Series 6: How States and D-SNPs Must Prepare to Protect Expansion Duals
Why states and health plans must act now to protect expansion duals from coverage gaps as Medicaid work requirements take effect in 2027.
Starting in January 2027, new Medicaid work requirements will pose significant challenges for a small but highly vulnerable group, “expansion duals.” This group consists of individuals who initially qualified for Medicaid through income-based expansion and later became eligible for Medicare due to a disability. Unlike traditional dual eligibles who are mostly older or SSI recipients and automatically exempt, expansion duals often face unclear exemption rules, forcing them to navigate redundant documentation despite already undergoing rigorous federal disability determinations. Losing Medicaid means losing critical wrap-around services like medications, transportation, and care coordination, rendering Medicare coverage nearly unusable. Though only a few hundred thousand people, about 2–4% of dual eligibles, are affected, the stakes are enormous. These individuals are younger and managing complex conditions like behavioral health and chronic pain. Concentrated in expansion states such as California and New York, policy decisions on automatic exemptions will determine whether they maintain access to care or fall through the cracks. For health plans and states, success hinges on minimizing administrative burden, integrating technology, and respecting existing disability determinations to protect this intensely challenged population.
With just 12 months left before implementation, states and D-SNPs face an urgent and complex race to prepare for Medicaid work requirements. States must move quickly to finalize critical policy decisions such as whether Medicare disability determinations will trigger automatic exemptions, what documentation standards will apply, and whether presumptive eligibility will protect members during processing. These choices will shape the administrative burden for both plans and beneficiaries. At the same time, D-SNPs must begin building infrastructure for risk stratification, exemption support, and verification workflows, while ensuring care coordinators are trained to navigate new requirements. Success will hinge on deploying flexible technology platforms, forging strong partnerships with providers for timely documentation, and implementing clear, accessible communication strategies to reach members with cognitive or language barriers. Any delay in policy clarity compresses timelines, increasing the risk of rushed rollouts, member confusion, and costly disruptions. Ultimately, the next year will determine whether expansion duals, those most vulnerable to policy complexity, retain the integrated care they depend on. Collaboration between states and health plans is not optional; it is the only path to ensuring continuity of care for this high-need population.
Explore Syam Adusumilli’s Series 6 articles for actionable strategies on risk stratification, exemption documentation, technology integration, state coordination, and other critical steps D-SNPs and states must take before work requirements begin.
Read Series 6 here:
6A: The Expansion Dual Challenge
6B: Managing Dual Eligibles Under Work Requirements:What D-SNPs and States Must Do
