What Agents Need to Know for 2025
The Centers for Medicare and Medicaid Services (CMS) is rolling out significant updates to Dual Special Needs Plans (D-SNPs), Low-Income Subsidy (LIS) programs, and Special Enrollment Period (SEP) rules in 2025. These changes impact not only how D-SNPs operate and how LIS benefits are administered but also when and how beneficiaries can enroll or switch plans through SEPs. For agents, understanding these updates is essential to better serve dual-eligible clients and capitalize on market opportunities.
This guide outlines the key CMS rule updates, their impact on QMB+, SLMB, and FBDE beneficiaries, and how SEP rules are evolving in this dynamic market.
Helpful CMS Resources:
👉 D-SNPs: Integration & Unified Appeals & Grievance Requirements
👉 New Special Enrollment Periods (SEPs) for Dually Eligible and Extra Help-eligible Individuals
Key CMS Changes for D-SNPs: 2024 vs. 2025
1. Enhanced Care Coordination Requirements
- 2024: CMS emphasized care coordination but left many processes up to plans and states.
- 2025: D-SNPs must now share care plans with state Medicaid programs and providers, ensuring smoother transitions and better access to care for dual-eligible beneficiaries.
2. Standardized Benefits for Certain Services
- 2024: Benefits like transportation and meal services varied across plans, making it difficult for beneficiaries to compare options.
- 2025: CMS is introducing standardized benefits for these services, ensuring consistency and improving equity.
3. Increased Transparency and Oversight
- 2024: Oversight efforts were increasing but lacked standardized metrics for performance and network adequacy.
- 2025: New reporting requirements will improve transparency on plan performance, beneficiary satisfaction, and network adequacy.
4. Integrated Enrollment Processes
- 2024: Dual-eligible beneficiaries often struggled with fragmented enrollment systems.
- 2025: Streamlined enrollment will make it easier for beneficiaries to access both Medicare and Medicaid benefits through a unified process.
5. Stricter Marketing and Compliance Rules
- 2024: CMS worked to curb misleading marketing practices.
- 2025: Marketing oversight will tighten further, requiring agents to ensure all materials and outreach strategies meet updated CMS standards.
LIS Status for QMB+, SLMB, and FBDE Beneficiaries
1. QMB+ (Qualified Medicare Beneficiary Plus Medicaid):
- LIS Status: Automatically qualifies for full LIS benefits.
- Benefits: Includes full assistance with Part A and B premiums, Medicaid cost-sharing, and reduced or no prescription drug costs under Part D.
- 2025 Updates: Improved coordination between D-SNPs and Medicaid will help QMB+ beneficiaries access their benefits more efficiently.
2. SLMB (Specified Low-Income Medicare Beneficiary):
- LIS Status: Qualifies for partial LIS, primarily covering Part B premiums.
- Benefits: Reduced premiums for Part D and capped prescription drug costs.
- 2025 Updates: Expanded LIS eligibility criteria will enable more SLMB beneficiaries to receive financial assistance.
3. FBDE (Full Benefit Dual Eligible):
- LIS Status: Automatically qualifies for full LIS benefits.
- Benefits: Includes Medicaid coverage for medical services and reduced Part D costs.
- 2025 Updates: Stronger integration between Medicare and Medicaid services will streamline access to benefits for FBDE beneficiaries.
SEP Status: How CMS Changes Impact Enrollment Options
Special Enrollment Periods (SEPs) provide dual-eligible and LIS beneficiaries flexibility to enroll, disenroll, or switch Medicare plans outside of the Annual Enrollment Period (AEP). With the changes CMS is implementing, there are key updates to how SEPs will work for 2025:
1. SEP for Dual-Eligible and LIS Beneficiaries
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New! Effective January 1, 2025, the quarterly Dual/LIS SEP will sunset. It will be replaced by a new Dual/LIS SEP that will allow dually eligible and LIS-only eligible individuals to elect a standalone prescription drug plan (PDP) in any month.
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In addition, effective January 1, 2025, a new Integrated Care SEP will allow full-benefit dually eligible individuals to elect an integrated dual eligible special needs plan (D-SNP) in any month to align coverage with a Medicaid managed care organization.
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CMS designed this resource [New SEPs for Dually Eligible and LIS Individuals (PDF)] to provide an overview of the new SEPs and help anyone who assists dually eligible and LIS-only eligible individuals with their Medicare coverage choices to better understand eligibility for and availability of both SEPs.
2. SEP for Loss of Medicaid or LIS Eligibility
- 2024: Beneficiaries losing Medicaid or LIS status had access to an SEP to transition to a new plan or adjust coverage.
- 2025: CMS is enhancing this SEP by requiring D-SNPs to provide additional outreach and support to affected beneficiaries, ensuring they understand their options and can transition smoothly.
What This Means for Agents:
Agents will need to:
- Be prepared to assist clients who lose Medicaid or LIS eligibility, helping them explore options like traditional Medicare or other Medicare Advantage plans.
- Stay updated on local Medicaid and LIS eligibility guidelines to provide timely advice.
3. SEP for Moving or Plan Changes
- 2024: Moving to a new service area or changes in plan availability triggered an SEP, allowing beneficiaries to enroll in a new plan.
- 2025: These rules remain largely unchanged but with improved transparency from CMS, making it easier for beneficiaries to understand their rights and options.
How We Can Help You Navigate SEP and LIS Changes
At PSM Brokerage, we’re committed to helping you stay ahead of these updates and better serve your clients. Here’s how we can support you:
- Compliance Training: Ensure you understand the new SEP rules and how they interact with LIS eligibility changes.
- Technology Tools: Use our platforms to track SEP windows for your clients and compare plan options seamlessly.
- Client Education Materials: Access clear, CMS-compliant resources to help clients understand their enrollment options and LIS benefits.
- One-on-One Support: Work with our experts to navigate complex cases, such as clients transitioning out of Medicaid or LIS status.
The CMS rule changes for 2025 bring significant updates to D-SNPs, LIS benefits, and SEP policies. These adjustments aim to improve care coordination, simplify benefits, and ensure greater transparency while creating new challenges for agents in navigating stricter SEP guidelines.
By staying informed and leveraging the right resources, you can position yourself as a trusted advisor for your clients, helping them make informed decisions about their healthcare. Let us partner with you to ensure your success in this evolving market.
