DualWorks — A New Operating Standard for D-SNP

Federal mandates

Plans aren't choosing this market. They're being told to enter it or lose what they have.

D-SNP enrollment has tripled since 2018. National carriers spent a decade building the infrastructure to run these plans profitably. Regional and community plans are being given a fraction of that time, under federal mandate, with far fewer resources.

2025–26

Look-alike plans lose CMS contracts. Non-SNP MA plans that hit 60% dual eligible concentration can no longer crosswalk members into other MA plans — only into D-SNPs. Enter or lose the members.

2027

New enrollment restricted to aligned members only. D-SNPs with affiliated Medicaid MCOs can only enroll members who are simultaneously enrolled in that MCO. One D-SNP per service area per parent organization.

2030

Unaligned member disenrollment required. Plans must disenroll every member not enrolled in the affiliated Medicaid MCO. Approximately 67,000 members face displacement in Wisconsin alone.

Ongoing

States are raising the integration floor. Michigan launched MI Coordinated Health in January 2026, requiring nine contracted plans to cover full LTSS under a capitated contract. Wisconsin, Colorado, California, and New York are moving the same direction.

Where plans struggle most

Building a compliant D-SNP from scratch is a multi-year lift. Nationals completed it a decade ago.

The operational challenge isn't one thing. It's every function running simultaneously, without the institutional muscle nationals built over years.

$627K

Revenue at risk

Risk adjustment undercoding

FQHCs' prospective payment model creates a structural coding gap. Behavioral health diagnoses go systematically undocumented. Plans lose risk-adjusted revenue they've already earned — and can't recover it at year-end.

Per 1,000 dual lives, at 5–10% RAF undercoding on FQHC-attributable revenue.

2.5 ★

Stars rating

Stars without infrastructure

Medicaid-focused plans discover Stars gaps in their third year, when they're already at 2.5. Quality measures aren't being tracked across departments — they're found at audit time when it's too late to close them.

71%

Compliance

Model of Care audit exposure

CMS audits what the plan committed to in its Model of Care — HRA completion rates, individualized care plans, LTSS coordination. Most plans have no system to know their audit readiness in real time.

18mo

Launch

No playbook for new entrants

A first D-SNP requires CMS application, Model of Care, NCQA approval, Medicaid network adequacy, care management infrastructure, unified appeals — all simultaneously. No vendor has built this specifically for regional plans.

120+

Operations

P&P drift

CMS issues 120+ APL updates a year, each rippling into policies, procedures, and workflows. Plans track these manually in SharePoint and email — and the gap between what CMS expects and what plan operations actually do widens with every cycle.

The platform

D-SNP operational infrastructure. Owned by the plan, kept compliant by DualWorks.

Every D-SNP commits to CMS exactly how it will identify, assess, and manage its members. DualWorks operationalizes that commitment across the full MOC-to-P&P-to-workflow stack — so every workflow, every member record, and every audit trail reflects what your plan said it would do. No other vendor in this market connects those three layers for community plans.

DualWorks is a lightweight mission-control platform that opens in your browser. From daily operators to P&L owners, plan teams see gaps and risks, receive next-best actions, and capture evidence as they work.

DualWorks brings the operational standard that turns your existing data into outcomes — and the system that holds the standard so it doesn't depend on a particular person, vendor, or audit cycle.

Capture revenue

Risk adjustment workflow

Surface undocumented diagnoses from FQHC charts. Route linked chart reviews to capture RAF revenue already earned. Behavioral health diagnoses don't quietly slip through the gap between the visit and the encounter file.

Lift quality

Stars tracking, in real time

Continuous Stars measure tracking across every department — UM, care management, member services, network. Close gaps inside the measurement window, not at audit time when the rating has already dropped.

Prove compliance

MOC audit readiness

Every workflow generates audit evidence tied to your MOC commitments — ICPs, TOC documentation, HRA rates, LTSS coordination. Know your audit readiness score before CMS does.

Stay nimble

P&P automation

CMS APLs flow into version-controlled P&P updates, checked automatically against your Model of Care. The compliance layer keeps pace with CMS — without a manual policy review every cycle.

app.dualworks.co · Partnership HealthPlan of CA · D-SNP CY2028

DualWorks Member risk queue

312 members Sorted by urgency

Member Action

M. Torres, 71

Discharge 2d ago · BH inpatient admission · no TOC contact logged

TOC needed

D. Okafor, 68

HRA overdue 47 days · CHF + DM2 · approaching 90-day CMS threshold

HRA overdue

R. Nguyen, 74

3 BH visits at FQHC · diagnoses documented, not coded · est. RAF gap $214

RAF gap

309 more members in queue

Book a demo to see the full platform →

What it's worth

~$7M of addressable economic impact per 5,000 dual lives.

The operational gaps don't compound in the abstract. They compound in dollars — every quarter that goes by without the discipline. Across four economic levers, total addressable impact ranges $4–11M per year for a plan with 5,000 dual lives. Year-one realized impact is typically 30–50% of addressable, as RAF and Stars improvements take 12–24 months to ripple through CMS payment cycles.

$3.5M

Revenue recovery

Risk adjustment from FQHC undercoding

DualWorks routes linked chart reviews against FQHC-attributable encounters to recover RAF score that goes systematically unreported under the PPS payment model. Recovered revenue compounds — captured codes carry forward in subsequent risk score calculations.

Range: $2.5–5M/year. Assumes 5–10% undercoding on FQHC-attributable revenue.

$4.2M

Stars bonus

5% quality bonus on a 1-star lift

Going from 2.5 to 3.5 stars unlocks the 5% Medicare quality bonus on Part C revenue. A 4.0 also unlocks rebate retention, which compounds every year a plan stays at the higher rating.

Headline assumes ~$84M Part C revenue base. Upside scales with plan size.

$0.75M

Risk avoided

MOC audit findings averted

A single MOC audit finding averages this much in executive attention, consultant fees, and corrective action plan work. Severe findings compound and can trigger member sanctions or contract non-renewal — outcomes whose downside is multiples larger.

Range: $0.5–1M per finding. Catastrophic-tail outcomes excluded.

$1.1M

Cost displaced

Legacy BPaaS admin spend

DualWorks displaces ~10% of typical BPaaS admin load (Cognizant/TriZetto, Wipro Infocrossing, AmeriHealth Caritas) by automating workflows currently run by humans and vendors in tandem. Savings widen as the platform absorbs more of the operational layer.

Range: $0.9–1.3M/year. Assumes $150–216 PMPM admin cost baseline.

The economic case is multi-year by design. RAF and Stars improvements take time to ripple through CMS payment cycles, and Stars in particular rewards plans that hold the discipline year after year. The biggest economic miss is the plan that delays the operational layer by one more cycle.

Who we serve

Built for the plans the nationals left behind

DualWorks is not for United, Humana, or Centene. It's for the regional Blues plans, health system-owned insurers, and community-rooted plans that hold the member relationships — and are now being asked to build the operational muscle to match.

Regional Blues plans

Single-state or regional Blues affiliates entering D-SNP for the first time or scaling existing programs under consolidation pressure.

E.g. BCBS Michigan, Capital Blue Cross, BCBS Alabama, Premera

Community health plans

ACAP-member plans and FQHCs-owned insurers operating D-SNP under state mandate, often with Medicaid as the core competency — not Medicare.

E.g. LA Care, SCAN, Healthfirst, VillageCare, Jefferson Health Plans

Health system plans

Hospital-owned or provider-sponsored organizations building D-SNP to anchor their integrated care model and retain dually eligible patients.

E.g. UPMC Health Plan, Presbyterian Health Plan, HAP CareSource

County and public plans

County-run Medi-Cal managed care plans now required to unify under a Medicare Advantage contract — entering D-SNP with no institutional infrastructure for it.

E.g. Partnership HealthPlan, San Francisco Health Plan, Alameda Alliance

How we work · Forward-deployed

Our team embeds with yours, not over a vendor SOW. We learn your Model of Care, your workflows, and your provider mix — then ship the first compliant workflow in 6–8 weeks. You own the platform. We own keeping it compliant as CMS rules evolve.

What plans do today

✕Spreadsheets tracking HRA completion across care managers
✕Manual policy reviews every time CMS issues an APL update
✕Stars reports pulled quarterly — too late to act on the gaps
✕Audit prep scrambles — pulling evidence from five different systems the week CMS arrives

The new operational standard

✓HRA completion above the 80% CMS threshold — tracked in real time, not discovered at audit
✓RAF revenue captured from FQHC visits that were treated but never coded
✓Stars gaps closed before the measurement window closes — not after the rating drops
✓CMS MOC audits passed with evidence already in the system — not assembled the week before

The team

Built by someone who has done this for health plans

DualWorks was founded on a simple observation: the tools health plans are handed to run complex government programs were not designed for those programs.

Amy Wang

Founder

Most recently Chief of Staff at Malama Health (YC S22), where she built the operational infrastructure that earned 90+ audit scores across every health plan partner — the same operational discipline plans need for D-SNP. As employee #1, she scaled operations from $120K to $3M+ ARR across 15 Medicaid MCOs in California, Texas, and Colorado, building the care management model, AI-enabled infrastructure, and care delivery team.

Prior to Malama, Amy led enterprise Mental Health Parity governance across legal, clinical, product, and network teams at Health Care Service Corporation. She holds an MPA from the University of Wisconsin-Madison.

Plans aren't choosing this market. They're being told to enter it or lose what they have.

Building a compliant D-SNP from scratch is a multi-year lift. Nationals completed it a decade ago.

D-SNP operational infrastructure. Owned by the plan, kept compliant by DualWorks.

~$7M of addressable economic impact per 5,000 dual lives.

Built for the plans the nationals left behind

Built by someone who has done this for health plans

See DualWorks on a D-SNP that looks like yours.