Dual-Eligible Strategy: A Roadmap for Health Plans
Tsuzuki KanaokaAs health plans increasingly focus on dual-eligible populations, Strive Health’s extensive experience creates durable value through lower total cost of care and aligned incentives in value-based care frameworks. We improve outcomes for these vulnerable and underserved populations by expanding access and delivering coordinated and specialized care for patients’ kidney disease and related comorbid conditions such as congestive heart failure, hypertension and diabetes.
– Paul Marchetti, President | Strive Health
The dual-eligible population — individuals eligible for both Medicare and Medicaid — represents a high-need, high-cost segment of the healthcare system.
According to the Kaiser Family Foundation, the proportion of dual-eligible individuals enrolled in Dual Eligible Special Needs Plans (D-SNPs) nearly tripled, rising from 11% to 29% from 2010 through 2021. Despite making up only 20% of Medicare beneficiaries, these beneficiaries account for 34% of total Medicare spending, as reported by the Medicaid and CHIP Payment and Access Commission (MACPAC). Many of these individuals suffer from multiple chronic conditions such as chronic kidney disease (CKD), diabetes and cardiovascular disease, yet they often experience fragmented care that leads to poor health outcomes and unnecessary hospitalizations.
For health plans, 2025 and 2026 present a critical opportunity to enhance care for dual-eligible populations through value-based care (VBC) models. Recent policy changes, including CMS incentives, expanded Special Enrollment Periods (SEPs) and Medicaid integration initiatives, provide a framework for improving outcomes while ensuring financial sustainability. Additionally, recent legislative changes introduce new eligibility and administrative considerations that may reduce access and impact coordination.
High-touch VBC strategies are more essential than ever, and VBC organizations can help health plans achieve better health outcomes and cost efficiency.
Why the Dual-Eligible Population Calls for Strategic Priority in 2025 and 2026
High Costs and Complex Needs
The dual-eligible population disproportionately drives healthcare spending. Key factors include:
- Dual-eligible patients are more likely to face social determinants of health (SDOH) factors such as food insecurity, housing instability and transportation issues, compounding the medical complexity of the population.
- Oftentimes, Medicaid and Medicare plans do not coordinate benefits for their beneficiaries, leading to confusion on what benefits are covered, a lack of clear ownership, frequent emergency room visits and avoidable hospitalizations.
- Over 50% of dual-eligible beneficiaries with CKD also have diabetes, hypertension or cardiovascular disease, leading to compounded healthcare costs.
The CDC reported that CKD-related costs exceed $87 billion annually in Medicare (including duals populations) with late-stage CKD often leading to costly dialysis treatments and hospitalizations. Avalere Health shared analysis from Pennsylvania that dual-eligible end-stage kidney disease (ESKD) patients had an average monthly cost of $9,321 per member, which was 24% higher than the $7,506 monthly cost for non-dual Medicare beneficiaries with ESKD. These challenges make dual-eligible populations a key priority for proactive, integrated care strategies that can improve both patient outcomes and cost efficiency.
The Role of CMS Incentives in Driving Value-Based Care
Recent CMS initiatives reinforce the importance of value-based care models that include dual-eligible beneficiaries. Health plans can position themselves for both improved patient outcomes and financial stability by adapting to these changes.
Key Policy and Payment Incentives:
- Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs): These plans now offer expanded supplemental benefits to support high-risk members, including chronic disease management, transportation and social services. Within D-SNPs, the number of Fully Integrated Dual Eligible (FIDE) SNPs plans is growing significantly.
- ACO REACH Model: Adjusted benchmarks encourage providers to focus on high-risk populations, including dual-eligible beneficiaries. Additionally, participation in the model assesses an organization’s ability to coordinate services across Medicare and Medicaid for dually eligible beneficiaries and prevent unnecessary utilization of higher-cost institutional care, according to CMS.
- Kidney Care Choices (KCC) Model: This model aligns financial incentives for early-stage CKD management, rewarding prevention and slowing disease progression. Dual-eligible members enrolled in traditional Medicare can participate.
- Medicaid Managed Care Integration: States are requiring greater coordination between Medicare and Medicaid benefits, making it essential for health plans to align incentives across both programs.
- Health Equity and Social Risk Adjustment: CMS continues to refine risk adjustment models, with a strong focus on program integrity and auditing. However, recent policy shifts have scaled back formal health equity requirements, signaling a de-prioritization of social risk adjustment and SDoH-related incentives.
Emerging Medicaid Policy Shifts
Recent legislation introduces changes that may affect dual-eligible access and enrollment, especially for those near the Medicaid eligibility thresholds. Key updates include:
- Home Equity Limit Adjustments: Stricter caps may reduce Medicaid eligibility for older adults in high-cost areas who rely on home value to qualify for long-term care.
- Shortened Retroactive Coverage: The 90-day retroactive Medicaid eligibility window has been reduced to 30 days, limiting coverage for individuals who need care before completing enrollment.
- Medicare Savings Programs (MSP) Auto-Enrollment Delays: Delays in Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB) auto-enrollment may reduce uptake of MSPs, increasing financial burden and churn.
- New Asset Verification Requirements: Tighter requirements may introduce further delays or deter eligible individuals from completing applications.
These changes may increase underinsurance, care gaps and care disruption. This emphasizes the importance for payors and providers to coordinate closely with VBC partners and provide robust member outreach to ensure continuity of care.
Special Enrollment Periods as a Competitive Advantage
On Jan. 1, 2025, CMS expanded Special Enrollment Periods (SEPs) for dual-eligible beneficiaries, offering health plans a greater ability to enroll and retain members in high-value care models. Key changes include:
- Monthly Enrollment Flexibility: Full-benefit dual-eligible individuals can change plans every month under certain conditions (such as enrolling in or disenrolling from a D-SNP), replacing the previous quarterly system. This increases touchpoints for member retention and targeted outreach.
- Integrated Care SEP: Encourages full-benefit dual-eligible members to enroll in Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) or Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs) to streamline benefits and improve care coordination. Plans offering these models align with CMS goals to reduce fragmented care and disruptive plan-switching.
How to Strategically Use SEPs
- Promote High-Value Integrated Plans: Use the Integrated Care SEP to enroll members into FIDE SNPs or HIDE SNPs for better care coordination.
- Optimize Member Retention: Address churn by improving customer service, offering tailored benefits and enhancing care coordination.
- Differentiate Through Outreach: Educate members about integrated plans and proactively communicate during SEP windows.
- Collaborate With States: Align with state contracts to meet integration requirements and gain competitive advantages.
How Value-Based Care Partnerships Can Drive Success
To maximize impact, health plans can benefit from value-based care partnerships focused on high-cost, high-need populations. CKD alone drives over $87 billion in annual Medicare costs and disproportionately affects dual-eligible members. With CMS accelerating integrated models and SEP flexibility, kidney care is a top lever for improving outcomes and reducing total cost of care, according to the CDC.
1. Expand Integrated Care Models
Health plans achieve better outcomes by prioritizing integrated care models that streamline benefits and enhance care coordination.
- Medicare-Medicaid Plans (MMPs) are being phased out by the end of 2025. D-SNP, FIDE-SNPS and HIDE-SNPs are taking over. They will impact a range of concerns such as care coordination, comprehensive care, integration and improved outcomes, according to findings shared through RTI and JAMA Health Forum.
- As states transition from MMPs to integrated D-SNPs, they often use procurement processes, such as RFPs, to select health plans that will offer these integrated services. Health plans will need to respond to state-issued RFPs to participate in the new integrated D-SNP models.
2. Align Financial Incentives through Risk-Sharing Agreements
By establishing risk-sharing arrangements with nephrology providers and care coordinators, health plans can:
- Reduce unnecessary emergency department visits and hospitalizations.
- Delay dialysis initiation through proactive disease management.
- Improve financial sustainability while enhancing care quality.
3. Address Social Determinants of Health to Improve Outcomes
Addressing SDOH is critical for managing chronic conditions effectively. Examples of impactful interventions include:
Transportation Support:
- A survey of dialysis social workers shared by the National Kidney Foundation reported that transportation problems accounted for an average of 4.5 missed treatments per month at their clinics. These missed sessions pose significant health risks to patients and disrupt clinic operations.
- Possible Intervention Example: Organizations like Strive Health work with patients to connect them to transportation resources and dig deeper into causes for missed appointments.
Nutrition Programs:
- Medically tailored meals are associated with lower health care utilization among patients with complex diet-related diseases, but are not a covered benefit in Medicare or Medicaid.
- Possible Intervention Example: Strive employs renal dieticians who are trained in providing diet guidance and provide benefits, such as cooking classes for patients. Social workers are then tasked with connecting patients with resources for finding healthy meals.
For 2025, CMS is encouraging D-SNPs to expand SDOH-related benefits, presenting an opportunity for health plans to differentiate themselves in the market while driving better outcomes for dual-eligible members.
The Path Forward for Health Plans
The 2025 regulatory landscape offers health plans a clear path to improving care delivery for dual-eligible populations while optimizing financial performance. To remain competitive, health plans can:
- Leverage SEPs to drive enrollment and retention.
- Expand integrated care models across Medicare and Medicaid.
- Align financial incentives through risk-sharing agreements.
- Invest in SDOH-based supplemental benefits to improve engagement and lower costs.
Health plans that prioritize dual-eligible value-based care will not only improve patient outcomes but also strengthen their financial performance. As the healthcare landscape continues shifting toward integrated, outcome-driven models, strategic partnerships with value-based care organizations will be essential for success.
About Strive
Strive Health is the nation’s leader in value-based kidney care and partner of choice for innovative healthcare payors and providers. Using a unique combination of AI technology, care interventions and seamless integration with local providers, Strive forms an integrated care delivery system that supports the entire patient journey from chronic kidney disease (CKD) to end-stage kidney disease (ESKD). To help patients, Strive partners with commercial and Medicare Advantage payors, Medicare, health systems and physicians through flexible value-based payment arrangements, including risk-based programs. Strive serves over 145,000 people with CKD and ESKD across 50 states and partners with over 6,500 providers. Strive’s case management and population health programs are accredited by the National Committee for Quality Assurance (NCQA), and its technology platform, CareMultiplier™, is certified by HITRUST. To learn more, visit StriveHealth.com.
Sources
https://www.cdc.gov/kidneydisease/basics.html
https://avalere.com/insights/comparison-of-dually-and-non-dually-eligible-patients-with-esrd
https://www.cms.gov/priorities/innovation/media/document/aco-reach-genfaqs
https://www.cdc.gov/kidney-disease/ckd-facts/index.html
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2819499
https://www.kidney.org/sites/default/files/v23_a6.pdf
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2797397
