Recognizing the diverse and complex needs of dually eligible individuals, state Medicaid agencies are increasingly seeking to better align Medicare and Medicaid services and financing to improve care for this population. To advance integration, states need to understand key features of the Medicare program — particularly Medicare Advantage — and how they intersect with Medicaid policy and program design.

Experience from states participating in the Center for Health Care Strategies’ (CHCS) Medicare Academy, supported by Arnold Ventures, the Commonwealth Fund, and The SCAN Foundation, underscores that Medicare fluency is not a “nice-to-have” capacity, but a foundational competency for effective integration. States report that building Medicare knowledge enables them to thoughtfully design integrated programs, improve internal and cross-agency collaboration, and understand the implications of evolving federal policy. This knowledge is especially important as states navigate complex Medicare Advantage requirements and expand requirements for dual eligible special needs plans (D‑SNPs).

This brief describes how states have applied and sustained Medicare knowledge to advance Medicare-Medicaid integration. It draws on these experiences to illustrate why ongoing Medicare capacity-building efforts — supported by cross-agency training, structured collaboration, and knowledge sharing — are essential for improving care for dually eligible individuals.

The Value of Medicare Knowledge in Advancing State Integrated Care Programs

States operating in diverse Medicaid landscapes have applied Medicare knowledge to successfully: (1) design effective integrated care programs; (2) enhance internal capacity and foster needed cross-agency collaboration; and (3) establish mechanisms to sustain expertise over time.

1. Medicare Knowledge Enables Thoughtful Program Design

Medicare expertise is fundamental for states working to integrate Medicare and Medicaid. Yet, it can be particularly challenging for Medicaid agency staff who are designing new programs to learn the nuances of Medicare Advantage regulations and ever-evolving federal guidance. For example, as Indiana’s Family and Social Services Administration (FSSA) and the District of Columbia’s Department of Health Care Finance began advancing their integration efforts, they relied on technical assistance and resources from federal partners to learn essential Medicare basics. As they encountered more complex policy options, both agencies prioritized the need to develop deeper expertise in Medicare Advantage by participating in CHCS’ Medicare Academy trainings.

In recent years, the state of Indiana adopted a managed long-term services and supports (LTSS) model to help rebalance care toward home- and community-based services. Indiana’s LTSS reform goals included pursuing Medicare-Medicaid integration, due to its large proportion of dually eligible individuals residing in nursing facilities. To achieve this goal, staff at FSSA needed to build technical Medicare Advantage expertise, including an understanding of plan benefit packages, Model of Care requirements, and how to use the state Medicaid agency contract (SMAC) to design a fully integrated program. As they gained this knowledge, state staff were better prepared to frame and weigh alternative policy options to further align the two programs, ask the “right” questions, and devise related SMAC requirements.

The District of Columbia followed a similar path to building Medicare knowledge when it transitioned its coordination-only D‑SNP program to a highly integrated Medicaid managed care option. Early on, as District staff considered how to better coordinate care for existing D‑SNP enrollees, they identified gaps in their understanding of how Medicare Advantage and Medicaid managed care requirements intersect. Staff routinely raised questions about Medicare policy and program features, noting that “they often didn’t know what they didn’t know until they were in the midst of it.” Ultimately, the District successfully designed its integrated program by using federal technical assistance resources to help build initial Medicare capacity. The District also partnered with health plans to learn about CMS Model of Care requirements as it considered how to align Medicaid care management expectations with D‑SNP processes. More recently, staff responsible for contract oversight and performance monitoring have participated in Medicare Academy trainings to build a deeper understanding of CMS’ Medicare Advantage oversight activities and the complementary role states can play in overseeing D‑SNPs.

2. Cross-Agency Training Enhances Capacity and Fosters Collaboration

Medicare knowledge is valuable to a wide range of state staff within Medicaid and across partner agencies. While the need to build Medicare expertise is clear for Medicaid officials directly engaged in integration-related policy and program development, staff working in managed care monitoring, population health, and quality management teams can also benefit from this knowledge. Beyond the Medicaid program, staff from partner agencies also play important roles in advancing integration, including those involved in member counseling and enrollment, D‑SNP contract oversight, and coordination of Medicaid LTSS policy and related oversight. As a result, Medicare trainings should ideally reach staff beyond the Medicaid agency, including partners focused on aging, behavioral health, and developmental disabilities.

For example, California’s Office of Medicare Innovation and Integration strategically trained a cross-agency team on Medicare and D‑SNP topics shortly after the state launched its integrated D-SNP model. The training strengthened participants’ understanding of the state’s integration goals and helped establish a shared language among staff working on issues affecting dually eligible individuals.

Several states have also expanded Medicare knowledge by partnering with state-level Medicare resources, including State Health Insurance Assistance Programs (SHIPs). Beyond building Medicare capacity among Medicaid staff, these partnerships can help SHIP counselors better educate dually eligible individuals about integrated care enrollment options. States also benefit from considering the enrollee perspective when designing integrated programs, and SHIPs have insights from working directly with members that can help Medicaid programs create a more person-centered experience. For example, in preparation for Virginia’s transition to exclusively aligned D‑SNPs, the state partnered with its SHIP to ensure counselors understood exclusively aligned enrollment, why it is required, and the benefits and potential drawbacks for dually eligible individuals — preparing counselors to advise enrollees on their plan options.

Health plans with experience operating integrated care models can also be valuable partners, offering expertise on Medicare Advantage program requirements and helping states assess how new federal rules may impact integration efforts. When states invest in expanding capacity across agencies and engaging partners with Medicare expertise, they are more likely to maintain Medicare capacity over time while strengthening key relationships that advance integration goals.

3. Internal Structures and Training Help Sustain Medicare Expertise

Sustaining Medicare expertise requires established strategies that can keep pace with the ever-evolving nature of federal Medicare policy and the related options states have to advance Medicare-Medicaid integration. Among states participating in the Medicare Academy, creating workgroups or dedicated units responsible for integration-related policy and programs, along with state-developed trainings, are two approaches that have helped continually build Medicare capacity over time.

Wisconsin created an internal workgroup to strengthen cross-agency collaboration for the state’s long-standing D-SNP program. The newly formed workgroup brought policy and contract management experts together to evaluate the potential for additional Medicare-Medicaid integration opportunities. A subset of the initial workgroup also analyzed D-SNP activity in the state including review of fee-for-service Medicaid, long term care, and Medicaid managed care program enrollment in overlapping D-SNP and Medicaid service areas. The group continues to work on development of an oversight plan drawing from the state’s existing Medicaid managed care oversight requirements. As this activity progresses, it has provided the state with improved ability to verify D‑SNP contract compliance, and it is enhancing the working relationship between the Medicaid agency and D-SNPs.Additionally, Wisconsin intends to continue internal collaboration to review Medicare program changes and increase staff understanding of D-SNP program requirements.

Other states, including California, have established dedicated workgroups to address policy and programmatic issues affecting dually eligible individuals. By creating an ongoing forum that brings together staff from across the Medicaid agency, states can more readily assess how federal Medicare policy changes affect their integration efforts. Workgroup members, including newly hired staff, learn from one another and are better positioned to stay current on Medicare program changes.

Both Washington State and Massachusetts created Medicare-focused training opportunities to strengthen Medicare capacity among new and existing state staff. Washington used the Medicare Academy model to develop a training series on foundational topics for staff and a broader audience, including other state agencies and community partners, such as Area Agencies on Aging, which built a shared fluency in Medicare terminology. However, the state recognized that one-time trainings were not sufficient and then created several shorter trainings addressing high-impact issues such as aligned enrollment, D-SNP participation, and new federal requirements, which improved knowledge retention. Massachusetts also developed trainings, including one designed to share newly acquired Medicareknowledge with teams that work closely on dual eligibility, such as operations and LTSS teams, and a second condensed training for all Medicaid staff on dual eligibility and the state’s integrated D‑SNP programs.

Across the examples, when Medicaid agencies developed workgroup structures and training opportunities to expand Medicare knowledge among staff who directly or indirectly work on Medicare-Medicaid alignment efforts, it fostered a shared understanding of integration goals and the dually eligible population, while also helping build Medicare knowledge over time.

Looking Ahead

As new Medicare rules are implemented and new CMS priorities arise, states working to increase access to integrated care will need to understand an ever-evolving Medicare landscape. Recently finalized and newly proposed federal rules are strengthening D‑SNP requirements by promoting greater alignment between D‑SNPs and Medicaid managed care programs for the growing proportion of dually eligible individuals in these plans. One notable example is CMS’ final rule for contract year 2026, which aims to broaden state use of aligned enrollment and expand access to policy levers that support state oversight of integrated D‑SNP programs.

States can expect to see continued growth in both Medicare Advantage enrollment and provider participation in Medicare accountable care organization (ACO) models. In particular, continued growth in ACO participation among dually eligible individuals (e.g., more than half of people with Original Medicare are attributed to Medicare ACOs) may have implications for states working to promote aligned enrollment in integrated D‑SNP programs. At the same time, the absence of coordination between Medicare ACO models and Medicaid programs presents opportunities to align incentives for dually eligible individuals. One such opportunity is the CMS Innovation Center’s recently announced ACO model, which includes a small-scale test of a new approach to improving data sharing and care coordination for dually eligible individuals on Original Medicare. As proposed, it would create incentives for Medicare and Medicaid providers to coordinate care and improve patient outcomes by developing a framework for how Medicare ACOs and Medicaid agencies work together.

This rapidly evolving Medicare landscape underscores the need for states to maintain up-to-date knowledge of the Medicare program as they navigate potential changes that lie ahead for their integrated care programs and consider new opportunities. Continued investment in both the activities and resources that can help states strengthen and maintain Medicare expertise will remain vital for the future advancement of integration.