Contract Year 2026 brings a different operating reality for Dual Eligible Special Needs Plans (D-SNP). Monthly Special Enrollment Periods (SEPs) introduced in 2025 are now the market’s “new normal,” steering full-benefit duals toward integrated offerings and reshaping how plans compete outside AEP. Meanwhile, the Medicare Advantage Value Based Insurance Design (VBID) model sunsets after 2025, removing a lever many plans used for $0 drug copays and broad supplemental benefits.
Layer on top the 2026 final rule’s protections around appeals/prior authorization, codified guardrails for Special Supplemental Benefits for the Chronically Ill (SSBCI), and automatic renewal for the Prescription Payment Plan, and you get a year defined by operational execution, not just benefit design.
Learn what is final, what is still proposed or not finalized, and what health plans should do now to stay ahead under evolving D-SNP regulations.
VBID Ends After 2025
CMS has terminated the Medicare Advantage VBID model after plan year 2025 due to unmitigable costs.1 For 2026, many plan features that were enabled or sweetened under VBID (e.g., blanket $0 copays across all covered Part D drugs, broad “wallets” for food and utilities) will no longer be available under that model. Expect more reliance on standard Part D/LIS cost-sharing rules and on SSBCI benefits that meet tightened requirements. This is a noticeable change members will ask about, especially those accustomed to $0 prescriptions. Plans generally can’t offer all drugs at $0, and non-medical supports like healthy food and utilities will require verification of a qualifying chronic condition, so Annual Notice of Change (ANOC) / Evidence of Coverage (EOC) and frontline Frequently Asked Questions (FAQs) should be prepared accordingly.
Operational To-Dos
- Re-price and re-position benefits that previously leaned on VBID and update formulary/member scripts to clarify where Extra Help/Low Income Subsidy (LIS) vs. plan design applies
- Refresh your Special Supplemental Benefits for the Chronically Ill (SSBCI) catalogs and eligibility verification workflows to avoid member abrasion at point of service
CY 2026 Final Rule (CMS-4208-F)
For 2026, the headline changes for D-SNP are operational and member-facing. CMS’s final rule clarifies that concurrent level-of-care decisions are organization determinations that can be appealed, requires stronger provider notifications when filing on a member’s behalf, and limits when plans can reopen previously approved inpatient stays, which means updating UM and provider-relations procedures for the new year.2 CMS also codifies tighter SSBCI rules, including clearer examples of non-allowable uses, so catalogs, eligibility checks, card programs, and member materials should reflect those guardrails in 2026.2
The rule also locks in automatic renewal of the Prescription Payment Plan (PPP) starting in 2026 unless a member opts out, which affects billing cadence and requires simple explanations that distinguish PPP from LIS in every channel.2
Operational To-Dos
- Update UM/appeals workflows and provider notices to reflect appealability of concurrent determinations and limits on reopening approved inpatient stays
- Institute SSBCI governance (benefit catalog review, eligibility proof, file/audit trails), including vendor oversight for compliant member-facing language
- Implement PPP auto-renewal changes with Pharmacy Benefit Managers (PBMs)/billing and add clear member-education touchpoints
Related Reading: Charting a New Course for D-SNP Compliance
Part D Redesign Continues
CMS’s CY 2026 Rate Announcement and the final Part D redesign program instructions continue the multiyear update to Part D benefit timing and liability, and they intersect with the Medicare Prescription Payment Plan’s shift to ongoing participation unless a member opts out.3 Your 2026 contact center talking points and digital cost calculators should reflect the year’s timing conventions so members understand how and when costs post. Two broad takeaways are that the redesign implements IRA driven updates that simplify how costs flow through the benefit and clarify the roles of plans, manufacturers, and CMS, including use of a selected drug subsidy tied to negotiated prices.
Operational To-Dos
- Sync pharmacy, PBM, and billing partners on cost-sharing timing and member notices
- Calibrate quality/call-handling Key Performance Indicators (KPIs) for first-contact resolution on “Why did my costs change?” and “What is PPP vs. LIS?”
2027 Integration Prep
While the compliance date is 2027, CMS finalized new federal requirements that certain integrated D-SNPs must issue integrated member ID cards (serving both Medicare and Medicaid) and perform a single integrated Health Risk Assessment (HRA) covering both programs. CMS also codified timeframes for HRAs and individualized care plans (ICPs). 2026 should be used for preparation: select vendors, align file feeds, update welcome kits, and rehearse cross-program data flows. Professional society summaries like those from ASHA called out these specifics as part of the final rule’s dually eligible experience improvements.4
Operational To-Dos
- Map your applicable contracts/populations and coordinate with state partners
- Blueprint integrated card issuance and the integrated HRA data model and pre-test member materials across literacy levels
2026 Readiness Checklist
- De-VBID Your Benefit Messaging: Remove VBID-specific language, pivot to LIS/plan design explanations, and update ANOC/EOC and digital copy.
- Strengthen SSBCI Governance: Vet 2026 catalogs against non-allowable examples, implement chronic-condition verification and audit trails, and review vendor copy to avoid prohibited dollar-value marketing.
- Re-tool UM/Appeals Standard Operating Procedures (SOPs): Incorporate appealability of concurrent determinations, strengthen provider notice workflows, and constrain inpatient reopening actions.
- Implement PPP Auto-Renewal Flawlessly: Coordinate billing/PBM partners, script “PPP vs. LIS” explanations, and tune your Interactive Voice Response (IVR), web, and agent tools to show enrollment status and next-bill estimates.
- Start the 2027 Integrated Build: Select vendors for integrated ID cards, design a single integrated HRA, align with state Medicaid partners, and plan member communications.
- Monitor (But Don’t Over-Invest in) proposals: Keep radar on marketing oversight, Medicare Plan Finder (MPF) directory data, and Artificial Intelligence (AI) guardrails, taking action only when final.
Entering into 2026 with Confidence
Contract Year 2026 is about strong execution. Focus on clear member communications, disciplined SSBCI governance, up-to-date UM and appeals workflows, and simple explanations of PPP and LIS. Use the year to strengthen cross-functional routines and set the foundation for 2027’s integrated requirements without adding unnecessary complexity.
The larger outcome for health plans and MCOs will be reduced compliance exposure, fewer member friction points, and steadier retention in D-SNP. Done well, these shifts support quality performance, predictable costs, and healthier state and vendor relationships that carry into future plan years.
If you want a steady partner for these updates, Clearlink can draw on clinical management and operational management expertise to help your teams put policy into practice. We can assess readiness, advise on benefit and policy implementation across functions, and support staff training and performance routines so your day-to-day operations keep pace with changing rules. Our goal is to help you keep members informed, providers aligned, and internal processes consistent across channels.
Contact us for some extra support in moving through 2026 with greater confidence.
Sources:
1. Medicare Advantage VBID Model to End after Calendar Year 2025, CMS
2. Fact Sheet: Contract Year 2026 Policy and Technical Changes, CMS
3. CMS Finalizes 2026 Payment Policy Updates for Medicare Advantage & Part D Programs, CMS
4. CMS Finalizes Policy Updates for the 2026 Medicare Advantage Contract Year, ASHA