Ask ten health plan executives what keeps them up at night, and at least seven will mention dual-eligible members somewhere in the answer. It makes sense once you look at the math. Roughly 12 million Americans qualify for both Medicare and Medicaid, and the two programs still spend over $300 billion a year on their care without fully talking to each other. That gap is exactly where Dual-Eligible Special Needs Plans, or D-SNPs, were supposed to step in. However, plenty of health plans discovered that launching a D-SNP and actually operating one are two very different jobs. This is where dual eligible D-SNP member support outsourcing earns its keep, and it is worth unpacking why.
Dual Eligible Member Services Support Is Not “Regular” Medicare Support
A dual-eligible member is not simply an older adult with a slightly bigger benefits packet. They are usually managing multiple chronic conditions, navigating a fixed and limited income, and juggling two sets of rules that rarely align cleanly. One call might involve a Medicare Part D formulary question. The next, from the same person, might involve a Medicaid long-term services and supports authorization. A generic contact center script simply cannot flex fast enough between those two worlds. That is precisely why dual eligible member services support has to be built as its own discipline, not bolted onto a standard Medicare Advantage playbook. Agents need working fluency in both programs, patience for lower health literacy, and the judgment to know when a call needs a warm handoff instead of a quick answer.
The Enrollment Curve Nobody Fully Budgeted For
Growth in this space has been anything but gradual. According to a peer-reviewed analysis published in The American Journal of Managed Care, dual-eligible enrollment grew at a mean annual rate of just 0.3 percent before D-SNPs received permanent authorization in 2018. After that, the growth rate jumped to 12.8 percent annually. That is not a rounding error; it is a completely different operating reality. Meanwhile, CMS keeps tightening the rules around who can even call themselves a dual-eligible plan. The threshold that defines a “look-alike” Medicare Advantage plan drops to 60 percent dual enrollment in 2026, according to KFF’s analysis of Special Needs Plan growth, pushing more members into true, compliant D-SNPs rather than plans that merely market to them. Consequently, member volume is rising and regulatory scrutiny is rising right alongside it, which is a demanding combination for any internal team to staff around.
Where Standard D-SNP Call Center Services Break Down
Here is where things get genuinely uncomfortable for health plans that treat D-SNP support like an afterthought. Justice in Aging, a national advocacy organization, illustrates the problem through a case they use in advocate training materials: a member they call Mrs. Lopez needed surgery, and although her plan offered some care coordination, she still struggled to understand which card to use, which number to call, and how to arrange help at home afterward. Nothing about her situation was exotic. It was simply two systems failing to speak the same language at the exact moment she needed clarity most. Multiply that single story across a member population in the hundreds of thousands, and you get a preview of what happens when D-SNP call center services are staffed like ordinary Medicare lines. Hold times stretch. Escalations pile up. Grievance rates climb, and Star Ratings quietly absorb the damage months later.
Even Washington has noticed the pattern. As Senator Bill Cassidy put it while introducing bipartisan legislation aimed at these members, “patients dually eligible for Medicare and Medicaid have much worse outcomes than other groups even though there is a lot more money spent on their care.” That is a fairly blunt admission from a sitting senator, and it doubles as a challenge to every health plan operating a D-SNP today. If policymakers are willing to say the quiet part out loud, plan leaders probably should too.
The Case for Dual Eligible D-SNP Member Support Outsourcing
So why does outsourcing solve a problem that sounds like it needs more internal control, not less? Because control and capacity are not the same thing. Building a dedicated, dual-fluent, Model-of-Care-trained internal team from scratch takes years, and most health plans do not have years before the next AEP cycle arrives. Dual eligible D-SNP member support outsourcing lets a plan borrow that specialized capacity immediately, instead of building it brick by brick while members wait on hold. A seasoned healthcare BPO partner has already trained agents on dual eligibility rules, already built compliant escalation paths for grievances and appeals, and already stress-tested staffing models against enrollment surges. That head start matters enormously when CMS deadlines do not move for anyone.
There is also a cultural argument here, and it is a little bit funny if you have lived it. Dual-eligible members are often the population every department in a health plan claims to prioritize, right up until budget season, when their support line quietly gets the leftover headcount. Outsourcing a purpose-built team removes that internal tug-of-war entirely. The members finally get a team whose entire job is understanding them, not a team squeezed in between three other priorities.
What a D-SNP-Ready Outsourced Team Actually Looks Like
Model-of-Care Fluency, Not Just Medicare Fluency
Every D-SNP operates under a CMS- and NCQA-reviewed Model of Care, and agents who do not understand it will mishandle calls no matter how polite they sound. A properly trained team treats the Model of Care as a working document, not paperwork filed away after certification season.
One Data View Across Both Programs
Members should never have to explain their own history twice. Outsourced teams built for this population need integrated access to Medicare and Medicaid case notes so an agent can see the full picture in a single screen, rather than piecing it together mid-call while a member waits.
Compliance-First Escalation, Every Single Time
Because D-SNPs face unified appeals and grievance requirements, an escalation path built for standard Medicare Advantage plans simply will not hold up. Agents need clear rules for when a call becomes a grievance, and they need those rules applied consistently, not left to individual judgment.
Ameridial builds exactly this kind of structure through its broader healthcare payer BPO services, extending it specifically to Medicare Advantage and dual-eligible populations through dedicated Medicare Advantage support services built around HRA engagement, benefit clarity, and CMS-aligned documentation.
Measuring Success Beyond Average Handle Time
Average handle time is a tempting metric because it is easy to track, but it is a poor proxy for whether a dual-eligible member actually got help. Better indicators include first-contact resolution across both Medicare and Medicaid issues, grievance rate per thousand members, and successful warm transfers to care coordination rather than dropped calls. Plans that lean too heavily on speed metrics often end up rewarding agents for closing calls fast rather than closing the member’s actual problem, which quietly inflates callback volume later. Dedicated population health and member outreach programs and structured member onboarding and education support both help shift the incentive back toward genuine resolution, since members who understand their benefits early tend to call back with fewer, simpler questions later.
The Ameridial Perspective
“Members who are dually eligible do not need a faster call center. They need one that already understands why their situation is different before the phone even rings,” notes an Ameridial Director of Healthcare Payer Solutions. That distinction shapes everything from hiring to quality scoring at a partner built for this population, and it explains why generic outsourcing models tend to underperform here even when their pricing looks attractive on a spreadsheet.
For health plans weighing this decision, the comparison is worth running against Ameridial’s broader healthcare call center outsourcing decision guide, since the build-versus-buy math for dual-eligible support tends to favor outsourcing even faster than it does for standard Medicare lines, given the compliance stakes involved.
Ready to Close the Gap Between Medicare and Medicaid for Your Members?
Dual-eligible members deserve a support experience that matches the complexity of their coverage, not one that ignores it. Ameridial has spent more than three decades building healthcare BPO expertise specifically for payers navigating Medicare, Medicaid, and everything in between. If your D-SNP support model is stretched thin heading into the next enrollment cycle, now is the time to fix that, not after Star Ratings reflect it. Connect with Ameridial’s healthcare payer team today to build a dual-eligible member support strategy that actually holds up under CMS scrutiny and member expectations alike.
