The 2025 Final Rule from the Centers for Medicare & Medicaid Services (CMS) introduces significant regulatory changes for Medicare Advantage (Part C), Medicare Prescription Drug benefits (Part D), and Dual Eligible Special Needs Plans (D-SNPs).
In particular, the changes that have gone into effect for D-SNPs aim to steadily promote integrated care for individuals eligible for Medicare and Medicaid in 2025 and beyond.
D-SNP beneficiaries include beneficiaries with Medicare Part A, Medicare Part B, or both, and those getting full Medicaid benefits or help with Medicare premiums or cost-sharing through a variety of Medicare Savings Program eligibility groups. These groups include:
| Program Name | Coverage Details |
| Qualified Medicare Beneficiary (QMB) Program | Covers all Medicare Part A and Part B costs, including premiums, deductibles, copayments, and coinsurance. |
| Specified Low-Income Medicare Beneficiary (SLMB) Program | Only helps pay for Medicare Part B premiums. |
| Qualifying Individual (QI) Program | Covers Medicare Part B premiums. People in this program can’t have any other Medicaid benefits. |
| Qualified Disabled Working Individual (QDWI) Program | Helps pay for Medicare Part A premiums. Available for certain people under 65 with disabilities who have returned to work. |
The Medicare Part D low-income subsidy (LIS) program, also referred to as the Extra Help Program, helps pay eligible enrollees’ Medicare drug plan monthly premiums, annual deductibles, and copayments. The program is for those who have or want Part D coverage and meet certain income and resource limits.
For these D-SNPs categories, key 2025 changes include:
Special Enrollment Periods (SEPs)
1. Elimination of Quarterly SEP: The SEP that allowed D-SNP individuals and LIS beneficiary recipients to switch Medicare Advantage plans every quarter ended as of January 1, 2025.
2. New Monthly SEPs:
For Dual/LIS – The new rules apply to full-benefit dually eligible individuals (QMB+, SLMB+, FBDE), partial-benefit dually eligible individuals (QMB, SLMB, QI, QDWI), and Extra Help-only eligible individuals to make a once-per-month election. This SEP allows beneficiaries to:
- Disenroll from a Medicare Advantage plan with prescription drug coverage
- Return to Original Medicare
- Enroll in a standalone Prescription Drug Plan (PDP)
- Switch between standalone PDPs
The change replaces the previous quarterly SEP and provides more frequent opportunities for beneficiaries to adjust their prescription drug coverage.
For Integrated Care – This SEP option offers a monthly opportunity for individuals with full dual eligibility (QMB+, SLMB+, FBDE) to enroll in comprehensive, integrated healthcare plans. These plans include:
1. Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs)
2. Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs)
3. Applicable Integrated Plans (AIPs)
The primary purpose of this special enrollment period is to synchronize enrollment between an integrated D-SNP and a Medicaid Managed Care Organization (MCO). This alignment ensures that eligible individuals receive coordinated care across both Medicare and Medicaid services. This applies only to states offering integrated D-SNPs. Some may not have access to this new SEP, depending on state regulations.
3. Restrictions: Partial-benefit dually eligible individuals and LIS-only recipients will no longer have quarterly SEP access unless they meet other enrollment criteria to switch to a new Medicare Advantage plan.
Source: CMS
D-SNP Enrollment
1. Alignment Requirements: Starting in 2027, D-SNPs affiliated with Medicaid Managed Care Organizations (MCOs) must align enrollment so that beneficiaries are enrolled in both the D-SNP and the affiliated Medicaid MCO. By 2030, only members enrolled in the affiliated Medicaid MCO can remain in these D-SNPs.
2. Limit on D-SNP Offerings: Parent organizations will be restricted to offering one D-SNP per service area if they operate an affiliated Medicaid MCO, with exceptions for plans serving different eligibility groups or partial-benefit dually eligible individuals.
Medicare Plan Finder Enhancements
The Medicare Plan Finder tool now displays both Medicaid and Medicare services offered by certain D-SNPs to help beneficiaries understand available benefits.
These changes aim to enhance care coordination, simplify plan choices, and improve transparency while addressing potential limitations in plan flexibility for some beneficiaries.
The Impact
These changes are designed to:
- Simplify the enrollment process for dually eligible individuals.
- Encourage enrollment in integrated plans that better coordinate Medicare and Medicaid benefits.
- Provide more frequent opportunities to adjust prescription drug coverage.
