Dual/LIS SEP Rules: What Insurance Agents Need to Know

The former quarterly Special Enrollment Period for dual-eligible and Low-Income Subsidy beneficiaries is no longer available.

Effective January 1, 2025, the Centers for Medicare & Medicaid Services replaced that election period with two narrower options:

1. The Dual/LIS Special Enrollment Period, which generally permits eligible individuals to make a once-per-month election involving a standalone Medicare Part D plan.
2. The Integrated Care Special Enrollment Period, which permits certain full-benefit dual-eligible individuals to enroll once per month in an eligible integrated Dual Eligible Special Needs Plan when Medicare and Medicaid enrollment are properly aligned.

The key compliance point is simple:

Dual or Low-Income Subsidy status no longer provides a general monthly or quarterly right to switch among Medicare Advantage plans.

Agents must confirm the client’s eligibility, intended coverage change, Medicaid status, plan type, alignment requirements, and current carrier instructions before selecting an election period.

What Happened to the Old MDE or Quarterly Dual/LIS SEP?

Before January 1, 2025, the quarterly Dual/LIS SEP generally allowed eligible beneficiaries to make one Medicare Advantage or Part D election per calendar quarter during the first nine months of the year.

That version of the SEP ended on December 31, 2024.

CMS replaced it with a once-per-month Dual/LIS SEP that is limited to standalone Medicare Prescription Drug Plan elections. CMS also discontinued the former backend election type code used for 2024 transactions and introduced a new processing code for the revised election.

Agents may still see labels such as “MDE,” “Dual/LIS,” or other abbreviations in quoting and enrollment systems. Platform labels are not always identical to CMS transaction terminology.

Do not choose an election period based only on a familiar abbreviation. Review the current carrier or enrollment-platform description and confirm that the client’s intended transaction is permitted.

What Can the Current Dual/LIS SEP Be Used For?

The current Dual/LIS SEP may generally be used once per month by eligible dual-eligible or Extra Help beneficiaries to:

• Leave Medicare Advantage and return to Original Medicare while enrolling in a standalone Prescription Drug Plan.
• Enroll in a standalone Prescription Drug Plan when eligible.
• Switch from one standalone Prescription Drug Plan to another.

The election generally becomes effective on the first day of the month after the plan receives the completed enrollment request.

The SEP is available to:

• Full-benefit dual-eligible individuals.
• Partial-benefit dual-eligible individuals.
• Individuals eligible only for the Part D Low-Income Subsidy, also called Extra Help.

An individual identified as an at-risk or potential at-risk beneficiary under applicable drug-management rules may not be able to use this SEP.

What Can the Dual/LIS SEP Not Be Used For?

The current Dual/LIS SEP does not permit a beneficiary to:

• Enroll in a non-D-SNP Medicare Advantage plan.
• Switch from one non-D-SNP Medicare Advantage plan to another.
• Enroll in an MA-only plan.
• Enroll in an MA-PD plan.
• Use dual or Extra Help status as a general monthly Medicare Advantage switching opportunity.

A client may still be able to make one of those changes through another valid election period, such as:

• The Initial Coverage Election Period.
• The Medicare Annual Enrollment Period.
• The Medicare Advantage Open Enrollment Period.
• A move-related SEP.
• An institutional SEP.
• A five-star SEP.
• A SEP related to gaining, losing, or changing Medicaid or Extra Help status.
• Another qualifying circumstance recognized by CMS.

The agent must identify the actual qualifying circumstance rather than using Dual/LIS status as a substitute.

What Is the Integrated Care SEP?

The Integrated Care SEP is a separate election period created for certain full-benefit dual-eligible individuals.

It may generally be used once per month to enroll in an eligible:

• Fully Integrated Dual Eligible Special Needs Plan, or FIDE SNP.
• Highly Integrated Dual Eligible Special Needs Plan, or HIDE SNP.
• Applicable Integrated Plan, or AIP.

The election must align the beneficiary’s Medicare enrollment with an affiliated Medicaid managed care organization.

A person generally must:

• Have full-benefit dual eligibility.
• Be enrolled in or enrolling in the affiliated Medicaid managed care organization.
• Select a D-SNP that qualifies for the Integrated Care SEP.
• Meet the plan’s service-area and eligibility requirements.

This is not a universal monthly D-SNP election.

Partial-benefit duals and Extra Help-only beneficiaries are not eligible for the Integrated Care SEP.

Dual/LIS SEP vs. Integrated Care SEP

The Dual/LIS SEP is limited to standalone PDP elections, while the Integrated Care SEP is limited to qualifying integrated plans and full-benefit dual-eligible individuals.

Do Not Confuse the Monthly SEP With a Change-in-Status SEP

The monthly Dual/LIS SEP is separate from election periods triggered when a beneficiary:

• Gains Medicaid.
• Loses Medicaid.
• Gains Extra Help.
• Loses Extra Help.
• Experiences a change in the level of Medicaid or Extra Help assistance.

A change in status may create different plan options and a different election window.

For example, a beneficiary who loses Medicaid may generally have three full months from the loss of eligibility or notice of that loss, whichever is later, to make certain Medicare Advantage or Part D changes.

Agents should not interchange:

• Ongoing Dual/LIS eligibility.
• A recent change in Dual/LIS status.
• The Integrated Care SEP.
• Another event-based SEP.

Document the event and use the matching election period.

Five Questions to Ask Before Selecting an SEP

1. What Coverage Does the Client Have Now?

Confirm whether the client is enrolled in:

• Original Medicare.
• Original Medicare with a standalone PDP.
• MA-only.
• MA-PD.
• A coordination-only D-SNP.
• A FIDE SNP.
• A HIDE SNP.
• An Applicable Integrated Plan.
• Another Medicare health plan.

2. What Coverage Does the Client Want to Enter?

The permitted election depends on the destination.

The current Dual/LIS SEP may support a standalone PDP election. It does not support a general switch into another Medicare Advantage plan.

3. What Is the Client’s Exact Eligibility Category?

Verify whether the client is:

• Extra Help-only.
• Partial-benefit dual.
• Full-benefit dual.
• QMB.
• QMB Plus.
• SLMB.
• SLMB Plus.
• QI.
• QDWI.
• Full-Benefit Dual Eligible.

The category can determine whether the Integrated Care SEP is available.

4. Is Medicare-Medicaid Alignment Required?

For the Integrated Care SEP, confirm whether the selected D-SNP is affiliated with the Medicaid managed care organization in which the client is enrolled or enrolling.

5. Is Another SEP a Better Match?

A move, institutional residence, plan termination, loss of Medicaid, gain of Medicaid, or another event may create a separate election opportunity.

Use the most accurate qualifying event rather than forcing the transaction into the Dual/LIS SEP.

A Practical Agent Workflow

Step 1: Verify Medicare and Medicaid Status

Confirm:

• Medicare Part A and Part B status.
• Medicaid eligibility.
• Medicaid category.
• Extra Help status.
• Current plan.
• Current Medicaid managed care organization.
• Relevant effective dates.

Use approved carrier, Medicare, Medicaid, and enrollment-system resources.

Step 2: Identify the Client’s Requested Change

Write down the movement clearly:

Current coverage → requested coverage

For example:

• MA-PD → Original Medicare plus standalone PDP.
• Standalone PDP → another standalone PDP.
• Coordination-only D-SNP → integrated D-SNP.
• Non-D-SNP MA-PD → another non-D-SNP MA-PD.

The first two may fit the Dual/LIS SEP. The third may fit the Integrated Care SEP if all requirements are met. The fourth requires another election period.

Step 3: Confirm the Permitted SEP

Review:

• Current CMS guidance.
• Carrier election-period guidance.
• The enrollment platform’s instructions.
• The client’s qualifying documentation.
• State Medicaid alignment requirements.

Do not rely on a prior-year study guide or saved screenshot.

Step 4: Document the Qualification

Record:

• The SEP selected.
• Why the client qualifies.
• The date eligibility was verified.
• The source used for verification.
• The current and new plans.
• The intended effective date.
• Any Medicaid alignment information.

Step 5: Explain the Effective Date

Tell the client when the new coverage is expected to begin, while noting that the plan must accept and process the enrollment.

Avoid promising an effective date before confirming the completed application, qualifying SEP, and carrier processing.

Step 6: Follow Up

Confirm:

• Enrollment acceptance.
• Effective date.
• Disenrollment from the previous plan.
• Prescription drug coverage.
• Identification cards.
• Provider and pharmacy access.
• Medicaid alignment when applicable.

PSM’s Agent’s Guide to Dual Eligible Special Needs Plans provides additional background on D-SNP eligibility, Medicaid categories, and integrated-plan terminology.

Common SEP Mistakes

Using the Old Quarterly Rule

The quarterly Dual/LIS SEP ended on December 31, 2024. It should not be used for 2025 or later effective dates.

Treating the Dual/LIS SEP as a Medicare Advantage Switching Right

The current Dual/LIS SEP does not permit enrollment in MA-only or MA-PD plans or changes between those plans.

Assuming Every D-SNP Qualifies for the Integrated Care SEP

The selected D-SNP must meet CMS integration requirements, and the beneficiary’s Medicare and Medicaid enrollment must be aligned appropriately.

Using an Abbreviation Without Reading the Description

Carrier systems can use different labels. Confirm the full election-period description and permitted transaction.

Failing to Verify Full-Benefit Dual Status

Only qualifying full-benefit dual-eligible individuals can use the Integrated Care SEP.

Confusing Ongoing Eligibility With a Change in Status

Gaining, losing, or changing Medicaid or Extra Help status can create a separate SEP with different options and timing.

Using an Outdated Reference Guide

Prior-year election charts may still contain the former quarterly rules. Do not use them for current enrollment decisions.

What PSM Should Update Alongside This Article

Refreshing the blog alone will not fully correct outdated guidance.

PSM should also:

1. Remove links to the outdated SEP Quick-Reference Guide.
2. Replace the PDF with a dated 2026 or 2027 edition.
3. Add a visible revision date to the new guide.
4. Separate the Dual/LIS SEP from the Integrated Care SEP.
5. Include a current transaction matrix.
6. Explain that carrier-platform labels can differ.
7. Link to CMS’s current integrated D-SNP list rather than embedding a static plan list.
8. Add a compliance-review date and annual maintenance owner.
9. Update any certification materials that repeat the former quarterly rule.
10. Review every PSM page tagged “SEP,” “LIS,” “Dual Eligibles,” and “D-SNP” for the same outdated language.

The Bottom Line for Medicare Agents

The old quarterly Dual/LIS SEP is no longer available.

Since January 1, 2025:

• The Dual/LIS SEP generally permits a once-per-month standalone Part D election.
• The Integrated Care SEP permits qualifying full-benefit duals to enroll once per month in an eligible integrated D-SNP when Medicare and Medicaid coverage are aligned.
• Neither SEP provides a general right to switch between non-D-SNP Medicare Advantage plans.

Before submitting an application, verify the client’s eligibility, current coverage, requested plan, Medicaid category, alignment requirements, applicable SEP, and carrier instructions.

Using the correct election period protects the client, reduces rejected applications, and supports a cleaner compliance record.

Strengthen Your Medicare Enrollment Process With PSM

PSM Brokerage supports independent insurance agents with Medicare product access, contracting, certification guidance, compliance resources, enrollment technology, and experienced account support.

Review PSM’s Medicare products and agent resources or explore the Agent’s Guide to Dual Eligible Special Needs Plans.

External Sources

• CMS: New Special Enrollment Periods for Dually Eligible and Extra Help-Eligible Individuals Provides CMS’s official comparison of the current Dual/LIS SEP and Integrated Care SEP, including eligible populations and permitted plan selections.

• CMS: D-SNP Integration and Unified Appeals and Grievance Requirements Confirms that the quarterly Dual/LIS SEP ended and explains the current monthly Dual/LIS and Integrated Care election periods.

• CMS: Dual/LIS SEP Enrollment Processing Guidance Explains that the revised Dual/LIS SEP is limited to standalone PDP enrollment and does not permit MA-only or MA-PD enrollment. It also provides CMS transaction-processing information.

• CMS: Integrated Care SEP Enrollment Processing Guidance Explains who may use the Integrated Care SEP and the Medicare-Medicaid alignment requirement for eligible integrated D-SNP enrollment.

• Medicare.gov: Special Enrollment Periods Provides current consumer-facing explanations of Medicare Special Enrollment Periods triggered by moves, loss of Medicaid, institutional residence, and other qualifying circumstances.

For licensed insurance agent education only. This article is not legal or compliance advice and does not replace current CMS, Medicare, Medicaid, state, carrier, or enrollment-platform instructions. Election-period eligibility, plan availability, Medicaid categories, alignment requirements, transaction codes, and effective dates may vary or change. Verify current requirements before submitting an enrollment.