D-SNP is a different network problem.
D-SNP adequacy requirements differ from standard Medicare Advantage in ways that matter at the build phase. Here's what changes and what doesn't.
Dual-eligible Special Needs Plans attract a lot of interest right now — the population is large, the margins can be favorable compared to standard MA, and the regulatory environment has been moving in a direction that rewards integration with Medicaid. What often gets underestimated is that a D-SNP is not simply a Medicare Advantage plan with supplemental benefits for low-income members. It has its own network requirements, its own Medicaid-side obligations, and its own compliance relationship with the state that a standard MA plan does not have.
Teams that build D-SNP networks using a standard MA build framework run into these differences about halfway through, when it becomes clear that some of what they have built doesn't satisfy the D-SNP-specific requirements.
The State Medicaid Agency Contract
Every D-SNP must have a contract with the state Medicaid agency in each state where it operates (the State Medicaid Agency Contract, or SMAC, required by MIPPA and 42 CFR 422.107). This is a formal agreement between the plan and the state that describes how the plan will coordinate care with Medicaid, exchange member data, and align care management activities.
The SMAC is due to CMS by the first Monday in July before the contract year, and the plan cannot operate as a D-SNP without it. Negotiating a SMAC with a state Medicaid agency takes time. The state has its own legal review process, its own policy requirements, and its own timeline. In states with active managed Medicaid programs, the state Medicaid agency is often in active negotiations with multiple plans and may not move quickly on a new entrant.
If you are building a D-SNP for the first time in a state where you don't have an existing Medicaid relationship, the SMAC negotiation timeline needs to be built into your plan from day one, not treated as a parallel track that will somehow come together by July.
Network requirements that differ from standard MA
D-SNP networks need to address several provider types that a standard MA network may not prioritize:
- Long-term services and supports (LTSS) providers: D-SNPs with LTSS integration requirements need to contract with home health agencies, personal care services providers, and potentially nursing facilities. These are not part of a standard MA network build.
- Behavioral health with SUD treatment: The dual-eligible population has higher rates of behavioral health conditions and substance use disorders than the standard MA population. Plan for SUD treatment capacity as its own category. Of SUD providers, only opioid treatment programs carry SAMHSA certification, so check what your state contract actually expects for the rest.
- Community-based organizations: Some states require D-SNPs to have relationships with community-based organizations (CBOs) for social determinants of health (SDOH) referrals. These are not traditional provider contracts but they are part of the network ecosystem.
- Dental, vision, and hearing: While supplemental benefits like dental, vision, and hearing are common across MA, D-SNPs are not required to offer them. Most D-SNPs offer them because the population needs them, and whatever you put in the bid you have to be able to deliver.
Care coordination expectations
D-SNP regulations require an Individualized Care Plan (ICP) for each enrolled member, coordinated between the plan's care management team and the member's primary care provider. This means the PCP network for a D-SNP is not just an adequacy box to check — it is the clinical infrastructure for a care coordination program.
When you are recruiting PCPs for a D-SNP network, the conversation is different from a standard MA conversation. You need PCPs who have experience with the dual-eligible population, who understand the care complexity of members with both Medicare and Medicaid coverage, and who are willing to participate in care plan coordination activities beyond just seeing patients for office visits.
Not every primary care practice that is willing to join your MA network will be the right fit for your D-SNP network. Building a D-SNP PCP network sometimes means being more selective than a straight adequacy exercise would suggest.
A D-SNP network that passes adequacy review but can't actually support the care coordination model is an adequacy problem waiting to happen at the first HEDIS cycle.
State-specific requirements
D-SNP requirements vary significantly by state because the Medicaid side of the equation is state-governed. Some states have highly prescriptive requirements about what a D-SNP network must include and how care coordination activities must be structured. Others have more flexibility.
Before you design your D-SNP network build, pull the state-specific D-SNP requirements for every state in your footprint. The CMS model of care requirements are the floor. Many states have built a ceiling above them.
Sources: 42 CFR 422.107 (D-SNP contracts with state Medicaid agencies); CMS, Medicare Managed Care Manual Chapter 16-B updates.