Medicare Advantage D-SNP Look-Alike Transitions: Where Members Go When the Look-Alike Ends

Medicare Advantage D-SNP look-alike transitions in 2027 must move eligible members into a dual eligible special needs plan when the organization uses the Centers for Medicare & Medicaid Services’ dedicated look-alike transition authority. For an enrollment, product or compliance employee, the revealing question is who decided which members went where. The old roster, the destination rules and the notice sent to each member can show whether the transition followed the required protections.

Why CMS Limits D-SNP Look-Alike Plans

The Centers for Medicare & Medicaid Services limits look-alikes because they enroll the people a D-SNP serves without carrying its coordination duties. A D-SNP serves people eligible for both Medicare and Medicaid, with an agency-approved Model of Care and a state Medicaid contract governing coordination between the programs. A look-alike is an ordinary Medicare Advantage plan that primarily enrolls those same people without the D-SNP requirements.

Benefit design helps explain the attraction. In its 2024 final rule, the agency described look-alikes putting more rebate money toward dental, hearing and vision benefits and less toward reducing Medicare cost sharing. Many dual-eligible members have protections against paying that cost sharing themselves. The benefits can therefore appeal to them even when the same package would leave other Medicare beneficiaries facing substantial bills.

The American Institutes for Research’s 2026 report, Medicare Advantage Fraud, Waste, and Abuse Policy Options, identifies the risk of selling an impression of integrated coverage while avoiding its costs. Those coordination requirements protect patients and public healthcare programs against unnecessary, duplicated or missed services. We see the problem plainly: attracting the population while sidestepping the obligations designed for it defeats the purpose of a special needs plan.

Why a Look-Alike Ends

The Centers for Medicare & Medicaid Services lowered the dual-eligible enrollment threshold to 70% for plan year 2025 and 60% for 2026 and subsequent years. For covered non-SNP plans, reaching the threshold blocks a new contract or renewal based on projected enrollment in bids, and renewal based on actual January enrollment. A plan’s projection and its membership file therefore answer different parts of the same question.

Both full-benefit and partial-benefit dual-eligible members count toward the threshold. For the actual-enrollment renewal test, the exception requires both a plan active for less than one year and enrollment of 200 or fewer people. The contracting limitation applies in a state where a D-SNP or another federally authorized plan exclusively enrolling Medicaid-eligible individuals operates.

The agency excludes special needs plans from this look-alike test, including chronic condition and institutional plans. The American Institutes for Research report explains the resulting policy concern: those plans can enroll substantial dual-eligible populations without the same coordination requirements as D-SNPs. Plan type matters alongside enrollment percentage.

Where Members Go When the Look-Alike Ends

Beginning with plan year 2027, the receiving plan under the dedicated look-alike transition authority must be a D-SNP. The agency adopted that restriction in the 2024 final rule. It can cover full-benefit and partial-benefit dual-eligible members, provided each person meets the receiving D-SNP’s eligibility requirements.

The receiving plan must offer Medicare Advantage and Part D coverage, have the same plan type as the departing plan, such as HMO or PPO, and have a combined Part C and D premium of $0 after the premium subsidy for full-subsidy-eligible individuals. The transition can cross contracts and Medicare Advantage organizations under the same parent organization. These conditions make the destination plan’s identity, ownership, benefits and eligibility criteria part of the transition decision.

The Centers for Medicare & Medicaid Services also preserves separate crosswalk processes, which move enrollment between plan benefit packages under their own conditions. An organization cannot combine a crosswalk or crosswalk exception with the dedicated look-alike transition pathway. Under the dedicated pathway, members who are not transitioned default to Traditional Medicare.

How Members Are Moved and Told

The look-alike transition process permits an end-of-year move without a new election form. The agency requires an annual notice of change describing the receiving plan and benefit changes, delivered at least 15 days before the annual election period begins. A member’s affirmative selection of another plan during that period takes precedence over the transition destination.

Members left out of the transition must receive a written nonrenewal notice. For an insider examining a possible enrollment without consent, the useful comparison is the authority used, the notice delivered and any different choice the member made.

CMS’s Diabetes Example Shows the Sorting Problem

The Centers for Medicare & Medicaid Services’ guidance for contract year 2025, issued April 5, 2024, described broader receiving-plan options than the later D-SNP-only restriction. It also made the health-status problem concrete:

The memo said an organization could not choose a destination based on health status when a member qualified for more than one receiving plan, with an exception for transition into a chronic condition special needs plan. For 2027, the dedicated pathway instead requires a D-SNP destination.

The connection to health-based steering lies in the selection decision. An enrollment employee may see a diagnosis field directing otherwise eligible people into different destinations. We see the problem in that example: a promise of coordinated care gives way to sorting people by their illness. We want to understand who chose that rule, what eligibility criteria it was supposed to implement and what management did when someone challenged it.

What an Insider Can See in the Transition File

The transition file connects a departing member to a receiving plan and the reason for that assignment. The agency’s historical memo requested the old and new contract and plan benefit package numbers, geographic service areas, expected membership movements and an explanation of who would go to each destination. It also requested an explanation of members who would not transition.

Those fields give substance to the roster. The destination-selection logic can be compared with full or partial dual status, the receiving plan’s eligibility rules and the member notices. The memo’s rollover batch process supplies another comparison: what the organization told the agency it intended to do against the member movements it submitted.

Government money follows enrollment. Medicare Advantage pays plans a monthly amount for each member, so in a potential Medicare Advantage fraud case, the enrollment decision belongs beside the payment trail. We work with insiders to connect what the organization represented, what its employees knew and which plan received the member and the money. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

Why the Destination Matters for Medicare and Medicaid

A D-SNP’s state contract identifies responsibilities that a new plan name cannot convey. The Integrated Care Resource Center’s 2015 study, State Contracting with Medicare Advantage Dual Eligible Special Needs Plans: Issues and Options, examined contracts in 12 states. It describes eligibility categories, Medicaid benefits, financial obligations, provider information and eligibility verification as core contract contents. For a transition employee, these are the details behind a promise of coordinated health care.

The Centers for Medicare & Medicaid Services’ April 2026 enrollment FAQs explain a separate alignment requirement beginning in 2027. Where the D-SNP organization or its corporate family also operates a Medicaid managed-care plan serving full-benefit dual-eligible individuals in an overlapping service area, new members must be enrolled in, or in the process of enrolling in, that Medicaid plan, subject to the exception below. Existing unaligned members can remain until 2030. For a look-alike transition into a D-SNP subject to this rule, the destination decision therefore depends on the member’s Medicaid enrollment too.

The FAQs also describe an exception for certain full-benefit members receiving Medicaid through fee-for-service. It depends on a state that does not mandate managed-care enrollment for all full-benefit dual-eligible individuals and a state contract allowing those fee-for-service members into a coordination-only or highly integrated D-SNP. A full-benefit look-alike member staying in an unrelated Medicaid managed-care plan cannot enter that D-SNP through this exception. The transition roster needs to reflect that difference, rather than treating every dual-eligible member as eligible for the same destination.

The American Institutes for Research report warns that automatic enrollment can disrupt continuity of care and leave needs unmet. That is why the roster, the notice and the state contract deserve to be read together.

When You Know Why Members Were Moved

If you worked on the transition roster, eligibility rules or member notices and know why the destinations did not match the promised coverage, speak with our whistleblower experts about those decisions. We build the case with you around the member movements, government payments and choices inside the organization, bring in Medicare Advantage whistleblower lawyers who understand enrollment and integrated care, and stay beside you throughout the case.