Medicare Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

If you or a family member has both Medicare and Medicaid, the rules governing how those two programs work together changed materially on 1/1/2026. The Centers for Medicare & Medicaid Services (CMS) sunset its decade-long Financial Alignment Initiative (FAI) on 12/31/2025, ending the Medicare-Medicaid Plan (MMP) demonstration that hundreds of thousands of dual-eligible Americans were enrolled in. The successor architecture is the Fully Integrated Dual Eligible Special Needs Plan, the FIDE-SNP, which CMS has positioned as the "high-integration" tier of dual-eligible coverage going forward.

This guide explains what a FIDE-SNP is, how it differs from a standard D-SNP, what changed on 1/1/2026, what changes again in 2027 and 2030, and what to compare when you shop for a plan.

In This Guide

• 60-Second Version
• Sources Used
• Where a FIDE-SNP Fits: D-SNP, HIDE-SNP, CO-D-SNP
• What a FIDE-SNP Means for You
• Why the Old Medicare-Medicaid Plans Went Away
• What Changes in 2026, 2027, and 2030
• State-by-State Landscape
• Star Ratings and Plan Quality
• What FIDE-SNPs Cover and What You Pay
• Care Coordination Architecture
• 10 Common Family Pitfalls
• H.R. 1 and the Retroactive Coverage Sunset
• Three Worked Examples
• What to Watch in 2026-2027
• Where to Get Help
• Learn More

60-Second Version

On 1/1/2026 every remaining capitated MMP state moved its enrollees into a FIDE-SNP or a HIDE-SNP, or ended the program. The state table below has the per-state result.

On 1/1/2027 a parent organization may run only one D-SNP per service area limited to full-benefit duals aligned with its Medicaid plan, and integrated D-SNPs must issue one member ID card and run one combined health risk assessment.2 H.R. 1 (signed 7/4/2025) also shortens retroactive Medicaid coverage that day: one month before the application month for the ACA-expansion group, two months for most others.3

On 1/1/2030 those D-SNPs may only cover duals who are in the affiliated Medicaid plan.2

Sources Used

Regulatory framework: 42 CFR 422.2 (plan-type definitions), 422.4, 422.52, 422.101(f), 422.107, 422.514(h), 422.561, and 42 CFR 438.210/400/402.1

Key rulemakings: the CY2023 MA/Part D Final Rule (87 FR 27704, May 9, 2022) ended the MMP demonstration; the CY2025 Final Rule (89 FR 30448, April 23, 2024, CMS-4205-F) set the alignment timeline; and the CY2027 Final Rule (91 FR 17384, April 6, 2026) left the EHO4All health equity index unimplemented. The FAI ran under §1115A of the Social Security Act; the retroactive-coverage change is in H.R. 1 / Public Law 119-21. This guide also draws on state policy memos and analyses from MACPAC, ATI Advisory, Justice in Aging, and the Integrated Care Resource Center.

Where a Medicare Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) Fits: D-SNP, HIDE-SNP, and CO-D-SNP

A Special Needs Plan (SNP) is a Medicare Advantage plan that restricts enrollment to one category of beneficiary. Under 42 CFR 422.4 there are three: D-SNPs for dual eligibles, C-SNPs for people with one of 15 CMS-listed chronic conditions, and I-SNPs for people who live in (or need the level of care of) a nursing facility. For a walkthrough of all three, see how Medicare Special Needs Plans work.

Within the D-SNP category, CMS ranks plans by how tightly they integrate with the state Medicaid program.

Coordination-Only D-SNP (CO-D-SNP)

Covers Medicare benefits only. Medicaid benefits, LTSS included, are reached separately through Medicaid fee-for-service or a different managed-care plan. The plan holds a State Medicaid Agency Contract (SMAC) under 42 CFR 422.107 setting minimum care-coordination duties, but financial integration is minimal. This is still the most common D-SNP nationally.

Highly Integrated Dual Eligible SNP (HIDE-SNP)

A D-SNP whose parent organization (or an affiliate) holds a capitated Medicaid contract for primary and acute care plus either LTSS or behavioral health, not necessarily both. Medicare and Medicaid stay under separate contracts. Examples in 2026: Michigan Coordinated Health, South Carolina plans, and Texas STAR+PLUS-aligned plans.

Fully Integrated Dual Eligible SNP (FIDE-SNP)

Under 42 CFR 422.2, a FIDE-SNP is a D-SNP delivered through a single entity holding both an MA contract with CMS and a capitated Medicaid managed-care contract with the state. That Medicaid contract must cover primary and acute care (including Medicare cost-sharing for plan year 2025 and later), behavioral health, home health, medical equipment, and Medicaid LTSS, including at least 180 days of nursing-facility coverage. For 2025 and later the plan must also run Exclusively Aligned Enrollment (EAE), so every member is also in the affiliated Medicaid plan, with no mismatched enrollment. FIDE-SNPs are "applicable integrated plans" under 42 CFR 422.561, which merges Medicare and Medicaid grievances and appeals into one process instead of two.1

In practice that also means one Care Manager for both programs, one member-services line, and combined member materials. Two clarifications worth holding onto: every FIDE-SNP is a D-SNP but most D-SNPs are not FIDE-SNPs, and a FIDE-SNP is not PACE, which is a separate and much smaller program under 42 CFR Part 460.

What a Medicare Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) Means for You

Strip out the regulation and the member experience is the point. A FIDE-SNP enrollee gets one plan card, one member-services number, one Care Manager who can see both the Medicare and the Medicaid side, one integrated appeal when something is denied, and, if they are in the QMB group, $0 Part A and Part B deductibles, coinsurance, and copays, because Medicare providers are not allowed to bill a QMB enrollee for services and items Medicare covers.1

Contrast that with the coordination-only world: a Medicare D-SNP card from one company, a Medicaid managed-care card from another, two prior-authorization queues, two appeal clocks, and no one person accountable for the gap between them.

The trade-off is a narrower network, because the plan has to align a Medicare network and a Medicaid network at once.

Why the Old Medicare-Medicaid Plans Went Away

The Financial Alignment Initiative was a §1115A demonstration launched under the Affordable Care Act in 2013-2015 to test whether pooling Medicare and Medicaid financing for dual eligibles produced better outcomes at lower cost. Its capitated arm created the Medicare-Medicaid Plans and served several hundred thousand people at peak; a managed fee-for-service arm ran in Washington and Colorado.

In the CY2023 MA/Part D Final Rule (87 FR 27704, May 9, 2022) CMS announced it would not renew MMPs past 12/31/2025. Its reasoning: the FIDE-SNP, a Medicare Advantage plan type defined at 42 CFR 422.2, had matured enough to absorb most MMP enrollees at comparable integration while sitting inside durable MA rules rather than a demonstration needing periodic renewal;1 MMPs confused members, because one company might sell an MMP, a D-SNP, and a Medicaid plan in the same state with overlapping benefits; and §1115A authority created year-over-year uncertainty for states and plans.

Two states left early: New York's FIDA ended 12/31/2019 and Virginia's MMP ended 12/31/2017. Even so, the 12/31/2025 sunset is the largest reorganization of dual-eligible coverage since Part D launched in 2006.

What Changes for Dual-Eligible Plans in 2026, 2027, and 2030

Alongside sunsetting the demonstration, CMS used the CY2025 MA and Part D Final Rule (89 FR 30448, April 23, 2024) to set a multi-year march toward a tightly aligned D-SNP market.

Already in effect. Every FIDE-SNP must run Exclusively Aligned Enrollment; it is written into the 42 CFR 422.2 definition for plan year 2025 and later. In parallel, the D-SNP "look-alike" threshold, the share of a non-SNP Medicare Advantage plan's enrollment that is dually eligible, at or above which CMS declines to renew the contract, stepped down from 80% before 2025 to 70% for plan year 2025 and to 60% for plan year 2026 and later.4

1/1/2027. Under 42 CFR 422.514(h), an MA organization (or its parent, or a commonly owned entity) is capped on how many D-SNP benefit packages it may offer in a service area alongside an affiliated Medicaid plan: in practice, one D-SNP per service area limited to full-benefit duals enrolled in that Medicaid plan. Separate provisions require applicable integrated plans to carry one member ID card for both plans and one integrated health risk assessment by contract year 2027.2

1/1/2030. Under 42 CFR 422.514(h), those D-SNPs may only enroll or keep covering people who are also in the affiliated Medicaid plan, so continued coverage, not just new enrollment, turns on the match.2

If your loved one is in a CO-D-SNP today, expect fewer choices as organizations consolidate, expect to move either the D-SNP or the Medicaid plan if different companies run them, and read each annual notice of change.

State-by-State Landscape

This is the picture as of 1/1/2026. The federal definition each state builds on sits at 42 CFR 422.2.1

Plus the native FIDE-SNP states, which built FIDE-SNPs with no MMP predecessor:

For each state's program in detail, see its state guide.

Star Ratings and Plan Quality

CMS rates Medicare Advantage plans, D-SNPs included, on a 1-to-5 star scale, and a contract at 4, 4.5, or 5 stars earns a 5% quality bonus payment on its county rates that plans typically spend on richer benefits. Ratings appear on the Medicare Plan Finder at medicare.gov/plan-compare. A five-star plan also carries its own enrollment right, usable once between December 8 and November 30 the following year.5

D-SNP ratings have historically trailed non-SNP MA plans for structural reasons: higher acuity, more social barriers, weaker preventive-care numbers. FIDE-SNPs tend to score above the broader D-SNP average, but check the specific plan rather than the category. The CY2027 Final Rule (91 FR 17384, April 6, 2026) confirmed CMS will not implement the EHO4All health equity index that plans expected would lift D-SNP scores, so don't count on it.

Look past the overall star to the member-experience measures ("Getting Care Quickly," "Care Coordination"), the complaint rate per 1,000 members, and the Medicaid-side disenrollment rate, which flags operational trouble.

What FIDE-SNPs Cover and What You Pay

On the Medicare side the plan pays for what Original Medicare would: Part A inpatient, skilled nursing, hospice and some home health; Part B physician, outpatient, equipment, labs and mental health; and Part D drugs through its own formulary, since a FIDE-SNP cannot be paired with a standalone drug plan. Most add the usual Medicare Advantage extras: dental, vision, hearing, an over-the-counter card, transportation, and meals after a hospital stay.

On the Medicaid side, under the capitated Medicaid contract, the same plan pays for LTSS (nursing-facility care plus home- and community-based services such as personal care attendants, adult day health, and assisted-living waiver services where a state offers them), behavioral health, and Medicaid-only extras such as routine non-emergency transportation.

What a full-benefit dual eligible actually pays:

• $0 monthly premium in most integrated D-SNPs. That is a common plan-design choice, not a legal guarantee, so confirm it plan by plan.
• $0 Part A and Part B deductibles, coinsurance, and copays for someone in the QMB group, because Medicare providers are not allowed to bill a QMB enrollee for services and items Medicare covers. Inside a FIDE-SNP this happens automatically at the point of service, and for plan year 2025 and later the plan's own capitated Medicaid contract must cover Medicare cost-sharing.1
• Part D drugs are cheap but not always free. In 2026 a full-benefit dual eligible in the QMB program pays no more than $4.90 for each covered drug, while other full Extra Help enrollees (Extra Help being the Part D Low-Income Subsidy, administered by the Social Security Administration) pay up to $5.10 per generic and $12.65 per brand-name covered drug, dropping to $0 once out-of-pocket drug costs reach the $2,100 annual cap.6

The big exception: nursing-facility residents must contribute most of their monthly income, less a personal needs allowance, toward their care. That holds in any plan, or none.

Care Coordination Architecture

The operational heart of a FIDE-SNP is a single accountable Care Manager, working inside the single-entity, exclusively aligned structure 42 CFR 422.2 requires.1 The title varies by state and plan: Care Coordinator, Service Coordinator, Geriatric Service Coordinator, Lead Care Manager. The job typically covers a comprehensive health assessment after enrollment, an individualized care plan spanning medical, behavioral health, LTSS and social needs, an interdisciplinary team that includes the member and family caregiver alongside the clinicians, hospital and nursing-facility discharge transitions, and authorization of waiver services.

LTSS authority is the sharpest difference from a CO-D-SNP. In a coordination-only plan, waiver authorizations come from a separate Medicaid case manager with no relationship to the Medicare plan. In a FIDE-SNP, the Care Manager holds authority across both. Behavioral health usually sits inside the same structure, which matters for a population with elevated rates of serious mental illness, depression, and dementia.

Massachusetts runs a variant: in SCO and One Care, a member with HCBS needs is assigned an Independent Living LTSS (ILLTSS) coordinator, usually based at an Aging Services Access Point, who authorizes the LTSS side. See Massachusetts SCO and One Care.

10 Common Family Pitfalls

1. Assuming every D-SNP is integrated. A coordination-only D-SNP covers Medicare only. Ask which tier a plan is, FIDE, HIDE, or coordination-only, before enrolling.
2. Confusing a FIDE-SNP with PACE. PACE is a separate program under 42 CFR Part 460, restricted to age 55+ at nursing-facility level of care and built around a day center. Most duals cannot enroll in it.
3. Assuming you can switch whenever you like. Dual eligibles get generous special enrollment rights, but they are not continuous. Confirm your current window with your State Health Insurance Assistance Program first.
4. Trading a FIDE-SNP for a less integrated plan and losing the Care Manager. A switch almost always breaks that relationship, and the new plan's coordination duties are weaker.
5. Checking only the doctors. FIDE-SNP networks are narrow. Check the physicians and the LTSS providers: the personal care agency, the adult day program.
6. Assuming the nursing facility is in network. It usually is. Confirm it anyway; FIDE-SNPs contract with specific facilities.
7. Letting Medicaid renewal lapse. Losing Medicaid, even briefly, can get a member involuntarily disenrolled. Plans provide a deemed-continued-eligibility grace period, but it is limited. Ask how long yours runs.
8. Not using the integrated appeal. FIDE-SNP appeals follow the applicable-integrated-plan rules at 42 CFR 422.561, combining Medicare and Medicaid into one process instead of two. That is a member protection, so use it.1
9. Enrolling two dual-eligible spouses in different plans. The same plan means a shared Care Manager and far less coordination work.
10. Not asking about supplemental benefits. Integrated capitation usually funds richer dental, vision, hearing and transportation benefits than a standalone D-SNP. Ask specifically.

H.R. 1 (2025) and the Retroactive Coverage Sunset

Federal law today requires every state Medicaid program to cover services furnished as far back as the third month before the month of application, if the person would have been eligible then. The statute is section 1902(a)(34) of the Social Security Act, implemented at 42 CFR 435.915. H.R. 1, the reconciliation law signed 7/4/2025 (Public Law 119-21), shortens that window for applications made on or after 1/1/2027: to two months before the application month for most enrollees, and one month for the ACA Medicaid expansion adult group.3

Most dual eligibles qualify through an aged or disabled pathway, so the two-month limit is the one that will bite. Apply as early as you reasonably can: the three-month cushion families have leaned on for decades is going away, and an application that takes weeks to process no longer has as much room behind it. For state timelines, see the state guides, such as Massachusetts income limits.

Three Worked Examples

Maria, 78, Massachusetts SCO member (FIDE-SNP)

Maria is a Spanish-speaking widow in East Boston with Medicare Parts A, B and D, MassHealth Standard, congestive heart failure, and mild cognitive impairment. Through 2025 she carried a Medicare D-SNP card from one company, a MassHealth managed-care card from another, and HCBS services authorized by an ASAP case manager, with no single point of contact.

On 1/1/2026, SCO converted to a FIDE-SNP, and all SCO enrollees must now hold both Medicare Part A and Part B; members who lacked both parts moved to MassHealth fee-for-service that day while keeping MassHealth Standard.7 Maria had both parts, so she now has one plan card, one Geriatric Service Coordinator, an ILLTSS coordinator at her ASAP for personal-care authorizations, member services in Spanish at one number, and one appeals process. When she was hospitalized in March 2026 for a heart-failure exacerbation, the coordinator convened a discharge meeting two days ahead with her physicians, the rehab facility, the ILLTSS coordinator, and her daughter Carmen. Under the old split arrangement, those transitions had gone badly every time.

James, 67, California Medi-Medi Plan member (EAE D-SNP)

James lives in Fresno County with Medicare Parts A, B and D and full-scope Medi-Cal, on dialysis for end-stage renal disease. Fresno sat outside the original Cal MediConnect demonstration, so through 2025 his D-SNP and his Medi-Cal plan had different parent organizations. When California's Medi-Medi Plan framework reached his county for 2026, the two came under one parent. His plan meets the HIDE-SNP threshold rather than full FIDE, because California is phasing LTSS integration in county by county, so he gets a single Care Manager and integrated member services but his personal care hours still flow through county-run In-Home Supportive Services.

Robert, 71, Ohio Next Gen MyCare member (FIDE-SNP)

Robert is an Air Force veteran in Cleveland with Medicare Parts A, B and D, Ohio Medicaid, COPD, and depression. On 1/1/2026 his MyCare Ohio MMP ended and he was passively enrolled in Next Gen MyCare, Ohio's FIDE-SNP architecture. Little changed from his side: same plan brand, same Care Manager under continuity rules, same providers, a new ID card and member-services number. His daughter did notice one thing: the Part D formulary shifted at the transition and one of his inhalers moved tiers. The Care Manager helped her file a formulary exception.

What to Watch in 2026-2027

• The CY2027 final rule landed 4/6/2026 (91 FR 17384, effective 6/1/2026). It leaves the EHO4All health equity index unimplemented and continues the CY2025 alignment timeline, including the 60% look-alike threshold.4
• H.R. 1 implementation. CMS guidance on the retroactive-coverage limits is expected through 2026, and states will file conforming plan amendments. The 1/1/2027 date is firm.
• State Medicaid contract cycles. What a FIDE-SNP actually covers is written into each state's Medicaid contract, so watch state RFPs and amendments.
• The 2030 disenrollment. CMS still owes guidance on default-enrollment mechanics, member notices, and continuity-of-care protections.

Where to Get Help

• Your State Health Insurance Assistance Program (SHIP) gives free, unbiased Medicare counseling, including side-by-side D-SNP comparison. Find yours through the locator at shiphelp.org, which also lists 877-839-2675, or the per-state phone directory in the back of Medicare & You 2026. Many states run theirs under another name, such as HICAP, SHINE, SHICK, or VICAP.8
• Medicare Plan Finder at medicare.gov lists every plan available in a ZIP code alongside its star rating.5
• The CMS Medicare-Medicaid Coordination Office (the Federal Coordinated Health Care Office) owns federal dual-eligible and D-SNP policy.1
• National organizations publishing free consumer or policy material on dual-eligible issues: the Medicare Rights Center, Justice in Aging, the Center for Medicare Advocacy, MedPAC and MACPAC, and the SNP Alliance.

Learn More

Find personalized help comparing Medicare and Medicaid dual-eligible coverage at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.