Navigating CMS 2027 D-SNP Requirements: Preparing Your Health Plan for HIDE and FIDE SNP Compliance

Health plans serving dual-eligible populations face significant regulatory changes from the Centers for Medicare & Medicaid Services (CMS). The 2027 D-SNP requirements introduce significant changes affecting Highly Integrated Dual-Eligible Special Needs Plans (HIDE SNPs) and Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs).

While the full rule doesn’t take effect until 2027, certain critical compliance requirements begin as early as 2025, necessitating immediate action. Gaining insight into these changes and preparing now will enable health plans to adapt and strengthen their position with dual-eligible populations.

Key Changes to CMS Requirements  

New regulatory requirements from CMS aim to enhance the integration of Medicare and Medicaid to simplify administration and improve care for dual-eligible beneficiaries. The changes that are in effect in 2025, and the more significant adjustments that health plans need to prepare for in 2027, include:

For 2025, health plans must implement exclusively aligned enrollment (EAE) for FIDE SNPs, ensuring members are simultaneously enrolled in both the Medicare SNP and the affiliated Medicaid managed care plan. They must also establish capitated contracts for HIDE SNPs that cover their entire Medicare service area, including behavioral health or long-term services and supports (LTSS). Plans should have already adjusted their enrollment processes, systems, and state Medicaid contracts.

By 2027, CMS requires all Dual-Eligible Special Needs Plans (D-SNPs) affiliated with Medicaid Managed Care Organizations to operate with exclusively aligned enrollment. Non-aligned SNP enrollments will no longer be allowed, which necessitates operational restructuring. Health plans must proactively prepare by assessing enrollment alignment and communicating effectively with members.

Why CMS is Making These Changes and Why Health Plans Must Act Now

With its latest guidance, CMS addresses historical issues related to fragmented and disconnected care for dual-eligible beneficiaries who previously navigated two separate healthcare systems (Medicare and Medicaid). This led to duplicative processes, multiple insurance cards, conflicting information, care delays, and significant frustration among members and caregivers.

New CMS regulations aim to:

• Ensure integrated, coordinated care across Medicare and Medicaid programs.
• Simplify administrative processes to improve the member experience
• Strengthen accountability and collaboration between Medicare and Medicaid to enhance healthcare outcomes and efficiency.

The transition to integrated Medicare and Medicaid for dual-eligible members is underway, and health plans should seek immediate action due to the operational complexity of this endeavor. Implementing exclusively aligned enrollment and service area adjustments requires significant changes across internal systems, processes, and training.

Additionally, health plans should engage early in state Medicaid negotiations and approvals, which can be a lengthy process. Early compliance with 2027 mandates and beyond mitigates risk and enhances health plans’ competitive positioning.

Immediate Steps Health Plans Should Take for HIDE & FIDE Compliance

The 2027 CMS integration requirements for HIDE SNPs, FIDE SNPs, and D-SNPs raise the stakes for health plans. At a minimum, to effectively prepare for CMS’s upcoming regulatory changes, health plans must assess their current enrollment structures to comply with exclusive enrollment requirements. Proactively engaging with state Medicaid agencies is crucial to secure compliant, capitated contracts that cover necessary service areas and benefits. Clear communication, both internally among teams and externally with members, will also facilitate a smooth transition.

However, investing in advanced technology infrastructure is equally critical. Without a modern care management solution, health plans risk non-compliance, which can lead to CMS penalties. Missteps can disrupt member care, inefficiencies can drain resources, and slow adopters will lose ground to more agile competitors. Modern care management technology is the essential element that helps health plans avoid these pitfalls. With a cutting-edge solution, health plans can optimize enrollment, simplify compliance oversight, and strengthen reporting capabilities This ensures health plans are well-equipped to provide exceptional, fully coordinated care while adhering to regulatory requirements.

How HealthEdge® Supports Health Plan Compliance

The HealthEdge GuidingCare® platform is designed to help health plans navigate regulatory compliance and integrated care delivery as CMS and state regulations continue to evolve. GuidingCare provides robust regulatory support and customizable workflows, enabling health plans to:

• Streamline Compliance. Automate enrollment and eligibility verification processes to reduce administrative complexity associated with CMS and state Medicaid requirements.
• Enhance Care Coordination. Integrate management of Medicare and Medicaid benefits, including behavioral health services and long-term supports (LTSS), to improve health outcomes for dual-eligible members.
• Improve Regulatory Reporting. Leverage comprehensive reporting capabilities for efficient compliance monitoring and auditing to meet CMS and state regulatory requirements.
• Support Operational Excellence. Utilize customizable workflows tailored to the unique needs of dual-eligible populations to facilitate proactive management of regulatory and operational changes.
• Ensure Scalability and Flexibility. Quickly adapt to changing regulations to seamlessly align operations in response to evolving compliance demands.

Investing in a care management platform such as GuidingCare strategically positions health plans for the future. The solution enables payers to meet immediate regulatory demands while establishing a strong foundation for long-term operational success, exceptional care management, and advanced member experiences.

Achieve Compliance and Operational Efficiency

By proactively addressing these new requirements related to dual-eligible populations, your health plan can meet compliance timelines, minimize disruption, and deliver superior member experiences. HealthEdge is committed to supporting health plans as they navigate these critical changes.

Contact us today to learn how GuidingCare can help your health plan stay ahead of evolving regulations.

Want to learn more about how solutions like GuidingCare empower health plans through compliance support? Read our blog, Adapt to CMS Standards and Improve Star Ratings with Digital Care Management .