As 2025 comes to a close, California health plans are reflecting on a year defined by regulatory changes, budget pressures, and growing demands for better care coordination, integration, and dual-eligibility management. The challenge has been clear: serve more complex populations, deliver more integration, and do so while operating under tighter margins.
Looking ahead, a major theme throughout plan years 2026 and 2027 will be whether plans can keep pace with state and federal expectations for dual-eligible populations. Here’s what 2025 taught us, what’s ahead, what SCAN’s FIDE SNP has already unlocked, and why other plans should be following that model.
2025 in Review: What Shaped the Market
Uneven CalAIM Progress
CalAIM continues to be a central force shaping Medi-Cal managed care; but progress has been uneven across counties and across components. Enhanced Care Management (ECM) and Community Supports are in place, yet utilization and provider readiness vary significantly. Eligibility verification, provider network capacity, outreach, and data systems remain common bottlenecks.
Rising Integration Standards for Dual-Eligibles
California has steadily increased its requirements for aligning Medicare and Medi-Cal for dual-eligible beneficiaries. One key policy tool is the Exclusively Aligned Enrollment (EAE) / Medi-Medi Plans model: DHCS requires that D-SNPs in many counties be affiliated with the same Medi-Cal Managed Care Plan (MCP), so dual-eligible members have both Medicare and Medi-Cal under one organization. These EAE D-SNPs (also called “Medi-Medi Plans”) are already in 12 counties as of January 1, 2024-25, with plans for expansion in 2026.
But the story doesn’t stop at alignment. SCAN Health Plan’s FIDE SNP provides a concrete example of what deeper integration can unlock. By operating as a Fully Integrated Dual Eligible Special Needs Plan, SCAN has been able to:
- Simplify member experience: one set of member materials and ID cards covering both Medicare and Medi-Cal benefits.
- Align appeals and grievances: members avoid navigating separate processes across programs.
- Integrate benefits beyond medical care: including long-term services and supports (LTSS), behavioral health, and home- and community-based services.
- Streamline oversight: one integrated contract with both CMS and DHCS, reducing duplication and clarifying accountability.
- Unlock richer data and insights: with combined Medicare and Medi-Cal information, plans can stratify risk more effectively and identify gaps sooner.
For other plans, the lesson is clear: integration unlocks value. Members are better served, compliance risks are lower, and plans can demonstrate greater efficiency to both CMS and DHCS.
Looking Ahead at 2026 & 2027
Key Regulatory / Compliance Updates & Deadlines
- Jan 2025: DHCS CalAIM D-SNP Policy Guide – notable focus on eligibility, integrated materials, and reporting
- Jul 2025:CMS CY 2026 Model Material Updates – specific tasks for integrated templates
- Jan 2026: DHCS Cal Aim D-SNP Policy Guide – focus on care plans, member engagement
- 2027: CMS § 422.514(h) Enrollment Limitation Rule – exclusive enrollment with aligned Medi-Cal MCPs
What’s Ahead in 2026 and 2027
- Expansion and enforcement of Exclusively Aligned Enrollment (EAE)
More counties will mandate alignment; plans that aren’t aligned risk enrollment restrictions or closure. - Necessity of FIDE SNP adoption
Plans that move toward FIDE structures will benefit from integration incentives; those that don’t risk penalties and competitive disadvantages. - Integration of carved-out benefits
LTSS, HCBS, and behavioral health will continue to migrate into integrated contracts, requiring stronger networks and oversight. - Member experience and equity at the forefront
FIDE SNPs will become the benchmark for demonstrating improved satisfaction, access, and outcomes. In a tighter labor and cost environment, integrated models will be essential to prevent service delays, grievances, or regulatory scrutiny. - Labor cost pressures under SB 525
California’s SB 525 law sets phased-in minimum wage increases for health care workers:- Large systems: ~$23/hour Oct 2024 → $24 July 2025 → $25 July 2026.
- Clinics: ~$21/hour Oct 2024 → $22 July 2026 → $25 July 2027.
- Other facilities: ~$21/hour Oct 2024 → $23 June 2026 → $25 by 2028.
These increases raise provider costs across home health, personal care, clinics, and behavioral health. Smaller providers may drop out or demand higher rates, tightening adequacy. Plans must adapt contracting strategies and workflows to sustain access.
The Risks of Not Moving Toward Integration
- Networks that fall short of adequacy, especially under SB 525 cost pressures.
- Weak performance and limited ability to prove outcomes.
- Rising costs of coordination that strain already tight budgets.
- Members waiting longer for services, filing more grievances, and regulators stepping in when gaps widen.
How Dina Helps Health Plans Get Ahead
- Personal care network management that solves for adequacy and sets the stage for results.
- Network performance management that ensures community providers deliver measurable outcomes.
- Dramatically reduced cost of coordination by extending the reach of care teams and automating workflows.
The result: lower costs, faster service delivery , fewer grievances – and readiness for regulatory change.
Marching Forward
As plan years 2026 and 2027 approach, integration isn’t just a regulatory requirement — it’s a strategic differentiator. SCAN’s FIDE SNP demonstrates what’s possible when plans embrace integration: streamlined operations, better member experience, and stronger relationships with state and federal regulators.
For plans across California the question is not if integration is coming, but how quickly you’ll adapt.
Want to learn how Dina can help you prepare for FIDE SNP readiness, EAE compliance, and dual-eligible integration — even in the face of SB 525 cost pressures? Let’s connect.
