Did you know that major changes are coming for Medicare and Medicaid integration?
The 2025 Medicare Final Rule introduces key updates that will significantly impact how dually eligible beneficiaries—those who qualify for both Medicare and Medicaid—receive their benefits. These changes are designed to simplify care delivery, improve outcomes, and reduce administrative hurdles for both clients and agents.
Whether you work directly with Dual Eligible Special Needs Plans (D-SNPs) or are simply looking to stay informed, this article breaks down what you need to know.
What’s Changing?
The Centers for Medicare & Medicaid Services (CMS) is pushing for greater integration between Medicare and Medicaid. One of the most significant shifts is the emphasis on “exclusively aligned enrollment.”
What Is Exclusively Aligned Enrollment?
Starting in 2025 and continuing through 2027, CMS will encourage or require dually eligible individuals to receive both their Medicare and Medicaid benefits from:
- The same health plan or organization, OR
- Two plans that operate under the same parent company
The goal? Better care coordination, fewer administrative headaches, and cost savings for clients and the healthcare system.
Enrollment Restrictions Coming in 2027
Beginning in 2027, certain D-SNPs will be limited to enrollees who are either already enrolled in—or actively enrolling in—an affiliated Medicaid managed care organization (MMCO).
This new alignment ensures that both Medicare and Medicaid benefits are managed under the same umbrella, paving the way for more consistent care and better outcomes.
New Special Enrollment Periods (SEPs) in 2025
Starting January 1, 2025, two new SEPs will be available for dually eligible individuals and those eligible for the Extra Help program (Low-Income Subsidy):
1. Dual/LIS SEP
- Available to: Full-benefit and partial-benefit dually eligible individuals, and those eligible for Extra Help
- Frequency: Once per month
- What it allows:
- A switch to Original Medicare + PDP
- A switch between standalone prescription drug plans (PDPs)
2. Integrated Care SEP
- Available to: Full-benefit dually eligible individuals
- Frequency: Once per month
- What it allows:
- Enrollment into a Fully Integrated D-SNP (FIDE SNP)
- Enrollment into a Highly Integrated D-SNP (HIDE SNP)
- Enrollment into an Applicable Integrated Plan (AIP)
These SEPs are meant to support ongoing, flexible alignment with integrated care models.
D-SNPs vs. FIDE SNPs: What’s the Difference?
Understanding the difference between Dual Eligible Special Needs Plans (D-SNPs) and Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) is essential for agents helping clients choose the right plan.
D-SNPs (Dual Eligible Special Needs Plans)
- General integration of Medicare and Medicaid benefits
- Require a CMS-approved Model of Care and offer some care coordination
- Vary in how well-integrated services are across providers and systems
FIDE SNPs (Fully Integrated Dual Eligible Special Needs Plans)
- Provide comprehensive coverage of both Medicare and Medicaid benefits
- Operate under a single legal entity
- Cover primary care, acute care, long-term services and supports (LTSS), behavioral health, and prescription drugs
- Offer a truly integrated experience across materials, enrollment, communications, and care delivery
What This Means for You as an Agent
As these changes roll out, agents should be ready to:
- Educate dually eligible clients on their new options and SEPs
- Help clients transition into integrated plans where applicable
- Stay compliant with CMS requirements around enrollment and plan comparisons
- Leverage FIDE SNPs where appropriate to offer simplified, cost-effective care
How to Make a CHC Plan Change
If a client needs to update their Community Health Choice (CHC) plan, they can:
- Log into their My Member Account portal
- Submit a change request (processed within 24–72 hours)
- The new plan becomes effective the following month
- Alternatively, contact CHC via:
- Live chat
- Text message
- Toll-free at 1-888-760-2600
Final Thoughts
With new rules and tools coming into effect, 2025 will be a pivotal year for agents serving dually eligible clients. The push for integration and improved flexibility through SEPs will ultimately create better outcomes—but only if agents are prepared.
At National Insurance Markets, we’re here to help you stay on top of every change—so you can keep delivering top-tier service to your clients.
📞 Need help navigating these changes or finding the right plans for your clients?
Contact National Insurance Markets or log into your agent portal for tools, training, and support.
