CMS’s 2025–2030 updates to Dual-Eligible Special Needs Plans (D-SNPs) are among the most sweeping reforms to date, and they signal a clear shift: dual-eligible care must move from fragmented compliance exercises to fully integrated, outcomes-driven operations. For health plans—especially Medicaid-only plans—the stakes could not be higher.
For many Medicaid-only health plans, these new requirements mean managing an entirely new set of programs they may have little to no experience with—programs such as Medicare Stars, Medicare Risk Adjustment, and value-based primary care. These are not optional add-ons; they are critical to the financial viability of DSNP participation. A small, high-cost dual-eligible population will now drive a disproportionate share of revenue risk, making Stars performance and accurate disease burden capture essential.
In short: failure to adapt jeopardizes revenue. Success requires new competencies in Medicare Advantage performance management, risk adjustment, and primary care alignment—competencies that Cozeva has been helping health plans build for over a decade.
Why Cozeva Matters Now
Cozeva’s all-in-one platform was purpose-built as bridge technology—integrating Medicare and Medicaid operations into a single workflow. By aggregating clinical, administrative, and social determinant data, Cozeva helps plans:
- Track member alignment and identify misaligned members in real time.
- Monitor SEP participation through automated alerts and dashboards.
- Engage primary care providers with tools that support value-based payment models.
- Drive Stars improvement, close care gaps, and strengthen revenue capture through accurate risk adjustment.
This unique combination—Medicare expertise, Medicaid integration, and provider engagement—is exactly what Medicaid-only plans need as they step into the world of Medicare Advantage performance.
Real-World Impact
A leading healthcare provider in California’s Central Valley illustrates the power of this approach. Managing a large, high-vulnerability DSNP population, the organization used Cozeva’s integrated platform to achieve measurable results:
- Increased Medicare Advantage Star Rating from 2.5 to 4
- Reduced uncontrolled A1C rates from 55–60% to 30%
- Improved RAF accuracy by 0.183
- Generated significant pay-for-performance revenue gains
These outcomes show how the right platform can help plans move beyond regulatory checklists to drive both financial viability and better outcomes for dual-eligible populations.
Primary Care at the Center
A critical factor in DSNP success is primary care alignment. CMS’s new requirements demand tighter provider engagement than many Medicaid plans are used to. Risk adjustment, quality performance, and Stars measures all depend on primary care providers delivering, documenting, and coordinating care effectively.
Cozeva brings years of experience engaging and aligning primary care networks to value-based models. Its platform delivers normalized Medicare and Medicaid data directly into provider workflows, allowing clinicians to see member alignment status, receive automated SEP alerts, and close care gaps during routine encounters. By making compliance tasks actionable in the exam room, Cozeva ensures providers are partners—not bystanders—in DSNP success.
The Path Forward
As CMS expands financial alignment requirements nationwide, the message is clear: plans that can integrate Medicare and Medicaid operations, support primary care engagement, and execute on Stars and risk adjustment requirements will thrive. Plans that cannot will see revenue at risk.
Cozeva’s early adopters are already demonstrating measurable improvements in DSNP readiness and performance. By investing in interoperable technology that bridges both lines of business, health plans can reduce administrative friction, retain members, improve quality scores, and secure the financial foundation needed to sustain dual-eligible care.
The time to act is now. Medicaid-only plans facing Medicare requirements for the first time must move quickly to close capability gaps. By partnering with a proven platform like Cozeva—one that understands both Medicare and Medicaid and brings unmatched expertise in primary care alignment—plans can turn regulatory mandates into measurable success.
