New Rules for Special-Enrollment Periods for Dual Eligibles Take Effect, but Concerns Remain About Plan Availability and Broker Incentives

Dual eligibles — that is, people eligible for both Medicare and Medicaid — have a wealth of Medicare options. These beneficiaries, who tend to have complex medical needs, can choose between traditional Medicare, Medicare Advantage (MA) plans, and dual-eligible special needs plans, or D-SNPs. These last plans are special Medicare Advantage plans that tailor benefits to the needs of the dually eligible population and, depending on the type of D-SNP, coordinate with Medicaid to varying degrees. While some D-SNPs are fully or highly integrated with Medicaid, many are not.

There are concerns that dual eligibles may choose plans that do not align with their best interests and may be disruptively shifted from plan to plan under the advice of brokers and agents. Recent changes to enrollment rules aim to reduce excessive plan switching and encourage enrollment into the types of D-SNPs that are designed to better integrate Medicare and Medicaid services.

Other Medicare beneficiaries can generally only switch plans at the beginning of the year during the standard open enrollment period, unless they qualify for special-enrollment periods (SEPs) due to triggers like a move or a change in eligibility. However, dual eligibles have regular SEPs throughout the year during which they can switch plans for any reason. As of January 1, 2025, SEPs are extended to allow dual eligibles to switch plans every month, instead of quarterly.

However, along with this increased frequency the Centers for Medicare and Medicaid Services is imposing restrictions on the types of plans dual eligibles can switch into during SEPs, which is discouraging enrollment in less integrated plans. D-SNPs vary in how much they integrate Medicare and Medicaid benefits: coordination-only D-SNPs (CO-SNPs) engage in minimal coordination with Medicaid; applicable integrated D-SNPs (AIPs) offer Medicaid and Medicare plans under a single organization and integrate some benefits; highly integrated D-SNPs (HIDE D-SNPs) integrate either long-term care or behavioral health services; and fully integrated D-SNPs (FIDE D-SNPs) coordinate both long-term care and behavioral health within a single managed care organization.

As of January 1, 2025, during SEPs, dual eligibles are only allowed to switch into AIP, HIDE, or FIDE D-SNPs, or traditional Medicare, rather than CO-SNPs or standard MA plans. How much will these changes increase enrollment in AIP, HIDE, and FIDE D-SNPs? This depends on whether dual eligibles actually use SEPs to switch plans, the incentives of the brokers and agents who facilitate plan switching, and the availability of such plans.

Switching Plans During Special-Enrollment Periods

Historically, dual eligibles have taken advantage of their ability to change plans throughout the year and are more likely, compared with non-dual eligibles, to make these changes. In 2022, 52 percent of dual eligibles’ plan switches took place between April and December, compared to only 24 percent among non-dual eligibles. This suggests that dual eligibles would likely welcome an increased ability to switch plans throughout the year. However, the incentives of brokers and agents and the limited availability of AIP, HIDE, and FIDE D-SNP plans may limit the amount of plan switching we see moving forward.

The Impact of Broker Incentives

Picking insurance plans is complicated, and many dual eligibles rely on the advice of brokers and agents. Because they can switch plans multiple times a year, dual eligibles have historically received considerable attention from brokers and agents, who are paid commissions from insurance companies for every beneficiary they enroll.

However, brokers and agents are compensated less for switching beneficiaries into traditional Medicare with or without a Part D drug plan than for switching beneficiaries into and within Medicare Advantage. Among dual eligibles, switching within MA (both among standard MA plans and D-SNPs) is much more common than switching into traditional Medicare. In 2022, 83 percent of dual eligibles switched from one MA plan to another, while only 17 percent switched from MA to traditional Medicare.

Brokers and agents will thus mainly benefit from the increased frequency of special-enrollment periods if they are encouraging individuals to switch into AIP, FIDE, and HIDE D-SNP plans, not traditional Medicare.

Limited Availability of Integrated D-SNPs

Because brokers and agents will be motivated to enroll beneficiaries in AIP, FIDE, and HIDE D-SNPs, we may expect this policy change will increase enrollment in such plans, but only where they are available.

As of December 2024, only 63 percent of D-SNP enrollees lived in counties where an AIP, FIDE, or HIDE D-SNP was offered. For these enrollees with access, the policy may induce heightened enrollment in AIP, FIDE, or HIDE D-SNPs. However, for the 37 percent of D-SNP enrollees without access, the only option will be traditional Medicare, which brokers are likely less motivated to promote. Until AIP, FIDE, or HIDE D-SNPs enter these markets, the policy will likely only be successful at its first goal of reducing plan-hopping but will not promote enrollment in plans with greater care integration.

Looking Forward

Reducing the types of plans that enrollees can switch into during special-enrollment periods will likely reduce plan-hopping, especially for current D-SNP enrollees with no access to integrated D-SNPs. But while the policy may accomplish its goals to reduce disruptive plan-hopping and shift enrollment toward AIP, HIDE, and FIDE D-SNPs for some dually eligible people, the work of ensuring access for dual eligibles is far from over.

While the policy may increase enrollment in integrated plans in markets where available, policymakers must also study whether these plans are appropriately serving the needs of the dually eligible population. Current evidence does not show that D-SNPs consistently produce better health outcomes for enrollees compared to other options, potentially due to limited care coordination, even among integrated plans, and a lack of tailored plan design. As this new policy goes into effect, policymakers should monitor not only how it affects enrollment decisions but also subsequent utilization and health outcomes.