Did You Know: Community Health Choices

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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