How Often Can Dual Eligible Change Plans?
Learn the frequency and rules for dual-eligible individuals to change their health plans. Understand your unique enrollment opportunities.
Individuals who qualify for both Medicare and Medicaid, known as dual eligibles, have unique opportunities to change their health plans throughout the year. These opportunities differ significantly from standard enrollment periods for other Medicare recipients. This article explores the various circumstances under which dual-eligible individuals can modify their Medicare Advantage and prescription drug plans.
Understanding Dual Eligibility and Plan Options
Dual eligibility refers to individuals entitled to both Medicare and medical assistance through their state’s Medicaid program. Medicare, a federal health insurance program, primarily serves individuals aged 65 or older, younger people with certain disabilities, and those with End-Stage Renal Disease. Medicaid, a joint federal and state program, provides healthcare coverage to low-income individuals and families.
For dual-eligible individuals, specialized health plans exist to coordinate benefits from both Medicare and Medicaid. These are known as Dual Eligible Special Needs Plans (D-SNPs), a type of Medicare Advantage plan. D-SNPs integrate care and services, frequently offering additional benefits beyond those covered by Original Medicare, such as vision, dental, and transportation.
Regular Opportunities for Plan Changes
Dual-eligible individuals have distinct and frequent opportunities to change their Medicare Advantage and Part D prescription drug plans. Beginning January 1, 2025, beneficiaries can make plan adjustments on a monthly basis.
This monthly Special Enrollment Period (SEP) enables dual eligibles to transition from a Medicare Advantage plan back to Original Medicare, or enroll in a standalone Part D plan. It also permits switching between different standalone Part D plans. This monthly SEP does not allow beneficiaries to enroll in a non-D-SNP Medicare Advantage plan or to switch between such plans. For full-benefit dual eligibles, a new “Integrated Care SEP” allows a once-per-month election into certain integrated D-SNPs when aligned with their Medicaid managed care enrollment. Any changes made using these monthly SEPs become effective on the first day of the month following the plan selection.
Additional Enrollment Periods
Beyond the regular monthly opportunities, dual-eligible individuals may qualify for other Special Enrollment Periods (SEPs) triggered by specific life events. These SEPs allow beneficiaries to adjust their coverage outside of typical enrollment windows. The availability and duration of these SEPs depend on the particular qualifying event.
One such event is the loss of Medicaid eligibility, which triggers an SEP allowing enrollment in a Medicare Advantage plan, adding Part D coverage, or changing existing plans. Moving to a new service area where the current plan is not available, or even within the same service area but with new plan options, also qualifies for an SEP. This moving SEP begins one month before the move (if notified in advance) or the month of the move, and extends for two full months afterward.
Other circumstances that may open an SEP include a current plan leaving the service area, significantly changing its benefits, or consistently receiving low Medicare star ratings. Gaining or losing employer-sponsored health coverage can also trigger an SEP, providing a window to enroll in Medicare Parts A and/or B, and for a shorter period, Part C or D. Entering or leaving a long-term care facility, such as a nursing home, also qualifies for an SEP to change Medicare Advantage or Part D plans. Medicare may also grant an SEP in other situations.