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The Centers for Medicare & Medicaid Services (CMS) has introduced new rules to better integrate Medicaid and Medicare services for dually eligible individuals. These changes, part of the 2025 Medicare Final Rule, aim to improve care coordination, accessibility, and affordability for enrollees.

One significant change is the push for "exclusively aligned enrollment," where beneficiaries obtain both Medicare and Medicaid benefits from either the same plan/organization or two plans under the same parent organization.

This approach is designed to streamline services, reduce costs, and improve outcomes for enrollees.

Starting in 2027, CMS will limit enrollment into certain Dual Eligible Special Needs Plans (D-SNPs) to individuals who are also enrolled in or in the process of enrolling in an affiliated Medicaid managed care organization (MMCO).

Starting January 1, 2025, there are two new Special Enrollment Periods (SEPs) for dually eligible individuals and those eligible for Extra Help (low-income subsidy):

  1. Dual/LIS SEP: This SEP allows full-benefit dually eligible individuals, partial-benefit dually eligible individuals, and Extra Help-only eligible individuals to make a once-per-month election into Original Medicare and a standalone prescription drug plan (PDP). It also allows a once-per-month election to switch between standalone PDPs.
  2. Integrated Care SEP: This SEP allows full-benefit dually eligible individuals to make a once-per-month election into a fully integrated dual eligible special needs plan (FIDE SNP), highly integrated dual eligible special needs plan (HIDE SNP), or an applicable integrated plan (AIP). This SEP is designed to align enrollment with an integrated D-SNP and Medicaid managed care organization (MCO).

The main differences between Dual Eligible Special Needs Plans (D-SNPs) and Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) lie in their level of integration and the scope of services they cover:

  1. D-SNPs (Dual Eligible Special Needs Plans):
  2. General Integration: D-SNPs are Medicare Advantage plans designed for individuals who are eligible for both Medicare and Medicaid. They coordinate Medicare and Medicaid benefits but may not fully integrate all services.
  3. Coordination of Benefits: D-SNPs must coordinate Medicare and Medicaid benefits, but the level of integration can vary. They are required to have a Model of Care approved by the National Committee for Quality Assurance (NCQA) and engage in care coordination.
  4. FIDE SNPs (Fully Integrated Dual Eligible Special Needs Plans):
  5. High Level of Integration: FIDE SNPs provide a higher level of integration by offering comprehensive coverage of Medicare and Medicaid benefits under a single legal entity. This includes primary care, acute care, long-term services and supports (LTSS), behavioral health services, and prescription drug coverage.
  6. Aligned Enrollment: FIDE SNPs require exclusively aligned enrollment, meaning beneficiaries must be enrolled in both the FIDE SNP for Medicare benefits and the organization's Medicaid managed care plan.
  7. Integrated Services: FIDE SNPs integrate member materials, enrollment processes, communications, grievances and appeals, and quality improvement processes across Medicare and Medicaid.
    In summary, while both D-SNPs and FIDE SNPs aim to coordinate care for dually eligible individuals, FIDE SNPs offer a more comprehensive and integrated approach to managing both Medicare and Medicaid benefits.

Learn more: https://www.pa.gov/agencies/dhs/resources/medicaid/chc/chc-mcos.html66

To make changes your Community Health Choice (CHC), you can follow these steps:

  1. Log into your My Member Account portal: You can access it here99.
  2. Request the change: Community Health Choice will process the change within 24-72 hours, and the effective date will be the next month.
    Alternative methods: You can also request to change your provider via live chat, text messages, or by calling their toll-free number at 1-888-760-2600.

Alternative methods: You can also request to change your provider via live chat, text messages, or by calling their toll-free number at 1-888-760-2600.

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If you have a client that resides in assisted living or a long term care facility, you will come across questions about drug coverage because the resident must use the pharmacy at the long-term care (LTC) facility and it’s typically at the standard Medicare Part D prices/rates which can be frustrating. They do not have an option of using an outside pharmacy. A POA (power of attorney) or family member cannot bring in medications.

These pharmacies play a crucial role in providing medications in a timely manner to their residents and work closely with the facility staff to manage, dispense, deliver medications, plus return, reuse, and dispose of unused medications. This enables medications to be purchased in bulk and sometimes at discounted prices.

LTC pharmacies are reimbursed for their services through Medicare Part A for skilled nursing facilities and Medicare Part D for prescription drugs. They may also receive payments from Medicaid, commercial insurers, and private payers.

LTC pharmacies ensure that residents of long-term care facilities receive the medications they need safely and efficiently, while complying with Medicare regulations and standards.

Learn more: CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services

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Medicaid provides a wide range of health care services for eligible individuals, including low-income adults, children, pregnant women, elderly adults, and people with disabilities. The specific services covered can vary by state, but there are certain mandatory benefits that all states must provide, as well as optional benefits that states can choose to offer.

Mandatory benefits include:

  • Inpatient and outpatient hospital services
  • Physician services
  • Laboratory and X-ray services
  • Home health services

Optional benefits that states may choose to provide include:

  • Prescription drugs
  • Case management
  • Physical therapy
  • Occupational therapy

If someone is on Medicaid & Medicare they do not need to enroll into another Medicare plan. However, D-SNPs are offered to this demographic to provide additional coverages if that makes sense for the client’s needs. It’s also extremely important to verify doctor network since D-SNPs typically work under a HMO network.

Here are some of the key additional benefits that a D-SNP might offer:

  1. Dental, Vision, and Hearing Services: These plans typically include coverage for dental care, vision exams and glasses, and hearing aids 
  2. Transportation Services: D-SNPs may offer transportation to and from medical appointments, which can be a significant help for those with mobility issues
  3. Fitness Programs: Many plans include access to fitness programs or gym memberships to help maintain physical health 
  4. Care Coordination: D-SNPs often provide care coordinators or personal assistance liaisons to help manage healthcare services and ensure that all aspects of a member's care are well-coordinated
  5. Prescription Drug Coverage: Enhanced coverage for prescription medications is often included, which can help manage the costs of necessary drugs 
  6. Additional Support Services: Some plans may offer meal delivery services, over-the-counter allowances, and other support services to improve overall quality of life

These additional benefits are designed to make healthcare more accessible and affordable, while also addressing the broader needs of individuals who qualify for both Medicare and Medicaid.

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The word Medicaid is used to vaguely describe healthcare coverage for Low Income individuals. However, people can have Medicaid in many different forms:

  1. Aged, Blind, and Disabled (ABD) Medicaid
    Coverage: This level provides comprehensive medical services, including hospital care, physician services, and long-term care. It often includes additional support services tailored to the needs of elderly and disabled individuals, such as home health care and personal care services.
  2. Home and Community-Based Services (HCBS)
    Coverage: HCBS waivers offer services that help individuals live independently in their homes or communities rather than in institutional settings. This includes personal care, homemaker services, respite care, and sometimes home modifications. These services are crucial for maintaining independence and quality of life.
  3. Institutional Medicaid (Long Term Care Medicaid)
    Coverage: This level covers the cost of care in nursing homes or other institutional settings. It includes room and board, medical services, and personal care. This is essential for individuals who require a high level of care that cannot be provided at home.
  4. Medicaid for Children and Families
    Coverage: Programs like CHIP and Medicaid for low-income families provide comprehensive health services for children and pregnant women. This includes preventive care, immunizations, maternity care, and other essential health services. These programs ensure that children and families have access to necessary healthcare.
  5. Medicaid Expansion (Affordable Care Act Adults)
    Coverage: In states that have expanded Medicaid, low-income adults up to 138% of the federal poverty level receive a broad range of health services. This includes primary care, hospital services, mental health services, and preventive care. Expansion has been linked to improved access to care and better health outcomes.
  6. Special Programs
    Coverage: These programs target specific populations, such as foster care children or individuals with specific health conditions like breast or cervical cancer. Coverage varies but generally includes targeted health services and support tailored to the needs of these groups.

Impact on Healthcare Needs

  • Comprehensive Care: Different levels of Medicaid ensure that various populations receive the care they need, whether it's basic medical services, long-term care, or specialized support. 
  • Preventive Services: Many Medicaid programs emphasize preventive care, which helps reduce the need for more intensive and costly treatments later on.
  • Support Services: Programs like HCBS and special programs provide additional support that can significantly improve quality of life and independence for individuals with specific needs. 

Overall, the different levels of Medicaid are designed to address the diverse healthcare needs of eligible individuals, ensuring that they receive appropriate and comprehensive care based on their specific circumstances.

Each state has their own program, here is PA: https://www.compass.dhs.pa.gov/home/#/

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