For Dual Eligible Special Needs Plans (D-SNPs), one of the most difficult operational challenges is fundamental to the model itself: coordinating Medicare and Medicaid administration around the same member.

D-SNPs serve individuals who are eligible for both Medicare and Medicaid. But those benefits originate from two distinct programs, with different eligibility structures, covered services, payment methodologies, reporting requirements, and administrative processes.

The result is an administrative environment in which one member can generate dependencies across enrollment, benefits, provider administration, authorizations, claims, encounters, and financial reconciliation.

That fragmentation has consequences beyond the back office. In its March 2026 report to Congress, the Medicare Payment Advisory Commission (MedPAC) states that dually eligible beneficiaries may receive fragmented or poorly coordinated care because of the challenge of navigating two distinct and complex programs. MedPAC also notes that integrated models have the potential to improve the enrollee experience by bringing together functions such as member materials, care planning, appeals, and grievances.

For health plans, delivering that more coordinated experience requires substantial coordination behind the scenes.

Eligibility needs to remain current. The right benefits must apply on the date of service. Provider and network rules need to resolve correctly. Authorizations must be available when a claim is adjudicated. Processed claims need to feed encounter reporting.

Finance teams need to understand whether expected government revenue matches what the plan actually received.

The challenge is not simply administering Medicare and Medicaid.