The Centers for Medicare & Medicaid Services (CMS) is seeking information related to dual-eligible enrollment in Medicare Advantage institutional special needs plans (I-SNPs). The agency is concerned that such plans have a high number of dual-eligible beneficiaries but are not designed specifically for this group, and is considering putting requirements in place that would align I-SNPs more closely with dual-eligible special needs plans (D-SNPs).

I-SNPs are Medicare Advantage plans tailored for people who require a nursing home level of care. Some I-SNP beneficiaries are eligible for both Medicare and Medicaid coverage; however, I-SNPs “do not integrate Medicare and Medicaid benefits and may not be the best approach for meeting the needs of dually eligible individuals,” CMS stated in a proposed rule issued Tuesday.

That same concern applies to dual eligible beneficiaries in chronic condition special needs plans (C-SNPs). The number of C-SNPs and the number of dual-eligible beneficiaries in C-SNPs have “grown significantly” in the last three years, according to the proposed rule. The number of dual eligible beneficiaries in I-SNPs has been “more stable,” but CMS is still seeking input on dual-eligible enrollment trends in both C-SNPs and I-SNPs in order to inform future policymaking.

The agency is particularly concerned about the growth of C-SNPs, which are plans designed to meet the needs of people living with chronic conditions such as heart failure or diabetes.

“The growth in C-SNP enrollment could be an intentional approach by MA organizations to circumvent Federal and State requirements for dual eligible special needs plans (D-SNPs), such as States determining which D-SNPs will be offered in a State through their State Medicaid agency contract authority and general coordination and integration requirements,” the proposed rule states.

Nearly all I-SNP enrollees are dually eligible for Medicare and Medicaid, according to a 2023 report from the Medicare Payment Advisory Commission (MedPAC). There were about 125,000 people enrolled in an I-SNP as of last year, representing about 12% of long-stay nursing home residents, according to a March 2025 MedPAC report.

There has been a pullback in the overall number of I-SNPs, with 5% fewer of these plans being offered for 2026, according to an ATI Advisory analysis. However, the number of I-SNPs led by a nursing home provider increased 2% year-over-year.

“I think I-SNPs are a very unique model and a very intimate model, is actually the word I would use,” said Rose Mollitor, managing director for ATI Advisory. “You’re talking about such a population that’s in a concentrated facility, a concentrated location. I think that it’s not surprising that we’re seeing provider-led growth.”

Dual eligible beneficiaries are a particularly vulnerable population that has historically suffered from fragmented care; ATI Advisory Founder and CEO Anne Tumlinson attributed this partly to a problematic “tug of war” that occurs between the Medicare and Medicaid programs.

I-SNPs do resolve some of the issues that compromise care for dual-eligible nursing home residents, but state involvement in these types of plans is not substantial enough to drive truly integrated care, according to David Grabowski, a professor of health care policy at Harvard Medical School and an authority on the nursing home sector.

D-SNPs are designed specifically for the dual-eligible population, but Grabowski is skeptical that D-SNPs will work well as the vehicle to improve care for dual eligibles residing in nursing homes.

“Even though from a state perspective, [D-SNPs] work well, I’m just worried that we’re ever going to get enough volume there for the nursing homes to really invest,” he said.

For its part, CMS is considering putting parameters around C-SNPs and I-SNPs that would bring these programs more in line with D-SNPs.

“CMS is exploring potential solutions including adopting a State Medicaid Agency Contract requirement for C-SNPs and/or institutional special needs plans (I-SNPs) with high concentrations of dually eligible individuals, like existing D-SNP requirements,” the agency stated in a fact sheet on the Nov. 25 proposed rule.

The full text of that proposed rule – entitled “Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program – is accessible via the Federal Register.