in the Department of Health and Human Services that administers the Medicare program and oversees state Medicaid programs. In addition, dual-eligibles may choose a type of MA plan called a dual-eligible special needs plan (D-SNP), which is designed to target the needs of this population. For Medicaid benefits, beneficiaries generally enroll in their state's Medicaid FFS program or a Medicaid managed care plan administered by an MCO under contract with the state. Recently, Congress and CMS have placed greater emphasis on the coordination and integration of Medicare and Medicaid benefits for dual-eligible beneficiaries. For example, the Medicare Improvements for Patients and Providers Act of 2008 required D-SNPs to contract with state Medicaid agencies to provide Medicaid benefits. More recently, the Affordable Care Act (ACA) established a type of D-SNP, referred to as a Fully Integrated Dual Eligible (FIDE) SNP, which—unlike other D-SNPs—is designed to integrate program benefits for dual-eligible beneficiaries through a single managed care organization, although payment is generally provided separately by each program. In 2011, CMS announced a financial alignment demonstration that is intended to further integrate the programs' services. CMS expects that the demonstration will decrease incentives for cost shifting and increase care coordination, resulting in improved care for beneficiaries and savings to Medicare and Medicaid. CMS projects that approximately 61 to 75 percent of savings will come from reductions in costly Medicare-covered services. Historical challenges with the dually-eligible Historically, one of the major challenges for the dually-eligible has been care coordination between Medicare and Medicaid. These two systems of care do not "talk to each other" systematically, so one physician that bills primarily through Medicare may not be familiar with benefits that are available through Medicaid. Additionally, since Medicaid benefits vary by state, it is difficult for care providers and consumers to understand the complexity that is inherent within the Medicaid system. Because duals tend to be the most vulnerable, and often sickest, adults, their care has historically been expensive, totaling $319.5 billion in 2011. One proposed reason for this significant cost would be that many Medicaid programs, prior to the 2010 passage of the Affordable Care Act (ACA) used a fee-for-service model. Fee-for-service models are typically more costly because they allow providers to charge for the quantity of care they provide, rather than the quality. In order to resolve these pain points, the ACA includes provisions that specifically address the coverage and care of duals.