Missed Last Week’s Healthcare.com Roundup? Here’s what happened:
This week’s series covers:
- 2025 D-SNP Changes: CMS replaces quarterly SEP with monthly SEPs for full-benefit dual-eligible individuals.
- 2026 Marketplace Rule Updates: CMS enhances oversight, transparency, health equity, and cost-sharing rules, and requires standardized plans.
Key 2025 Changes for D-SNP Categories
In Case You Missed It: The Centers for Medicare & Medicaid Services (CMS) introduced significant updates for Dual-Eligible Special Needs Plans (D-SNPs) effective January 1, 2025.
These changes impact special enrollment periods (SEPs), integrated care options, and enrollment alignment requirements.
Special Enrollment Periods (SEPs)
- Elimination of Quarterly SEP: D-SNP and Low-Income Subsidy (LIS) beneficiaries can no longer switch Medicare Advantage plans every quarter as of January 1, 2025.
- New Monthly SEPs:
- For Dual/LIS Beneficiaries: Full-benefit (QMB+, SLMB+, FBDE) and partial-benefit (QMB, SLMB, QI, QDWI) dually eligible individuals, along with Extra Help-only recipients, can make one change per month. This allows them to:
- Disenroll from a Medicare Advantage plan with drug coverage
- Return to Original Medicare
- Enroll in or switch between standalone Prescription Drug Plans (PDPs)
- For Integrated Care Beneficiaries: A new monthly SEP applies to full-benefit dually eligible individuals (QMB+, SLMB+, FBDE) in states offering integrated D-SNPs, enabling them to enroll in:
- Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs)
- Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs)
- Applicable Integrated Plans (AIPs)
- This ensures coordinated Medicare and Medicaid care within an affiliated Medicaid Managed Care Organization (MCO).
- For Dual/LIS Beneficiaries: Full-benefit (QMB+, SLMB+, FBDE) and partial-benefit (QMB, SLMB, QI, QDWI) dually eligible individuals, along with Extra Help-only recipients, can make one change per month. This allows them to:
- Restrictions:
- Partial-benefit dually eligible individuals and LIS-only recipients lose quarterly SEP access unless they qualify under separate enrollment criteria.
- A SEP for integrated care is only available in states with integrated D-SNPs. Depending on state regulations, some may not have access to this new SEP.
For more details, read our recent article on D-SNP enrollment updates, including alignment requirements for 2027 and 2030, and new plan limits.
HHS Finalizes 2026 Marketplace Rule: Strengthening Consumer Protections, Expanding Access, and Enhancing Transparency
HHS & CMS finalized the 2026 Benefit and Payment Rule to enhance consumer protections, marketplace integrity, and enrollment.
Effective Jan 15, 2025, these key updates include stricter broker oversight, clearer cost-sharing rules, expanded health equity measures, greater transparency, and standardized plans.
- Consumer Protection & Compliance: CMS gains authority to suspend brokers for misconduct, enforce compliance, and improve transparency.
- Cost-Sharing Reduction (CSR) Loading: Ensures CSR adjustments follow state law and promote market stability.
- Health Equity & Disparities: Allows issuers to set premium payment thresholds, adjust rebate calculations, and certify Essential Community Providers.
- Simplified Enrollment: Extends notification rules for tax reconciliation and updates payment calculations for Basic Health Programs.
- Plan Standardization: Requires issuers to offer standardized plan options and clarify dental/vision coverage.
- Marketplace Transparency: CMS will publicly release marketplace spending and quality improvement data.
- Risk Adjustment Updates: Improves risk models, audit processes, and appeals for financial accuracy.
- Consumer Impact: Adjusts user fees, ensures accurate subsidy payments, and clarifies plan certification rules.
Explore our Resources and Blog for more content.
