Upcoming Adjustments for Dually Enrolled People: The Closing 2025 Medicare Benefit Rule

Introduction

In April 2024, the Facilities for Medicare and Medicaid Companies (CMS) issued a last rule for 2025 Medicare Benefit Plans and Prescription Drug Plans (“Half C/D Rule” or “Closing Rule”).^[1] This rule makes a number of modifications related to people dually eligible for Medicare and Medicaid (“dually eligible people”), together with:

• Adjustments to the Particular Enrollment Interval (SEP) to go away a Medicare Benefit plan, return to Unique Medicare, and choose a brand new Prescription Drug Plan;
• Creation of an SEP to enroll into sure built-in Twin Eligible Particular Wants Plans (D-SNPs);
• Adjustments to who can enroll in sure D-SNPs and when;
• Adjustments to Medicare Plan Finder; and
• Adjustments to how plans handle Particular Supplemental Advantages for the Chronically In poor health (SSBCI).

These modifications will happen over time, beginning in 2024 and persevering with to 2030.^[2] Efficient dates are famous all through this temporary.

Adjustments to Particular Enrollment Durations for Dually Eligible People and Low-Earnings Subsidy/Further Assist Enrollees

The brand new Half C/D Rule made modifications to when a dually eligible particular person can depart or swap Medicare Benefit Plans (together with D-SNPs). Particularly, the Closing Rule modified an present SEP and launched a brand new SEP for sure D-SNPs. Following the Closing Rule, dually eligible people and Low-Earnings Subsidy (LIS) recipients will be capable of make month-to-month modifications to their enrollment in Medicare Benefit plans. The principles range for full-benefit dually eligible people, partial-benefit dually eligible people, and people who find themselves enrolled within the LIS program however who will not be additionally enrolled in Medicaid (this group might be known as “LIS-only”).[3] In abstract, the Closing Rule makes the next modifications to SEPs described in additional element beneath:

• The present quarterly SEP out there to all dually eligible people and LIS-only people, which allowed people to modify, or in sure circumstances, disenroll from a Medicare Benefit plan is eradicated (as of January 1, 2025).^[4]
• There’s a new month-to-month SEP for all dually eligible people and LIS-only people to disenroll from a Medicare Benefit plan with prescription protection (Medicare Benefit Prescription Drug plan, or MAPD plan), return to Unique Medicare, and enroll in a standalone prescription drug plan (as of January 1, 2025).^[5]
• There’s a new month-to-month SEP for all dually eligible people and LIS-only people to vary standalone Prescription Drug Plan enrollment (as of January 1, 2025).^[6]
• There’s a new month-to-month SEP for full-benefit dually eligible people to enroll into built-in and aligned D-SNPs (as of January 1, 2025). ^[7]
• All different SEPs stay the identical.^[8]

New Month-to-month SEP for Dually Eligible People and Low-Earnings Subsidy recipients

In 2018, CMS created a quarterly SEP that permitted dually eligible people and LIS recipients to enroll or disenroll from a Medicare Benefit plan with the prescription profit or standalone Half D plan as soon as per quarter (each three months).^[9] At this time, enrollment or disenrollment is efficient the primary day of the next month if the change is made within the first three quarters of the yr. Within the final quarter of the yr, dually eligible people and LIS recipients should wait till the Annual Enrollment Interval (Oct. 15 – Dec. 7). Any modifications made throughout this time are efficient January 1st of the next yr. Efficient January 1, 2025, this quarterly SEP is eradicated.

Instead of the quarterly SEP, CMS created a brand new SEP for dually eligible people and LIS-only people to make modifications to their MAPD and Prescription Drug Plan enrollment on a month-to-month foundation, one time monthly.^[10] This SEP permits people to modify to a distinct standalone prescription drug plan or disenroll from a Medicare Benefit plan into Unique Medicare and enroll in a standalone prescription drug plan.^[11]

Whereas people can use this SEP to return to Unique Medicare and enroll in a standalone Prescription Drug Plan on a month-to-month foundation, the SEP can’t be used to enroll into one other Medicare Benefit plan. This new month-to-month SEP is efficient January 1, 2025.

Who’s impacted?

All dually eligible people and other people receiving LIS or “Further Assist.”

New Built-in Particular Enrollment Interval

To facilitate enrollment into built-in Medicare Benefit plans, the Closing Rule creates a brand new SEP for full-benefit dually eligible people: the Built-in SEP. Beginning January 1, 2025, full-benefit dually eligible people can select to enroll into, or swap between, built-in D-SNPs on a month-to-month foundation.^[12] This SEP is restricted and might solely be utilized by full-benefit twin eligible people to enroll into built-in plans to align enrollment between their Medicare and Medicaid plans. This SEP can be utilized to enroll into: (1) A Absolutely Built-in Dually Eligible Particular Wants Plan (FIDE SNP); (2) A Extremely Built-in Dually Eligible Particular Wants Plan (HIDE SNP); or (3) A D-SNP that’s an Relevant Built-in Plan (AIP). For extra on the several types of D-SNPs, see Justice in Growing old’s, Twin Eligible Particular Wants Plans: What Advocates Have to Know.

This SEP is not out there to enroll into (1) A Coordination Solely D-SNP that can also be not an AIP or (2) A regular Medicare Benefit plan. CMS cited their targets of accelerating dually eligible enrollment in aligned plans in states the place they’re out there as the premise for creating this new built-in SEP.

Who’s impacted?

This SEP is restricted to full-benefit dually eligible people with entry to an built-in, aligned plan. LIS-only people, partial-benefit dually eligible people, and Medicare-only people can not use this SEP. At present, partial-benefit dually eligible people and LIS-only people have a quarterly SEP to modify Medicare Benefit Plans; as described above, this selection is eradicated starting January 1, 2025.

All populations will proceed to have the ability to make a Medicare Benefit plan alternative through the preliminary enrollment interval, the annual enrollment interval, and Medicare Benefit Open Enrollment interval. Different SEPs may even proceed to be out there. For extra details about instances when people can enroll in, change, or disenroll from Medicare Benefit plans, see CMS’ web site on Becoming a member of a Plan.

What occurs if an individual makes use of each the month-to-month and built-in SEP in the identical month?

If the month-to-month SEP and the built-in SEP are utilized in the identical month, the SEP that was chosen final in time might be efficient. For instance, Mr. Rufio makes use of the month-to-month SEP to disenroll again to Unique Medicare on September 3^rd and on September 15^th, makes use of the built-in SEP to enroll into “Built-in Plan A.” The built-in SEP is final in time and Mr. Rufio might be enrolled into Built-in Plan A on October 1^st.

Enrollment Restrictions In comparison with Present SEP Coverage

Whereas the brand new SEPs simplify enrollment selections and advance targets of integration, the modifications additionally act to restrict enrollment and disenrollment choices in comparison with earlier than the Closing Rule as follows:  

• People with LIS, however who will not be additionally enrolled in Medicaid, will now not be allowed to modify Medicare Benefit plans on a quarterly foundation. They need to wait till Open Enrollment, an preliminary enrollment interval, or meet the necessities for one of many different SEP choices out there.^[13] 
• Partial-benefit dually eligible people will now not be allowed to modify between Medicare Benefit plans on a quarterly foundation. They need to wait till Open Enrollment, an preliminary enrollment interval, or meet the necessities for one of many different Medicare Benefit SEP choices out there.
• Full-benefit dually eligible people will now not be allowed to modify Medicare Benefit plans on a quarterly foundation when their alternative of plan is just not built-in and aligned. They need to wait till Open Enrollment, the Medicare Benefit Open Enrollment interval, an preliminary enrollment interval, or meet the necessities for one of many different Medicare Benefit SEP choices out there to enroll into an un-integrated and aligned plan.
• Some states prohibit when an individual can change Medicaid managed care plans. Mixed with the Closing Rule that requires Medicaid managed care alignment to enroll into an built-in D-SNP, people might have restricted alternatives to vary plans.

Advocacy Alternatives

Advocates can push states to align their Medicaid managed care plan “lock in” guidelines to coordinate with alternatives to vary Medicare Benefit plans (e.g. through the Medicare Benefit enrollment interval from January to March annually).

Abstract of Particular Enrollment Interval Adjustments in 2025

*A Medicare Benefit Prescription Drug Plan is a Medicare Benefit Plan that features prescription drug protection. Most, however not all, Medicare Benefit plans are additionally Medicare Benefit Prescription Drug Plans.

Adjustments to D-SNP Enrollment and Contracting

CMS additionally launched new guidelines that can restrict the variety of sure D-SNPs {that a} guardian group can supply and who can enroll in these D-SNPs. Collectively, these new insurance policies are meant to extend aligned enrollment between the D-SNP and Medicaid Managed Care Group (MCO). First, some definitions:

• An aligned Medicaid MCO is described within the federal regulation as a Medicaid MCO that operates beneath a contract with the state and (a) the D-SNP; (b) the D-SNP’s guardian group; or (c) one other entity that’s owned and managed by the D-SNPs guardian group.
• Aligned enrollment describes a state of affairs the place a person is enrolled in each a D-SNP and the D-SNP’s aligned Medicaid MCO.
• Solely aligned enrollment is a time period that refers to a scenario the place D-SNP enrollment is restricted solely to people who obtain their Medicaid advantages by way of the D-SNP or the D-SNP’s aligned Medicaid MCO. Solely Aligned Enrollment insurance policies could be set by federal guidelines, state guidelines, or the plans themselves.

For instance, the insurance coverage guardian firm “CareRight” operates CareRight Full D-SNP and CareRight Most well-liked Medicaid MCO. If an individual have been enrolled in each that D-SNP and that Medicaid MCO, it might be thought-about “aligned enrollment.” If CareRight, or the state, or the federal authorities required that Care Proper Full D-SNP solely permit CareRight Most well-liked Medicaid MCO members to enroll within the D-SNP, then that will be thought-about “completely aligned enrollment.”

Adjustments to Solely Aligned Twin Eligible Particular Wants Plans

CMS is phasing in two modifications to D-SNPs who serve full-benefit dually eligible people and whose guardian group additionally function a Medicaid MCO in the identical, or overlapping, service space because the D-SNP.

First, beginning January 2027, if a D-SNP has an affiliated Medicaid MCO, then their guardian group can solely supply one D-SNP for full-benefit dually eligible people in a service space.^[14] At present, Medicare Benefit organizations might supply multiple D-SNP that serves the identical service space, or county, with little discernible distinction between D-SNP choices.

Second, additionally beginning January 2027, these D-SNPs will solely be permitted to enroll new members who’re additionally enrolled within the affiliated Medicaid MCO, and, efficient January 1, 2030, these D-SNPs will solely be permitted to have members who’re additionally enrolled within the affiliated Medicaid MCO.^[15] Enrollees who will not be enrolled within the affiliated MCO after January 1, 2030 might be disenrolled from the D-SNP. This rule solely applies to D-SNPs that serve full-benefit twin eligible people and who’ve affiliated MCOs.

Who’s impacted?

Beginning in 2027, a full-benefit dually eligible particular person who enrolls in D-SNPs with an affiliated Medicaid MCO won’t have a alternative of Medicaid MCO and should be within the matching, or affiliated Medicaid MCO. By January 1, 2030, all enrollees of those D-SNPs should be enrolled within the affiliated Medicaid MCO or they are going to be disenrolled from the D-SNP. If the D-SNP has partial-benefit dually eligible members, they may even be disenrolled from the D-SNP.

There are a couple of exceptions to the requirement that organizations solely function one D-SNP in a service space.

• Organizations can function a number of D-SNPs in overlapping service areas if the corporate doesn’t additionally function a Medicaid MCO. If a D-SNP doesn’t have an affiliated Medicaid MCO, they’re permitted to enroll full dually eligible people no matter their Medicaid MCO enrollment.
• Organizations can function multiple D-SNP with an affiliated Medicaid MCO if the D-SNPs serve totally different eligibility teams, equivalent to totally different age teams or to align enrollment within the D-SNP with the Medicaid MCO eligibility standards current in a state.^[16]These differentiations should be required by the State Medicaid Company Contracts. For instance, a Medicare Benefit group can supply two D-SNPs in the identical service space, with one serving solely members aged 65 plus and one other serving youthful people who find themselves on Medicare on account of incapacity and never age (beneath 65).
• This restriction additionally doesn’t apply to D-SNPs whose plan membership is restricted to partial-benefit dually eligible people. A Medicare Benefit guardian group can function a further D-SNP in the identical service space if membership is targeted completely on partial-benefit dually eligible people, even when that guardian group has an affiliated Medicaid MCO.

There are additionally exceptions to the enrollment restrictions.

• If a D-SNP doesn’t have an affiliated Medicaid MCO, they are going to be permitted to enroll full dually eligible people no matter their Medicaid MCO enrollment standing. (Observe that if a person is enrolling in such an unaffiliated D-SNP, then they might not be capable of use the Built-in SEP).
• This enrollment restriction additionally doesn’t apply to D-SNPs whose plan membership is restricted to partial-benefit dually eligible people.

Serving to Dually Eligible People with Plan Selection

Additional Restrictions on “D-SNP look-alikes”

At present, lots of of non-D-SNP Medicare Benefit plans enroll excessive percentages of dually eligible people.^[17] These plans are sometimes called “D-SNP look-alikes” and so they enroll numerous dually eligible people, however will not be topic to necessities designed to serve these dually eligible people. D-SNP look-alikes are beneath elevated scrutiny as a result of they undermine efforts to enhance built-in care and don’t have any contractual duty to coordinate care, not like true D-SNPs. Please see Justice in Growing old’s subject temporary Twin Eligible Particular Wants Plan (D-SNP) Look-Alikes: A Primer, to study extra.

The Closing Rule builds on prior rulemaking to curb D-SNP look-alikes. If a Medicare Benefit plan is recognized as a “look-alike” by CMS, CMS won’t contract, or renew their contract, with the plan^[18] At this time, the present enrollment threshold of dually eligible people that triggers a plan designation of “look-alike” is 80%. For plan yr 2025, the edge will drop to 70%. For plan yr 2026 and past, the edge will drop additional to 60%.^[19] If this provision was in impact right now, it might have an effect on 70 Medicare Benefit plans.^[20]

This provision will assist dually eligible people by lowering the incentives to steer them into plans that is probably not designed to fulfill their wants.

Adjustments to Medicare Plan Finder

Medicare Plan Finder permits people to seek out out there Medicare Benefit and Half D plans by zip code. Following a solicitation of feedback as a part of the Closing Rule course of, CMS has determined to take administrative motion and alter Medicare Plan Finder to assist dually eligible people perceive the total vary of advantages out there to them. For sure D-SNPs^[21], in 2025, Medicare plan finder will point out each Medicaid and Medicare providers as out there.^[22]

Enhancing Particular Supplemental Advantages for the Chronically In poor health

Particular Supplemental Advantages for the Chronically In poor health (SSBCI) are advantages that Medicare Benefit plans are allowed to supply along with Conventional Medicare providers. They will embody transportation, meals help, dwelling modification, and even money playing cards. In the previous couple of years, Medicare Benefit plans have closely marketed supplemental advantages, together with SSBCI, and this advertising and marketing has pushed plan alternative and enrollment. And but, CMS nonetheless has little knowledge on whether or not eligible people are capable of entry SSBCI as soon as they enroll in plans. The Closing Rule makes a variety of modifications to enhance transparency and entry to SSBCI by:

• Curbing deceptive SSBCI promoting. Beginning October 2024, Medicare Benefit plans might want to embody extra info of their promoting relating to the eligibility standards for SSBCI to clarify that not everybody who indicators up for a Medicare Benefit plan will get that plan’s SSBCI advantages.^[23]
• Stabilizing eligibility standards. Beginning in January 2025, Medicare Benefit plans won’t be allowed to vary eligibility standards in the midst of a plan yr. Medicare Benefit plans might be required to make use of goal standards when figuring out whether or not an enrollee is eligible for SSBCI.^[24]
• Documenting SSBCI approvals and denials. Beginning in January 2025, Medicare Benefit plans might want to hold a report of each once they approve and once they deny a request for SSBCI. That knowledge should be offered to CMS on request.^[25]
• Exhibiting proof of SSBCI effectiveness. Medicare Benefit plans at the moment are required to submit proof of SSBCI effectiveness as a part of their bids submitted to CMS in an effort to supply a particular SSBCI.^[26]
• Notifying Medicare Benefit enrollees of obtainable SSBCI. Beginning in January 2026, Medicare Benefit plans might be required to ship notices to enrollees letting them know which SSBCI they’re doubtless eligible for and never utilizing.^[27] The Closing Rule doesn’t require plans to let members learn about SSBCI that they’ve used however not exhausted.

Advocacy alternatives

Advocates can observe and report on how plans are implementing these necessities, and file complaints when they don’t seem to be being correctly adopted. For instance, some SSBCI notices might not embody clear directions for tips on how to entry SSBCI, or a plan might change its eligibility standards in the midst of a plan yr.

Different Rule Adjustments

Further modifications related to dually eligible people within the Closing Rule embody:

• New Community Adequacy Guidelines for Psychological Well being and Substance Use Dysfunction Companies. Beginning January 1, 2025, CMS would require Medicare Benefit plans to point out they’ve a sure variety of psychological well being or substance use dysfunction remedy suppliers inside their plan space.^[28]
• Restrictions on D-SNP Most well-liked Supplier Group (PPO) Price-Sharing. Beginning in 2026, D-SNP PPOs could have their cost-sharing quantities restricted.^[29] This may deal with some points with excessive cost-sharing that states are paying for out-of-network PPO providers for Medicaid enrollees.
• Improved Language Entry. Beginning for contract yr 2026, CMS will change the required languages within the Discover of Availability of Language Help Companies and Auxiliary Aids and Companies (“Discover of Availability”, previously often known as the “multi-language insert”). These modifications might be extra consistent with Medicaid necessities and with the languages spoken within the state.^[30]
• Adjustments to Prior Authorization and Different Utilization Administration. Medicare Benefit plans might be required to subject an annual report on their prior authorization knowledge and the way it intersects with well being fairness (beginning in 2025). Medicare Benefit plans may even be required to have no less than one utilization administration committee member with expertise with well being fairness (efficient January 1, 2025).^[31]
• State Entry to Encounter Information. Efficient January 1, 2025, the Closing Rule makes it simpler for states to entry Medicare Benefit encounter knowledge, which might be useful for states to evaluate the state of their dually enrolled inhabitants. ^[32]
• Brokers and Brokers. Brokers and brokers will now be topic to contract and cost restrictions designed to forestall massive inducements to signal people up for Medicare Benefit plans (word that this provision has been paused on account of an ongoing lawsuit). ^[33]

Conclusion

The Closing 2025 Medicare Benefit Rule makes main modifications to D-SNP enrollment and contracting; Medicare Benefit plan alternative, SSBCI, and different areas. These modifications have the potential to enhance the expertise of dually eligible people. Nevertheless, the D-SNP panorama is sophisticated, and will give rise to unintended penalties. Advocates who’re involved concerning the influence of the Closing Medicare Benefit Rule ought to contact Rachel Gershon at Rgershon@justiceinaging.org.

Endnotes

1. Heart for Medicare and Medicaid Companies, Medicare Half C and D 2025 Closing Rule, 89 FR 30,448 (April 23, 2024). ↑

2. Applicability dates could be discovered at 89 FR 30,448. ↑

3. Full-benefit dually eligible people have full Medicaid along with Medicare. They could even be enrolled in a Medicare Financial savings Program. Partial-benefit dually eligible people have a Medicare Financial savings Program along with Medicare, however shouldn’t have full Medicaid. LIS-only people have LIS, however shouldn’t have Medicare Financial savings Program or full Medicaid. ↑

4. 89 FR 3,0677. The regulation for this SEP is presently at 42 C.F.R. § 423.38(c)(4). ↑

5. 89 FR 30,677. To be codified at 42 C.F.R. § 423.38(c)(4)(i). ↑

6. 89 FR 30,677. To be codified at 42 C.F.R. § 423.38(c)(4)(i). ↑

7. 89 FR 30,677. To be codified at 42 C.F.R. § 423.38(c)(35). ↑

8. See CMS, Particular Enrollment Durations. ↑

9. 42 C.F.R. § 423.38(c)(4). ↑

10. People enrolled in a Medicare Benefit plan that doesn’t embody drug protection shouldn’t have the chance to disenroll from the Medicare Benefit plan utilizing this SEP. ↑

11. 89 FR 30,678. ↑

12. 89 FR 30,676-30,678. ↑

13. For a whole record of 2024 Particular Enrollment Durations for Half D, see CMS, “Particular Enrollment Durations,” and Medicare Interactive, “Altering Half D Plans.” ↑

14. 42 C.F.R. § 422.514(h)(1)(i)). ↑

15. 42 C.F.R. § 422.514(h)(2)). ↑

16. 42 C.F.R. § 422.514(h)(3)). ↑

17. 89 FR 30,707 ↑

18. Enrollees might be transitioned out of the plan. 42 C.F.R. § 422.514(d); See additionally CMS memo, Twin Eligible Particular Want Plan “Look-Alike” Transitions for Contract Yr 2025, (April 5, 2024). ↑

19. 42 C.F.R. § 422.514(d) ↑

20. 89 FR 30,707 ↑

21. Particularly, for D-SNPs which can be Relevant Built-in Plans. ↑

22. CMS memo, “Medicare Plan Finder Enhancements for Contract Yr 2025,” (Could 31, 2024). Observe that the web site linked offers people a possibility to obtain a zipped file containing HPMS memos from the week of Could 27 – 31. The CMS memo referenced right here is in that zipped file, entitled CY2025_MPF_HPMS_updates_05312024_final. ↑

23. To be codified at 42 CFR § 422.2267(e)(34). ↑

24. To be codified at 42 CFR §422.102(f)(3)(v); 422.102(f)(4)(iv). ↑

25. To be codified at 42 CFR § 422.102(f)(4)(v). ↑

26. To be codified at 42 CFR § 422.102(f). ↑

27. To be codified at 42 C.F.R. §§ 422.111, 422.2267(e)(42). Efficient date at 89 FR 30,565. Price-sharing reductions won’t be included within the mid-year discover. ↑

28. To be codified at 42 C.F.R. § 422.116(b)(2)(xiv). ↑

29. To be codified at 42 C.F.R. § 422.100(o). ↑

30. To be codified at 42 C.F.R. § 422.2267(e)(31). ↑

31. To be codified at 42 C.F.R. § 422.137. ↑

32. To be codified at 42 C.F.R. § 422.310. ↑

33. To be codified at 42 C.F.R. § 422.2274; See Maya Goldman, “Choose Pauses New Pay Cap Coverage for Medicare Brokers” (July 9, 2024); See Individuals for Beneficiary Selection v. HHS, Civil Motion Nos. 4:24-cv-00439-O, 4:24-cv-00446-O (July 3, 2024). ↑