Clarification on DSNP plan switches for 2025

[Special Agent]

Just got off UC training webinar for 2025 changes.ONLY Full Medicaid peeps can change monthly-not QMB,SLMB etc.

 

[Baseball7]

There’s always another SEP.
maybe cms shouldn’t hand out sep’s every time it rains

 

[Special Agent]

There’s always another SEP.
maybe cms shouldn’t hand out sep’s every time it rains

ok then

 

[TwoCents]

Just got off UC training webinar for 2025 changes.ONLY Full Medicaid peeps can change monthly-not QMB,SLMB etc.

I do agree with the comment that there's always another SEP (to ask about). But which SEP specifically are you referring to? I suspect the new one where a person can only enroll into specific DSNP types operated by the same plan/company they get their Medicaid from.

 

[Special Agent]

I do agree with the comment that there's always another SEP (to ask about). But which SEP specifically are you referring to? I suspect the new one where a person can only enroll into specific DSNP types operated by the same plan/company they get their Medicaid from.

referring to the (SEP -Integrated Plan ) that is available only to full medicaid in 2025.Doesn't have to be the same DSNP carrier that prospect has managed medicaid with but the DSNP carrier has to have a managed medicaid plan contract in that state for people with original medicare.

 

[DonP]

Do what the call centers do. They use move , SPAP , dst . Carriers don’t check any of it

 

[TwoCents]

referring to the (SEP -Integrated Plan ) that is available only to full medicaid in 2025.Doesn't have to be the same DSNP carrier that prospect has managed medicaid with but the DSNP carrier has to have a managed medicaid plan contract in that state for people with original medicare.

Thanks for playing. Here's a toaster. The whole point of the new SEP is to align Medicaid and DSNP coverage.

From the 2025 final rule CMS-4205-F
After considering the comments received, we are finalizing the integrated care SEP with a narrower scope so that dually eligible individuals may use the SEP to enroll in a FIDE SNP, HIDE SNP, or AIP if they are enrolled in or in the process of enrolling in the sponsor’s affiliated Medicaid managed care plan.

From the Code of Federal Regulations:
(i) The individual is a full-benefit dual eligible individual (as defined in § 423.772) making a one-time-per month election into a fully integrated dual eligible special needs plan as defined in § 422.2 of this chapter, a highly integrated dual eligible special needs plan as defined in § 422.2 of this chapter, or an applicable integrated plan as defined in § 422.561 of this chapter.

(ii) The SEP is available only to facilitate aligned enrollment as defined in § 422.2 of this chapter.

Aligned enrollment refers to the enrollment in a dual eligible special needs plan of full-benefit dual eligible individuals whose Medicaid benefits are covered under a Medicaid managed care organization contract under section 1903(m) of the Act between the applicable State and: the dual eligible special needs plan's (D-SNP's) MA organization, the D-SNP's parent organization, or another entity that is owned and controlled by the D-SNP's parent organization. When State policy limits a D-SNP's membership to individuals with aligned enrollment, this condition is referred to as exclusively aligned enrollment.

 

[DonP]

Thanks for playing. Here's a toaster. The whole point of the new SEP is to align Medicaid and DSNP coverage.

From the 2025 final rule CMS-4205-F
After considering the comments received, we are finalizing the integrated care SEP with a narrower scope so that dually eligible individuals may use the SEP to enroll in a FIDE SNP, HIDE SNP, or AIP if they are enrolled in or in the process of enrolling in the sponsor’s affiliated Medicaid managed care plan.

From the Code of Federal Regulations:
(i) The individual is a full-benefit dual eligible individual (as defined in § 423.772) making a one-time-per month election into a fully integrated dual eligible special needs plan as defined in § 422.2 of this chapter, a highly integrated dual eligible special needs plan as defined in § 422.2 of this chapter, or an applicable integrated plan as defined in § 422.561 of this chapter.

(ii) The SEP is available only to facilitate aligned enrollment as defined in § 422.2 of this chapter.

Aligned enrollment refers to the enrollment in a dual eligible special needs plan of full-benefit dual eligible individuals whose Medicaid benefits are covered under a Medicaid managed care organization contract under section 1903(m) of the Act between the applicable State and: the dual eligible special needs plan's (D-SNP's) MA organization, the D-SNP's parent organization, or another entity that is owned and controlled by the D-SNP's parent organization. When State policy limits a D-SNP's membership to individuals with aligned enrollment, this condition is referred to as exclusively aligned enrollment.

So according to this is it means they can only use the monthly sep to align the plan and after that outside aep/oep they can’t switch either? Is that correct? In the state of Indiana they’re going to full alignment in 2025. But they’re sending out letters to give members a choice of carrier to align with . If they don’t answer the letter they auto align with their dsnp carrier Jan 1st . If thats the case how can the monthly sept be used to auto align?

 

[TwoCents]

So according to this is it means they can only use the monthly sep to align the plan and after that outside aep/oep they can’t switch either? Is that correct? In the state of Indiana they’re going to full alignment in 2025. But they’re sending out letters to give members a choice of carrier to align with . If they don’t answer the letter they auto align with their dsnp carrier Jan 1st . If thats the case how can the monthly sept be used to auto align?

That's the catch -- while the SEP is available monthly, in reality there won't be too many opportunities to use it based on the number of carriers set up to offer an aligned DSNP.

 

[Special Agent]

So according to this is it means they can only use the monthly sep to align the plan and after that outside aep/oep they can’t switch either? Is that correct? In the state of Indiana they’re going to full alignment in 2025. But they’re sending out letters to give members a choice of carrier to align with . If they don’t answer the letter they auto align with their dsnp carrier Jan 1st . If thats the case how can the monthly sept be used to auto align?

Full disclosure i don't sell DSNP in any state that dictates which DSNP plan peeps can enroll in and when they can enroll but for states with the typical rules like Florida it means that agents can only use the election code( SEP -Integrated Plan) for DSNP applications for Full Dual eligibles as long as the DSNP carrier you want to enroll them in has a managed medicaid contract in that state- it does NOT have to be the same managed medicaid plan they are currently enrolled in.In Florida for example this means in 2025 you can't enroll someone in a DSNP using (SEP-Integrated Plan) that doesn't have a MMA contract like AETNA DSNP and UHC DSNP ( unless they win the appeal about losing the MMMA contract in 2025)