D-SNP integrated operations alignment is the work of matching a dual eligible special needs plan's member processes (notices, handoffs, integrated appeals and grievances, and delegate oversight) to its State Medicaid Agency Contract and the CMS rules at 42 CFR 422.107 and 422.629 through 422.634. It is for plans operating dual-eligible products under state contracts. Integral Healthcare Solutions (IHS) crosswalks your state contract and CMS D-SNP duties to your member processes and drafts the procedures; your counsel and clinical teams decide.

Last reviewed: October 2026.

This work sits within IHS's Compliance Services.

What is a D-SNP?

A D-SNP is a Medicare Advantage plan built for people who are also eligible for Medicaid. The regulation defines it: “Dual eligible special needs plan or D-SNP means a specialized MA plan for special needs individuals who are entitled to medical assistance under a State plan under title XIX of the Act that— (1) Coordinates the delivery of Medicare and Medicaid services for individuals who are eligible for such services” (42 CFR 422.2, source).

The governing texts, read on eCFR (current as of September 30, 2026):

• 42 CFR 422.107, the requirements for the plan's contract with the State Medicaid agency (eCFR).
• 42 CFR 422.2, the D-SNP definitions (eCFR).
• 42 CFR 422.629 through 422.634, the unified appeals and grievance rules for applicable integrated plans (eCFR).
• The plan's own State Medicaid Agency Contract (SMAC).

The State Medicaid Agency Contract

Every D-SNP starts from its state contract. 42 CFR 422.107(b): “MA organizations seeking to offer a dual eligible special needs plan must have a contract consistent with this section with the State Medicaid agency.” (source) At a minimum the contract must document “The MA organization's responsibility to— (i) Coordinate the delivery of Medicaid benefits for individuals who are eligible for such services” (42 CFR 422.107(c)(1), source).

Unified appeals and grievances

For applicable integrated plans, CMS sets one process across Medicare and Medicaid. 42 CFR 422.629(a): “The provisions in this section and in §§ 422.630 through 422.634 set forth requirements for unified appeals and grievance processes with which applicable integrated plans must comply.” (source) Under 422.629(b), “An applicable integrated plan must create integrated processes for enrollees for integrated grievances, integrated organization determinations, and integrated reconsiderations.” (source)

States can go further. 42 CFR 422.629(c): “A State may, at its discretion, implement standards for timeframes or notice requirements that are more protective for the enrollee than required by this section ... The contract under § 422.107 must include any standards that differ from the standards set forth in this section.” (source) That is why the crosswalk starts from your state contract, not from the federal text alone.

On grievances, 42 CFR 422.630: “An enrollee may file an integrated grievance at any time with the applicable integrated plan.” and “An enrollee may file an integrated grievance orally or in writing” (source).

Who needs it and what triggers it?

The buyer is a plan operating a dual-eligible product under a state contract. The trigger is the operating interface the rules create: the state contract and the CMS integration and unified appeals and grievance requirements assign duties that cross Medicare and Medicaid processes, notices and teams.

Whether the unified appeals and grievance rules apply to your plan depends on whether it is an applicable integrated plan. That term is defined at 42 CFR 422.561, which this page does not quote. Read the definition against your contract with counsel.

How IHS helps

IHS crosswalks your state contract and CMS D-SNP duties to your member processes and drafts the procedures; your counsel and clinical teams decide. The work runs in this order:

1. Gap assessment of member processes against the State Medicaid Agency Contract and the CMS D-SNP rules that apply to your plan.
2. Document and evidence mapping: a crosswalk from each contract duty to a process owner, a notice and a record.
3. Drafting: procedures for notices, Medicare-Medicaid handoffs, integrated appeals and grievances, and delegate oversight, for your leaders to review and approve.
4. Mock audit of sample grievance, determination and reconsideration files against the crosswalk.
5. Readiness support: drafted responses to findings, for your plan to send.

What your plan supplies: the state contract, current procedures, notices, sample files, counsel, and clinical and operations owners.

The limits: benefit design, actuarial work and legal interpretation stay with the plan. IHS does not make clinical determinations on any appeal or grievance.

What to have ready

Items that cite a section reflect that section's text (eCFR, current as of September 30, 2026). Others are IHS's working list. The plan's own contract governs where it differs.

1. The executed State Medicaid Agency Contract and every amendment (42 CFR 422.107(b), eCFR).
2. A list of the contract's coordination duties, starting with coordinating delivery of Medicaid benefits (42 CFR 422.107(c)(1), eCFR).
3. Any state timeframes or notice standards in the contract that differ from the federal text (42 CFR 422.629(c), eCFR).
4. Counsel's determination of whether the plan is an applicable integrated plan (42 CFR 422.629(a), eCFR).
5. Current procedures for integrated grievances, integrated organization determinations and integrated reconsiderations (42 CFR 422.629(b), eCFR).
6. Intake records showing grievances accepted at any time, orally or in writing (42 CFR 422.630, eCFR).
7. Current member notice templates, matched to the federal and state standards that apply (42 CFR 422.629(c), eCFR).
8. A sample of recent grievance, determination and reconsideration files for the mock audit (IHS working-list item).
9. A statement of the plan's integration level, including whether it is a FIDE SNP (42 CFR 422.2, eCFR).
10. Delegation agreements for any vendor that handles part of these processes, with the plan's oversight records (IHS working-list item).

To walk through this list against your own contract and files, start with the introductory call.

How it compares

D-SNPs run at different levels of integration with Medicaid. The one level this page quotes is the FIDE SNP, which 42 CFR 422.2 describes as a D-SNP “That provides dual eligible individuals access to Medicare and Medicaid benefits under a single entity that holds both an MA contract with CMS and a Medicaid managed care organization contract under section 1903(m) of the Act with the applicable State” (source).

Which level a plan operates at is set by its contracts with CMS and the state, not by IHS. The crosswalk method is the same at any level; what changes is the list of duties it maps. Related IHS work: compliance program development.

What does D-SNP operations alignment cost?

CMS does not publish a fee schedule on the pages we reviewed; fees depend on scope. IHS found no CMS fee for this work on the pages reviewed; the cost is your plan's staff time and any outside help it chooses. The main drivers are the number of contract duties, the number of delegated vendors, and how far current procedures and notices are from the contract.

IHS scopes each engagement after a free introductory call.

What this is not

• This page is not legal advice. Interpretation of your state contract and of CMS rules is your counsel's.
• IHS does not correspond with CMS or the state Medicaid agency, and does not submit anything to either. IHS drafts; your plan sends.
• IHS does not set benefit design, perform actuarial work, or decide any appeal or grievance.

Frequently asked questions

What is a D-SNP and what does the State Medicaid Agency Contract have to include?

42 CFR 422.2 defines a D-SNP as a specialized Medicare Advantage plan for individuals entitled to Medicaid that coordinates the delivery of Medicare and Medicaid services. Under 42 CFR 422.107, the plan must have a contract with the State Medicaid agency, and at a minimum the contract documents the organization's responsibility to coordinate delivery of Medicaid benefits.

Which D-SNPs must run unified appeals and grievance processes?

42 CFR 422.629(a) says applicable integrated plans must comply with the unified appeals and grievance requirements in 422.629 through 422.634. Whether your plan is one turns on the definition at 42 CFR 422.561, which this page does not quote; read it with counsel.

What is an applicable integrated plan?

It is the term 42 CFR 422.629 uses for plans that must run unified appeals and grievance processes. The definition sits at 42 CFR 422.561. This page does not quote it, so check it against your plan's contracts.

What is a FIDE SNP?

42 CFR 422.2 describes a FIDE SNP as a D-SNP that gives dual eligible individuals access to Medicare and Medicaid benefits under a single entity holding both an MA contract with CMS and a Medicaid managed care organization contract with the state. Other integration levels are defined in the same section; this page does not quote them.

How do integrated organization determinations and integrated reconsiderations work?

42 CFR 422.629(b) requires an applicable integrated plan to create integrated processes for enrollees for integrated grievances, integrated organization determinations and integrated reconsiderations. The detailed steps sit in 422.630 through 422.634 and in any differing state standards written into your contract.

Can our state set stricter timeframes or notice rules than CMS?

Yes. 42 CFR 422.629(c) lets a state set timeframes or notice requirements more protective for the enrollee than the federal rule, and the state contract must include any standards that differ. Your contract, not the federal text alone, sets the timeframes your procedures must meet.

How do we crosswalk our state contract duties to member notices and process owners?

IHS lists each duty in the state contract and the applicable CMS rules, then maps it to a process owner, the notice that carries it and the record that proves it. Gaps become drafted procedures for your leaders to approve, and a mock audit of sample files tests the result.

How do we oversee delegates under integrated appeals rules?

The rules quoted on this page place the integrated process duties on the applicable integrated plan. Where a vendor handles part of a process, IHS drafts delegate oversight procedures that tie the vendor's work back to the plan's duties. How your contracts allocate responsibility is your counsel's call.

How long does it take to align D-SNP operations before a new contract year?

Neither CMS nor the rules quoted here set a timeline for this work. It depends on the number of contract duties, delegated vendors and procedures that need rewriting. IHS scopes timing after a free introductory call.