in Utah, and the state has not released an RFP. For senior citizens along the Wasatch Front, SelectHealth’s integrated model provides the functional equivalent of care coordination even if the regulatory designation falls below FIDE. For rural Utah seniors, the options are far more limited.

Nevada has one of the fastest-growing senior populations in the country. Clark County (Las Vegas) and Washoe County (Reno) concentrate the majority of the state’s Medicare and dual eligible populations. Nevada expanded Medicaid and operates managed care through multiple MCOs, but D-SNP integration is early-stage. The state’s dual eligible population is growing faster than its integration infrastructure. D-SNP options exist in the Las Vegas and Reno markets from UnitedHealthcare, Anthem, and Centene-affiliated plans, but rural Nevada is largely unserved. The state has not participated in the FAI, does not have FIDE SNP infrastructure, and PACE does not operate in Nevada, though grassroots activity suggests interest. Nevada’s challenge is that it is simultaneously building a Medicaid managed care system, absorbing rapid population growth, and now preparing for work requirement implementation, all with a state Medicaid agency scaled for a smaller and less complex program.

Synthesis

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The state map reveals three categories. The integration leaders are states with FIDE SNP infrastructure, stable Medicaid managed care, and post-FAI experience: New York, Ohio, Massachusetts, Rhode Island, and Illinois. These states have the institutional knowledge, plan relationships, and regulatory infrastructure to operate high-integration D-SNPs at scale. Their challenge is maintaining integration quality while absorbing the administrative burden of work requirement implementation.

The integration builders are states that have the policy foundation for FIDE or HIDE development but are earlier in the build-out: Pennsylvania, Michigan, California, Virginia, Wisconsin, Washington, Indiana, Arizona, and Oregon. Oregon’s CCO infrastructure gives it a Medicaid integration foundation most states lack; Washington’s automatic D-SNP alignment and behavioral health integration under managed care position it for FIDE development. These states have Medicaid managed care infrastructure and state agency engagement but face specific barriers, whether behavioral health carve-outs, rural access gaps, or recently transitioned managed care systems. Their trajectory depends on state agency capacity and political commitment.

The integration gap states are those without FIDE infrastructure, without FAI experience, and in some cases without Medicaid expansion: Florida, Texas, Georgia, Tennessee, Missouri, North Carolina, Colorado, Idaho, Utah, and Nevada. Florida and Texas have large dual eligible populations and competitive D-SNP markets, but their non-expansion status and CO-dominated plan landscapes limit integration depth. The Pacific Northwest and Mountain West growth states, Idaho, Utah, and Nevada, share a common profile: ballot-initiative Medicaid expansions implemented with varying political enthusiasm, thin D-SNP markets, limited or no PACE availability, and state Medicaid agencies scaled for programs smaller than what they now administer. Georgia’s simultaneous work requirement implementation and D-SNP development illustrate the resource competition that many of these states face.

The work requirement overlay cuts across all three categories. States implementing work requirements in 2027 while simultaneously building D-SNP integration infrastructure will face a zero-sum competition for state Medicaid agency bandwidth. The states best positioned to manage both are those with established managed care systems, experienced agency staff, and modern eligibility systems. The states least prepared are those building managed care infrastructure from a low base while also constructing verification systems from scratch.

For national plans evaluating D-SNP market entry or expansion, the state map determines strategy. The integration leaders offer the deepest integration opportunity but the most competitive landscapes. The integration builders offer market growth potential with execution risk. The integration gap states offer enrollment volume in CO D-SNPs but limited integration depth, meaning plans entering these markets should anticipate a regulatory environment that will eventually require investment in integration capabilities that are not yet mandated.

Related Reading

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MCR-02_06 State-by-State Rate Impact Analysis: Top 20 Markets MCR-11_01 California: The Medicare Market That Sets National Precedent