The new SEPs for DNPs and LIS 2025 change when a dual eligible can leave or switch Medicare Advantage Plans. The Final Rule changed existing SEPs and put a new SEP for D-SNPs in place. Starting in 2025, dual eligible and LIS (Low-Income Subsidy) recipients can change their Medicare Advantage plan enrollment once per month. The rules vary according to the beneficiary’s level of help and include full-benefit dual eligibles, partial-benefit dual eligibles, and individuals enrolled in the LIS program but are not also enrolled in Medicaid (LIS-only).
Watch our recorded webinar on the changes to SEPs for DSNPS
SEP changes starting Jan 1, 2025:
- The current SEP for Dual eligibles and LIS only individuals is available once per quarter. It lets individuals switch or disenroll from a Medicare Advantage plan. This SEP will be end as of Jan 1, 2025.
- A new monthly SEP for all dual eligibles and LIS only individuals to disenroll from a MAPD plan and go back to Original Medicare and a stand-alone PDP plan.
- There will be a new SEP for all Dual eligibles and LIS only individuals to switch PDP plan enrollment.
- A new monthly SEP for full duals to enroll in an integrated and aligned D-SNP plan.
Monthly SEP for Dual Eligibles and LIS recipients
As of 2018, CMS put a quarterly SEP in place. This SEP allowed duals & LIS recipients to either enroll or disenroll in a MAPD or PDP plan. The enrollment or disenrollment goes into effect the first day of the following month after the enrollee makes a plan change during the first three quarters. If the change is made in the last quarter AEP from Oct 15 – Dec 7, the plan goes into effect as of January 1st of the following year.
CMS created a new SEP to replace the quarterly SEP. In 2025, dual eligible individuals and LIS-only individuals can change their MAPD and PDP enrollment one a month. Those who qualify can switch to another standalone PDP plan or disenroll from a Medicare Advantage plan and go back to Original Medicare and a standalone PDP plan. Individuals cannot use this SEP to enroll in another Medicare Advantage plan.
Integrated SEP
The CMS Final Rule created an SEP that will help facilitate enrollment for Dual eligibles into integrated Medicare Advantage plans. Each month, Full-benefit dual eligibles have the option to enroll in, or switch between, integrated D-SNPs. This SEP is only available to full-benefit dual eligible individuals who wish to enroll in integrated plans. Doing this will align enrollment between their Medicare and Medicaid coverage.
Those eligible can use this SEP to enroll in either a FIDE SNP (Fully Integrated Dual Eligible Special Needs Plan); or a HIDE SNP (Highly Integrated Dually Eligible Special Needs Plan); or a D-SNP that is an AIP (Applicable Integrated Plan).
What you can’t do with the SEP
Individuals cannot use the SEP to enroll in a Coordination only D SNP that is not an AIP, or a standard Medicare Advantage plan. The goal CMS has with this AEP is to have dual eligible individuals enroll in aligned plans if they are available in their home state.
Who can use this SEP
This SEP is only available to full-benefit dual eligible individuals who have access to an integrated, aligned plan. The following individuals cannot use this SEP: partial-benefit dual eligible individuals, and Medicare-only individuals cannot use this SEP. Presently, partial-benefit dual eligible individuals and LIS-only individuals have a quarterly SEP they can use to switch Medicare Advantage Plans. Keep in mind, this SEP will end as of Jan 1. 2025.
What happens if a person uses both the monthly and integrated SEP in the same month?
If an individual attempts to use the monthly SEP and the integrated SEP the same month, the SEP used last in will be effective. For example, Ms. Smith uses the monthly SEP to go back to Original Medicare on March 10th and on March 16th, she uses the integrated SEP to enroll in an Integrated Plan A, the integrated SEP is last used, and Ms. Smith will be enrolled into Integrated Plan A on April 1st.
SEP Changes for DSNPS & LIS 2025
| Beneficiary type | Current rules | Final Rule start January 1, 2025 |
| full-benefit dually eligible individuals, partial-benefit dually eligible individuals, and LIS-only individuals) | quarterly, these individuals can disenroll from their MAPD plan and join Original Medicare. They can enroll in a standalone PDP Plan at same time. | Once a month, these individuals can disenroll from their MAPD and join Original Medicare. They can enroll in a standalone PDP Plan at that time. |
| Full-benefit dually eligible individuals | Quarterly, these individuals can change Medicare Advantage plans. | monthly, these individuals can change from Original Medicare or a Medicare Advantage plan to (1) A Fully Integrated Dually Eligible Special Needs Plan (FIDE SNP), a Highly Integrated Dually Eligible Special Needs Plan (HIDE SNP), or a D-SNP that is an Applicable Integrated Plan (AIP) aligned with their Medicaid managed care enrollment. |
| Partial-benefit dually eligible individuals | Quarterly, these individuals can change Medicare Advantage plans. | Partial-benefit dually eligible individuals will no longer have a SEP to change Medicare Advantage plans on a quarterly basis.Other SEPs may apply including the new monthly SEP to return to Original Medicare and a standalone PDP |
| LIS-only individuals | Quarterly, these individuals can change Medicare Advantage plans. | LIS-only individuals will no longer have an SEP to change Medicare Advantage plans on a quarterly basis.Other SEPs may apply including the new monthly SEP to return to Original Medicare and a standalone PDP |
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