Malcolm A Jeffcoat

In 2026, ~8.2M enrollees chose special needs plans, giving them 23% of all private federal health plan enrollment, up from 21% in 2025.
Overall private federal health plan growth slowed, yet special needs plans still drove most new enrollment, reshaping the market’s mix and drawing more advisor attention.
Chronic-condition plans: severe or disabling conditions, ~20%
Institutional-care plans: 90-day institutional-level care, 2%
Dual-eligible plans: largest segment, ~78%
For advisors, rising interest makes client education essential because the label alone does not explain eligibility, benefits, or how a plan differs.
Each special needs plan needs a tailored care model reviewed against federal standards, plus health risk reviews within 90 days of enrollment and yearly.

US Special Needs Plans Gain Share

Federal policy often pays hospitals more than independent physicians for the same outpatient service, creating incentives for consolidation and higher imaging costs for patients.
The proposed imaging rule would narrow payment gaps, aiming to make patients pay based on care received rather than a hospital-owned office setting.
Broader site-neutral reforms across outpatient care could lower out-of-pocket costs, reduce premiums, and help preserve more independent community medical practices for patients nationwide.
Hospital ownership can also bring added facility fees for the same care in the same building, and clearer claims labeling could improve transparency.
Because private insurers often follow federal payment policy, one study estimated broader reforms could cut premiums and cost-sharing by $135B-$466B over 10 yr.