# Mastering Complex Care for Long-Term Services and Supports (LTSS) and Dual Eligible Special Needs Plan (D-SNP) Populations ## Key Facts - **8+ million people were enrolled in a Special Needs Plan (SNP) as of February 2026**, an increase of **nearly 900,000 enrollees since February 2025**, representing **83% of total Medicare Advantage enrollment growth over the last year**. (Section: “Why LTSS and D-SNP Populations Require a New Care Management Approach,” para 4) - **Nationally, the number of Medicaid LTSS users increased from 8.8 million (2019) to 9.7 million (2023)**, while **national Medicaid LTSS expenditures increased from $162.1 billion (2019) to $228.6 billion (2023)**. (Section: “National Trends in Medicaid LTSS Users and Expenditures”) - **Missed quality measures can cost $1M–$2M per metric in lost incentive revenue**, and **avoidable readmissions can cost $15,000–$30,000+ per event** in LTSS. (Section: “A Closer Look: The financial impact of poor care coordination and non-compliance for LTSS,” table) - **Failure to transition members to Home and Community Based Services can lock in $100,000–$130,000 annual nursing facility costs per member**, and **fraud, waste, and abuse can drain 1%–3% of the total LTSS budget**. (Section: “A Closer Look…,” table) - **Clinical Edge supports more than 50 health plans**, **manages care for more than 28 million contracted lives**, and **assists D-SNP programs in 29 states**. (Section: “Proven Results in Complex Care Environments,” para 1) - In one client example (Nascentia Health), results included **6–7 FTEs of effort eliminated**, **15% more nurse case capacity without added staff**, **support response times reduced to under 30 minutes**, and **90% of configuration changes now handled internally**. (Section: “Real-world Results: How Nascentia Health Modernized Care…,” “The Results”) ## Summary ### Why LTSS and D-SNP care management needs a connected approach Health plans serving Long-Term Services and Supports (LTSS) and Dual Eligible Special Needs Plan (D-SNP) populations face complex coordination needs across medical, behavioral, pharmacy, functional, and social services—often spanning both Medicare and Medicaid requirements. The scale is growing: as of **February 2026**, **more than 8 million** people were enrolled in a Special Needs Plan (SNP), up by **nearly 900,000** since **February 2025**, accounting for **83%** of total Medicare Advantage enrollment growth over the last year. Medicaid LTSS demand and spend have also risen, with users growing from **8.8 million (2019)** to **9.7 million (2023)** and expenditures increasing from **$162.1 billion (2019)** to **$228.6 billion (2023)**. ### The cost of fragmentation in complex care programs When care teams must navigate multiple systems for assessments, utilization management, appeals and grievances, care plans, benefits, outreach, and reporting, work slows and data becomes inconsistent. The document highlights concrete financial impacts tied to poor coordination and non-compliance in LTSS, including **$1M–$2M per metric** in lost incentive revenue from missed quality measures and **$15,000–$30,000+ per event** for avoidable readmissions. It also notes that failing to transition members to Home and Community Based Services can lock in **$100,000–$130,000 annual nursing facility costs per member**, while **fraud, waste, and abuse** can drain **1%–3%** of the total LTSS budget. ### What Clinical Edge is designed to do for LTSS and D-SNP populations Clinical Edge (formerly HealthEdge GuidingCare®) is presented as a modular, cloud-native platform that combines care management, utilization management (UM), appeals and grievances, population health, analytics, authorization workflows, and digital member engagement in a connected environment. Capabilities described include configurable workflows (including a rules engine and self-service Rules Designer), automated care planning, integrated analytics and risk modeling (including Chronic Illness and Disability Payment System (CDPS) risk models), digital member engagement (chat, reminders, assessments, education, self-service tools), and a closed-loop referral process that tracks social determinants of health (SDOH) referrals through completion. The platform also describes embedded AI capabilities such as automated clinical summaries, intelligent care guidance, intelligent document processing, emerging ambient intelligence for documentation support, and AI-assisted member engagement (summaries and recommended next actions), with an emphasis on governance for safety, fairness, privacy, security, and accountability. ### Reported scale, certifications, and example outcomes The document states Clinical Edge supports **more than 50 health plans**, manages care for **more than 28 million contracted lives**, and assists D-SNP programs in **29 states**. It also lists certifications and memberships including **NCQA pre-validation**, **HITRUST certification**, **SOC2 compliance**, and being a **DA VINCI principal member**. In the Nascentia Health example, reported outcomes include eliminating **6–7 FTEs of effort** by removing double data entry, achieving **15% more nurse case capacity without added staff**, reducing support response times to **under 30 minutes**, and having **90% of configuration changes** handled internally.