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As a Medicare agent, mastering all the different enrollment periods is crucial to ensure smooth enrollment for your clients. It also helps you stay compliant and that is also very important. Understanding IEP vs ICEP is essential to anyone in Medicare sales. Although these two sound similar, they serve distinct purposes and apply to different parts of Medicare.

IEP (Initial Enrollment Period)

First we will go over The IEP. Most agents know that this is the first window of time when someone is eligible to enroll in Original Medicare; specifically Parts A and B.

• Who is eligible to apply: Individuals turning 65 who worked and paid Medicare taxes for a period of at least 10 years (40 quarters) or their spouse or ex-spouse. Those who are under 65 with a qualifying disability, ESRD or ALS are also eligible to enroll.
• Timing: For those who are turning 65; The IEP spans 7 months: it begins 3 months before their 65th birthday, includes their birth month and ends 3 months after the month they turn 65.
• Timing: Individuals who are under 65 and qualify due to a disability; the IEP begins 3 months before the 25th month of their disability benefit entitlement.

Example: If a client turns 65 in May, their IEP runs from February 1st to August 31st.

What beneficiaries can do during IEP

1. Enroll in Medicare Part A and/or Part B
2. Enroll in a Medicare Part D plan (if they have Part A and/or Part B)
3. If they enroll in both Part A & Part B, they may also opt for either a Medicare Advantage (Part C) plan or a Medicare Supplement (Medigap) plan.

ICEP (Initial Coverage Election Period)

When an individual is first eligible for Medicare, the ICEP can specifically be used to enroll in a Medicare Advantage (Part C) plan.

• Who can use the ICEP: Individuals who are first enrolling in both Medicare Part A and B, and want to join a Medicare Advantage plan.
• Timing: Usually, the ICEP coincides with the IEP. However if an individual delays Part B enrollment (e.g., due to employer coverage), the ICEP does not start until they have both Part A and Part B and ends the last day of the month before their Part B coverage begins.

Example 1 (standard case): Client enrolls in A & B to begin July 1. Their ICEP runs from April 1 to June 30.

Example 2 (delayed Part B): Client took Part A at 65; delayed Part B until they retired at 67. Their ICEP begins when they enroll in Part B and ends the last day of the month before Part B becomes effective.

What beneficiaries can do during ICEP

1. Enroll in a Medicare Advantage (Part C) plan, with or without drug coverage (MAPD or MA-only).

Differences at a Glance

Why Understanding IEP vs ICEP Matters to Agents

Confusing IEP and ICEP could lead to enrollment mistakes, missed opportunities, and compliance issues. Knowing when each applies ensures:

• You recommend the right plans at the right time.
• You help clients avoid penalties for delayed Part D enrollment.
• You position yourself as a knowledgeable and trusted resource.

Watch a YouTube video on Medicare enrolment periods

Important: Always ask clients if they’ve enrolled in both Part A and B before discussing Medicare Advantage options. This small question helps determine whether they’re in their ICEP.

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For many people trying to navigate Medicare, understanding how and when out-of-pocket costs apply can be overwhelming. The terminology “first dollar Medicare services” may cause confusion for some individuals. We will explain what it actually means and how they work in the context of Medicare services.

First Dollar Coverage

First dollar coverage refers to insurance benefits that begin immediately. The enrollee is not required to, pay a deductible, copay, or coinsurance before the carrier provides coverage for a medical service. This coverage literally begins from the “first dollar” of a medical bill providing the highest level of financial protection.

With Original Medicare (Parts A and B), this kind of coverage is not included by default, although it may be accessed through either supplemental plans or Medicare Advantage plans in some circumstances.

Original Medicare: No First Dollar Coverage

Medicare is divided into Part A (hospital insurance) and Part B (medical/outpatient insurance).

Original Medicare enrollees are responsible for the following out-of-pocket costs:

• Deductibles: Part A ($1,632 per benefit period in 2025); Part B ($240 annual)
• Coinsurance: 20% for most Part B services after the deductible
• Copays: Varies depending on the service or provider

Please note; although Medicare covers a significant portion of approved healthcare costs, it does not offer first dollar coverage when used on its own. Beneficiaries are responsible for cost-sharing amounts unless they purchase supplemental coverage.

First Dollar Coverage for Medicare Services

In general, there are two ways Medicare beneficiaries receive first dollar coverage:

1. Medicare Supplement (Medigap) Plans

The Medigap plans listed below cover most or all out-of-pocket costs after Original Medicare pays its share.

• Plan F: Offers true first dollar coverage. This plan covers both Part A and Part B deductibles as well as all coinsurance and copays for approved medical expenses as well as excess charges.
• Plan C: Similar to Plan F but doesn’t cover excess charges. Important: Plans F and C are not available to individuals who were eligible for Medicare after January 1, 2020.
• Plan G: Covers all approved Medicare expenses; except the Part B deductible, making this plan very close to first dollar coverage.

Beneficiaries enrolled in a Plan F shouldn’t have to pay anything out-of-pocket for Medicare covered services.

2. Some Medicare Advantage (Part C) Plans

Medicare Advantage plans are an alternative to Original Medicare. Some Medicare Advantage plans offer enrollees:

• $0 monthly premiums
• $0 copays for primary care, lab work, preventive services, or telehealth
• Reduced out-of-pocket costs through annual limits

Although technically they are not considered “first dollar” coverage, some plan benefits can effectively eliminate upfront costs for specific services, depending the plan design.

Keep in mind: Medicare Advantage plans may include networks, referrals, and prior authorization requirements.

Watch a quick YouTube video on Medicare enrollment periods

Examples of First Dollar Medicare Service

• Example 1: A Medigap Plan F enrollee visits the emergency room. The bill is fully covered; no deductible, no copay, no coinsurance. This is real first dollar coverage.
• Example 2: A Medicare Advantage plan enrollee has a $0 copay for a primary care visit. Although the plan may have a deductible for other services, this specific visit is a first dollar service.
• Example 3: A individual with Original Medicare and no supplemental coverage uses the services of a specialist. This individual must meet the Part B deductible and then pay 20% for all approved charges. In other words, this is not first dollar coverage.

Why First Dollar Coverage Matters

• Predictable healthcare costs
• Easier budgeting for individuals on fixed incomes
• Reduces the risk of surprise bills
• Encourages timely medical visits and screenings

Possible Downside

• Higher monthly premiums (especially with Medicare Supplement Plans)
• Less flexibility (if beneficiaries opt for a Medicare Advantage Plan) they must use specific provider networks.
• Limited plan availability for more recent enrollees (Medicare Supplement Plan F and Plan C enrollment restrictions).

First dollar Medicare services are about financial peace of mind. While Original Medicare doesn’t provide this level of coverage on its own, many beneficiaries learn that Medicare Supplements or Medicare Advantage plans reduce or eliminate the high price of medical care.

Beneficiaries who like predictable expenses and minimal out-of-pocket costs, may opt for a plan that offers first dollar coverage. As a licensed Medicare agent, it is important to understand your clients healthcare needs and budget to offer plan choices that provided the best benefit options.

Understanding Medicare Advantage enrollment periods; when to join, switch or leave a plan is crucial to receive necessary healthcare coverage. Although even if you know which plan you want, when you can enroll in a Medicare Advantage plan isn’t always straightforward.

In this post, we break down the Medicare Advantage enrollment periods so beneficiaries do not miss an opportunity to get teh coverage they need.

Medicare Advantage

Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. In other words, these plans provide coverage for Part A (hosptial) & Part B (medical) expenses. They are offered by private insurance companies that are approved by Medicare. The plans often include extra benefits like vision, dental, hearing, and Part D (prescription drug coverage).

However, individuals can’t just sign up any time they want to. There are specific rules that specific govern when individuals can join or make changes.

Initial Enrollment Period (IEP)

This enrollment period is for those who are either turning 65 or newly eligible for Medicare.

The Initial Enrollment Period is a 7-month window:

• Starts 3 months before the month individuals turn 65
• Includes the birthday month
• Ends 3 months after the birthday month

During this time, individuals can enroll in Original Medicare (Parts A and/or B). They can also choose to enroll in either a Medicare Advantage plan with or without Part D or a Medicare Supplement and a stand-alone Part D plan.

Annual Enrollment Period (AEP)

Medicare’s AEP runs from October 15 through December 7 each year. This enroll,ment period is a time whe anyone enrolled in a Medicare plan should meet with theor Medicare agent and go over their options for the coming year.

During this time, beneficiaries can:

• Switch from Original Medicare to a Medicare Advantage plan
• Switch from one Medicare Advantage plan to another
• Drop a Medicare Advantage plan and return to Original Medicare
• Join, drop, or switch a Part D prescription drug plan

Changes made during AEP take effect January 1 of the following year.

Medicare Advantage Open Enrollment Period (MA OEP)

Each year the MA OEP runs from January 1 through March 31. This enrollment period is available to those already enrolled in a Medicare Advantage plan

During this time, beneficiaries can:

• Switch to a different Medicare Advantage plan
• Drop Medicare Advantage and return to Original Medicare (and optionally join a Part D plan)

Please Note: Medicare beneficiaries cannot join a Medicare Advantage plan for the first time during MA OEP.

Watch a quick YouTube video on Medicare OEP best practices.

Special Enrollment Periods (SEPs)

Medicare SEP are available to beneficiaries who experience specific life events.

Individuals may qualify for an SEP ( Special Enrollment Period) if they:

• Move out of their plan’s service area
• Lose other health coverage (like employer sponsored insurance)
• Qualify for Extra Help or Medicaid
• Live in or move into a nursing home
• Miss a valid election period due to a FEMA declared emergency
• Experience plan contract changes (e.g., plan termination)

The time allowed to use an SEP varies. Therefore, it is important for eligible beneficiaries to act promptly so they don’t miss the enrollment opportunity.

5-Star Special Enrollment Period

If a Medicare Advantage plan earns a 5-star rating from CMS, beneficiaries can switch from their current plan to the 5 star plan from December 8 – November 30 of the following year. Plan enrollees can use this election period only once per calendar year.

This allows plan enrollees to move to a top-rated plan outside of the usual enrollment windows.

When it comes to Medicare Advantage enrollment, timing is important. Missing an enrollment window can mean waiting months for another opprotunity to change coverage. This can leave beneficiaries in a plan that no longer fits their coverage needs.

Each year, Medicare eligible indivduals wonder which type Mediare plan will cover their helath care needs best. Many beneficiareis wonder if they should enroll in a Medicare Supplement or a Medicare Advantage plan. Although both options provide comprehensive coverage, it is important for individuals to consider their needs and budget to make the best choice. In this post, we will go over some ways to decide the best candidates for MAPD Plans.

People Who Want All-in-One Coverage

MAPD plans are good for; anyone who prefers having all their healthcare benefits managed under a single plan. Plan enrollees only need to carry one ID card and pay for Part B and 1 plan premium. Although, some plans do not even charge a premium.

Private insurers offer Medicare Advantage plans (Part C) and bundle together:

• Part A (hospital coverage)
• Part B (medical insurance)
• Often Part D (prescription drug coverage)
• Plus extra perks like vision, dental, hearing, and wellness benefits

Budget-Conscious Individuals

Many MA plans offer low or even $0 monthly premiums. This is in contrast to Medigap plans (used with Original Medicare), which usually have higher premiums.

While enrollees are still responsible for copays and out-of-pocket costs, Medicare Advantage plans have annual out-of-pocket maximums. The maximums provide financial protection Original Medicare alone doesn’t offer. In other words, these plans are a great choice for those on a fixed income trying to cap their annual healthcare costs.

People Who Don’t Travel Often

Because Medicare Advantage plans generally have local provider networks, enrollees must see doctors and hospitals within the plan’s service area for non-emergency care.

These plans are a good choice for individuals who don’t travel often and usually receive care in their local area. MAPDs might not be a good fit for those who live in multiple states throughout the year.

Those Who Value Extra Benefits

Because Medicare Advantage plans usually offer additional benefits beyond what Original Medicare provides, some people prefer them over other options.

Some of the additional benefits (not included in Original Medicare) plans may offer are:

• Dental exams
• Vision exams and an eye wear allowance
• Hearing exams and hearing aid coverage
• Gym memberships
• Transportation to medical appointments
• OTC items
• Healthy food cards

Please note; this list varies by carrier plan type and area. Not all benefits are included in every plan.

Comfortable with Managed Care

Many Medicare Advantage plans involve managed care structures, like HMOs or PPOs, that coordinate your services and may require referrals or prior authorizations.

People who are comfortable navigating provider networks, or calling their plan for care coordination support may find these plans are a good option.

Those in Good Health

Because MA plans often come with copays for services, they may be more cost-effective for individuals who don’t expect to need frequent medical treatment. In other words, Medicare Advantage plans may be a good fit for healthy retirees who normally see a doctor a few times a year for annual checkups or minor services.

Best Candidates for MAPD Plans

Choosing the right Medicare plan depends on personal health needs, budget, and lifestyle. A Medicare Advantage plan can offer convenience, cost savings, and extra benefits,, only if it aligns with how much and where helathcare is needed.

Before enrolling, consider:

• Current doctors (are they in the plan’s network?)
• Medications (are they covered?)
• How often you travel
• Comfort level with managed care.

Medicare Advantage plans are not one-size-fits-all, but for the right person, they can be a useful, value-packed healthcare solution.

Agents click here to learn how Connecture and Sunfire can make quoting and enrollment easier

Before switching or enrolling for the first time, be sure to review options carefully. It is important to check each year during Medicare’s Annual Enrollment Period (AEP) for the plan that best suits current health care needs and budget. A licensed Medicare agent can provide options and help find the most suitable coverage option.

Unfortunately, as people age, the risk for chronic conditions like heart disease, diabetes, and cancer increases. Although with the right preventive measures in place, many of these conditions can be delayed, managed effectively, or even avoided. That is why we will go over the importance of preventative services for Medicare beneficiaries.

Preventive Healthcare

The objective of Preventive healthcare is to maintain wellness and discover health issues before they become serious. It includes regular checkups, screenings, immunizations, counseling, and lifestyle intervention. These services are all designed to detect potential health problems early or prevent them from happening.

Why Preventative Service for Medicare Beneficiaries Matters

Early Detection

Some serious conditions, such as colorectal cancer or high blood pressure, may not show symptoms until they’ve progressed. That is why routine screenings are important. They can catch these conidtions early, when they’re easier to treat. This helps the beneficiary have a better qualityof life and save money on treatments.

Managing Chronic Conditions

Due to the fact that, over two-thirds of Medicare beneficiaries suffer from multiple chronic conditions, preventative care is essential. Preventive care helps manage these illnesses more effectively, avoiding emergency visits, hospitalizations, and complications. Annual wellness visits give beneficiaries an opportunity to review medications, coordinate care, and update personalized prevention plans.

Immunizations

Keep in mind; Flu shots, shingles vaccines, and COVID-19 boosters can be life-saving for older adults whose immune systems may not be as strong as younger individuals. Medicare Part B covers many of these vaccines. Staying up-to-date with immunizations can help prevent avoidable illness and hospital stays.

Mental and Cognitive Health

Preventive care also includes screenings for depression and cognitive impairment that are critical as people age. These services allow early interventions that can improve quality of life and help individuals maintain independence.

Health Education and Lifestyle Support

Through programs like smoking cessation counseling and diabetes self-management training, Medicare supports healthier living. Lifestyle changes such as, eating healthier foods, excercising or quitting smoking can dramatically reduce the risk of future health problems.

Overcoming Barriers to Access

Despite the clear benefits, many beneficiaries don’t fully utilize preventive services. Reasons include lack of awareness, confusion about coverage, transportation challenges, or simply not knowing what’s available to them. That’s why education and outreach; especially from healthcare providers, caregivers, and community organization are so crucial.

In the event a client wants to have better coverage for an illness, agents should understand the benefitof ancillary products to avoid gaps in coverage.

Agents: Watch a quick YouTube video on why and how to sell ancillary products

Preventive healthcare isn’t just about avoiding illness. It’s about living better, longer, and keeping your independence. For Medicare beneficiaries, taking advantage of all the preventive services Mediare covers is one of the smartest health decisions they can make.

Medicare Advantage (MA) plans are growing in popluarity as an alternative to Original Medicare, often attracting enrollees with low premiums, extra benefits, and all-in-one coverage. However, understanding the true Medicare Advantage Plan cost breakdown is crucial to avoid unexpected financial burdens. Here’s a detailed look at the key expenses associated with Medicare Advantage plans.

Premiums

Many MA plans advertise low or even zero-dollar premiums. However, enrollees must still pay the standard Medicare Part B premium ($185 per month in 2025) unless they qualify for financial assistance. Some plans may also charge an additional monthly amount for extra benefits, like dental comprehensive coverage.

Deductibles and Copays

Unlike Original Medicare, which has standardized costs, Medicare Advantage plans vary widely in deductibles and copay amounts. Enrollees of some MA plans must to meet an annual deductible before coverage kicks in, and they charge copays for doctor visits, hospital stays, and prescription drugs.

Out-of-Pocket Maximums

One advantage of MA plans is that they have an annual out-of-pocket maximum, unlike Original Medicare. In 2025, the maximum amount a MA plan CMS allows MA plans to charge for in-network services is $9,350. Please keep in mind, not all plans charge this amount for an out-of-pocket maximum; most plans have lower MOOPs. This is the most they are allowed to charge, the amount varies greatly by plan. Once this limit is reached, the plan covers all additional costs for the remainder of the year.

Out-of-Network Care

Most MA plans operate within a provider network. HMO plans require enrollees to use only in-network providers, while PPO plans allow some out-of-network visits at a higher rate. Please note; unless you are in a emergency situation, seeking care outside the network can lead to significant additional expenses.

Prescription Drug Costs

Many Medicare Advantage plans include Part D prescription drug coverage. The cost for prescrptions vary based on the plan’s formulary. Factors such as tiered formulary pricing and preferred pharmacy networks can influence out-of-pocket expenses for medications. Most plans also have a prescription deductible to meet for medications over a specific tier level.

Hospitalization and Specialist Care

While MA plans cover hospital and specialist care, costs can add up quickly. Some plans charge daily copays for hospital stays. Additionally, specialist visits usually have higher copays than PCP visits or require referrals, adding another charge.

Extra Benefits and Hidden Costs

Medicare Advantage plans often include extra benefits like dental, vision, and hearing coverage. However, these benefits may have limitations, such as caps on coverage or a restricted provider network, which can lead to unexpected out-of-pocket expenses.

Travel and Emergency Care Costs

Unlike Original Medicare, which offers nationwide coverage, most MA plans have geographic restrictions. If you travel frequently, you may face higher costs for out-of-network emergency care or require a plan with national coverage options.

Agents see how easy it is to compare MA plans with Sunfire and Connecture

Medicare Advantage plans can be a cost-effective option for some enrollees, but it’s essential to understand the full financial picture. By carefully reviewing plan details, including premiums, out-of-pocket limits, network restrictions, and prescription drug costs, enrollees can make informed decisions about healthcare coverage and avoid expensive surprises.

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As a Medicare insurance agent, maintaining a strong reputation and ensuring client satisfaction is essential for success. While providing the best possible service, agents must also be proactive in preventing client complaints that could damage their credibility, lead to compliance issues, or impact their business. We will explain how to avoid client complaints and build better client relationships.

Explain plan details and costs clearly

Many complaints arise from misunderstandings about plan coverage, costs, or network restrictions. To avoid this, agents should take the time to explain plan details, including premiums, deductible and co-pays. Do not forget to include out-of-pocket plan limits.

Remember to emphasize any network restrictions as well as provider availablity. This is extremely important for Medicare Advantage plans. It is helpful to provide a summary of benfits so clients can review them before enrolling in a plan.

Ensure clients enroll in the correct plan

Sometimes complaints occur if the client feels they were enrolled in a plan that does not fit their needs. The best ways to avoid this are; conduct a thourough needs assessment. Be sure you consider all medications, docotors and expected healthcare useage. Comparing mulitple plans and explaining the pros and cons of each helps the client make an informed decision.

Learn about rapid disenrollments

Be transparent coverage changes

Because Medicare plans can change every year, clients may be unhappy if they experience unexpected costs or coverage changes. To prevent this; be sure you procactively inform them of any modifications to their current plan, Remind them to take a look at their annual notice of change (ANOC). Offer an annual review during AEP to ensure thye are still in the best plan for their coverage needs.

Follow CMS compliance guidelines

The CMS has strict marketing and sales guidelines. Agents must avoid misleading or high-pressure sales tactics, use only approved marketing materials and be sure to obtain consent before discussing any pans. It is also important to never make unverified claims about coverage, benefits or plan costs.

Provide ongoing support

Clients appreciate agents who are accessible and responsive. To maintain trust; return calls and emails promptly. Offer assistance after enrollment, such as claims questions and benefit explanations. It is always a good idea to follow up to make sure clietns are happy and understand hw to use their plan benefits.

Handle issues and complaints professionally

Even with the best practices, complaints may still come up. When they do; be sure you listen attentively to the client’s concerns without interruption. It is important to acknowledge their frustration and provide a solution oriented repsonse. If it is necessary, escalate issues to the appropriate carrier rep or Medicare support services.

Document interactions

Keeping records of client communications, plan discussions, and enrollments helps protect agents and clients in case of disputes. Maintain notes from meetings, make note of any special concerns. Keep written enrollment confiramtions and copies of signed documents, authorizations especially the SOA.

Stay updated on Medicare rules and plans

Medicare regulations, plan offerings, and compliance rules change regularly. Stay informed by attending carrier training and webinars. Complete all annual certifications including AHIP. Join industry groups and network with other agents to stay updated on all industry and CMS rules.

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Medicare agents play an important role helping clients navigate complex healthcare decisions. By being transparent, compliant, and client-focused, agents can minimize complaints, enhance client satisfaction, and build a strong reputation in the industry. Providing top-notch service not only leads to long-term client relationships but also increases referrals and business growth.

The Medicare Advantage market has experienced substantial growth in recent years, with Medicare C-SNP market growth one of the fastest-growing segments. C-SNPs cater to individuals with specific chronic illnesses, offering tailored benefits and care coordination. As healthcare costs rise and the over 65 population grows, C-SNPs are becoming the plan of choice for both beneficiaries and insurers.

What Are C-SNPs

Medicare Advantage Special Needs Plans (MA SNPs) provide targeted care and services to specific beneficiaries. Within this category, C-SNPs focus on beneficiaries with qualifying chronic conditions such as diabetes, cardiovascular disease, or chronic lung disorders. C-SNPs offer enhanced care management, specialized provider networks, and condition-specific benefits. These plans go beyond what traditional Medicare or standard MA plans provide.

Growth of the C-SNP market

Several factors are fueling the growth of the C-SNP market:

Chronic disease prevalence – Due to the aging U.S. population, the number of individuals with chronic conditions is rising. According to the CDC, six in ten adults have at least one chronic disease. This has increased the demand for tailored healthcare solutions.

Regulatory support – CMS continues to promote C-SNP expansion, offering increased flexibility in plan design and benefits to better meet the needs of chronically ill beneficiaries.

Increased insurer participation – As health plans recognize the financial and clinical benefits of offering C-SNPs, more insurers are entering the market. This leads to greater competition and plan innovation.

Improved care coordination – C-SNPs focus on the management or chronic conditions and care coordination, which aligns with the healthcare industry’s push towards value-based care.

Enhanced supplemental benefits – Many C-SNPs offer non-medical benefits, such as meal delivery, transportation, and in-home support services. This makes them attractive to eligible beneficiaries.

Challenges of C-SNPs

Regulatory issues – C-SNPs must meet stringent CMS requirements, including annual Model of Care (MOC) approvals and strict care coordination standards.

Enrollment requirements – Because C-SNPs require beneficiaries to have a qualifying chronic condition, plan enrollment may be more complicated than traditional MA plans.

Provider networks – Ensuring access to specialists and chronic disease management programs may be difficult in rural or underserved areas.

Watch a quick YouTube video on changes to DSNP & LIS members

The Future of C-SNPs

The future of the C-SNP market seems promising, with continued growth in personalized healthcare solutions and care coordination. As CMS allows flexibility in benefit design and insurers look for growth strategies, C-SNPs have an opportunity to become an even bigger part of the Medicare Advantage market.

Even with some challenges ahead, the potential for improved patient outcomes and cost efficiency make C-SNPs an important part of Medicare’s future.

In a memo dated March 20, 2025, CMS withdrawals DST SEP change. CMS announced the withdrawal of the changes to the enrollment process that were set to take place on April 1,2025. In other words, there will be no changes to the DST SEP policy that is currently in place.

Why this is good news

The reversal of this decision is great news for both agents and their clients. Because it takes the burden off of already stressed clients who have had to deal with a weather related or other FEMA declared area emergency.  This means, the current SEP will not change. Beneficiaries do not have to self-enroll using 1-800-Medicare to use this SEP.

As per the CMS memo of March 20, 2025, insurance carriers will accept enrollment applications submitted by licensed agents. This helps Medicare beneficiaries avoid both stress and confusion. It also allows agents to ensure the process is completed correctly and in a timely manor.

Medicare DST SEP

The DST SEP is an enrollment election period for qualified Medicare beneficiaries . CMS provides this SEP to those who miss a valid election period due to weather-related emergencies or FEMA declared disasters.

Only areas where state or local government officials declare an emergency or disaster can use this SEP. This SEP starts the date the incident occurs and continues for two months after it starts or the extension period begins. It can be in place for up to a year after the incident.   

Please note: Beneficiaries can either enroll in or disenroll from a Medicare plan using the DST SEP. New coverage goes into effect the first day of the month following the submission of the application.

Eligibility for the DST SEP

To qualify for this SEP, the beneficiary must live in the area the disaster occurred in. In addition, they must have missed a valid election period (AEP, IEP or OEP, or an SEP) because of the emergency.

In some cases, individuals use the SEP if they require help from a family member or caregiver who is impacted by a disaster. This can prevent them receiving the assistance they need during an enrollment period.

Watch a quick YouTube video on the changes to DSNP SEPs

A couple more reasons to use the DST SEP: When a disaster causes the inability to access Medicare plan information or submit an application. Another example is; when a disaster impacts a healthcare facility or provider. This can hinder the beneficiary’s access to information necessary to make an informed enrollment decision.  

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Due to the recent changes in DSNP SEPs, many agents are asking questions about the different levels of Medicare DSNPs. Medicare Dual-Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan designed specifically for individuals who qualify. These plans offer specialized benefits tailored to meet the unique healthcare needs of dual-eligible individuals. However, not all D-SNPs are the same, and understanding the different types can help beneficiaries make informed decisions about their coverage.

We provide an overview of the DSNP models below:

CO-D-SNPs (Coordination Only D-SNPs)

CO D-SNPs meet the minimum CMS requirements for D-SNPs. All plans meet state requirements and hold a contract with state Medicaid agencies in the states they operate in. These plans also coordinate the delivery of Medicare and Medicaid services to their members. Because these plans do not qualify as HIDE or FIDE, beneficiaries cannot use the DSNP SEP to enroll in one of these plans. However, they can enroll in these plans during another valid election period.

Learn more about the DSNP SEP

AIP D-SNPs (Applicable Intergrated Plans) – Coordination Only EAE

AIP D-SNP is a fully integrated DSNP with exclusively aligned enrollment or a highly integrated DSNP plan with exclusively aligned enrollment and cover certain Medicaid benefits. To qualify as a AIP DSNP, plans must be either FIDE or HIDE SNP with EAE or a CO D-SNP with EAC that covers primary and acute care. It must also cover Medicare cost sharing and at least one of these home health services; medical supplies, equipment appliances or nursing facility services.

AIP D-SNPs must implement unified plan level appeals as well as grievance procedures.

Click here for full definition of DSNPs

HIDE SNPs (Highly Intergrated D-SNPs)

The HIDE SNPs provide Medicaid benefits to members either through the plan or an affiliated Medicaid managed care plan. Coverage includes LTSS (long term services and support), behavioral health care or both. Plans have a contract for Medicaid coverage with the state Medicaid agency. This may be accessed through the DSNP, the DSNP’s parent organization or another organization owned by the DSPs parent company. This contract must cover the entire service area.

FIDE SNPs (Fully Integrated D-SNPs)

These plans provide Medicare and Medicaid benefits under one entity that holds a Medicare advantage contract and a contract with the state Medicaid agency. FIDE SNPs must cover both Medicaid primary and acute care as well as LTSS, This includes at least 180 days each year of nursing facility coverage.

What is EAE

EAE is exclusively aligned enrollment which happens when states require DSNP enrollment be limited to only those who are fully dual eligible. Individuals must also receive coverage of Medicaid benefits through the DSNP or a Medicaid managed care plan owned by the same parent company as the DSNP. When a plan is exclusively aligned, it facilitates coverage integration ensuring better care for enrollees.

Why we need alignment

Alignment provides assurance that Medicare and Medicaid work together to provide comprehensive, coordinated coverage for dual eligible individuals. This provides members with a well organized system of care that improves health outcomes.

Watch a quick YouTube video on the new DSNP enrollment

How it works with D-SNPs

Aligned FIDE SNPs – these plans align Medicare and Medicaid under 1 carrier as 1 entity. Members access benefits with only 1 ID card. This helps members avoid confusion and ensures members easily get all the benefits they need.

Aligned HIDE SNPs – HIDE plans align Medicare and Medicaid under 1 carrier using 2 separate entities, possibly requiring members to use 2 different ID cards. In some cases, this may be confusing for members.

Unaligned HIDE SNPs – Unaligned plans operate as 2 separate managed care plans. The Medicare plan is managed by the Insurance Carrier while the Medicaid coverage is managed by the state Medicaid organization. This can result in at least 2 ID cards and in some cases, more.

Find out about other SEPs for Medicare enrollment

Choosing the Right D-SNP Plan

When selecting a D-SNP, it is crucial to consider the level of Medicaid eligibility, the extent of additional benefits, and the coordination of services. Since plan availability varies by state, beneficiaries should use licensed Medicare agents to review their options carefully to find a plan that best meets their needs.

For more information on Medicare D-SNP options in your state, consult Medicare.gov or your local Medicaid office.