Medicare Special Enrollment Period: What To Know
Key Takeaways
- A Special Enrollment Period (SEP) allows you to make changes to your Medicare coverage outside of regular enrollment periods.
- There are a number of qualifying circumstances for a Special Enrollment Period.
- The length of the SEP depends on what event qualified you for the period.
- While there are a variety of opportunities to enroll using a SEP, there are certain cases where you may not qualify for a SEP.
During a Special Enrollment Period, you may be able to enroll in or make changes to your Medicare coverage. You can use these unique enrollment periods to ensure you have the benefits you need.
What Is a Medicare Special Enrollment Period?
Each year, there are two significant Medicare enrollment periods: the Annual Enrollment Period, from October 15 to December 7, and Open Enrollment, from January 1 to March 31.
If you happen to miss these enrollment periods, you may be asking yourself: When can I enroll in a Medicare plan or make changes to my Medicare coverage? This is where Medicare Special Enrollment Periods come in. A Medicare Special Enrollment Period (SEP) allows you to join or make changes to your Medicare coverage based on unique circumstances.
You can usually use these periods at any time of the year, but most have specific time limits. If you miss your window, you lose your opportunity and must wait until the next enrollment period to make changes to your Medicare plan. In certain situations, this delay can leave you without coverage for months and expose you to penalties.
If you are eligible for one of the many Special Enrollment Periods and successfully change your coverage, your new coverage will begin on the first day of the following month. If you qualify for an SEP in July, for example, your new plan will begin on the first day of August.
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When Do You Qualify for a Medicare Special Enrollment Period?
Special Enrollment Periods cover a wide range of circumstances. We will discuss some of the most common situations used to switch Medicare Advantage (Medicare Part C) or Medicare Part D prescription drug plans. However, some SEPs also impact Original Medicare coverage and Medicare Supplement (also known as Medigap) policies.
Here are some common Special Enrollment Periods to consider:
- You moved. This includes moving outside your plan’s service area, moving back to the United States after living abroad, or moving into or out of a skilled nursing facility.
- You lost your existing coverage. This includes losing Medicaid eligibility, leaving a job that provided health insurance, or losing creditable prescription drug coverage. For coverage to be considered creditable, it must provide benefits that are equally good or better than a Medicare Part D plan.
- Your plan changed. The Centers for Medicare and Medicaid Services (CMS) may have removed your plan option due to a reported problem or ended your plan’s contract. Under certain circumstances, insurance carriers may choose not renew their contract with the CMS or to stop providing plans in your area at the end of the year.
- Your eligibility changed. You are now eligible for both Medicare and Medicaid, you qualify for Extra Help with Medicare prescription drug coverage, or you enroll in a Special Needs Plan and no longer have the medical condition that led you to sign up for it.
- You are eligible for both Medicare and Medicaid. Dual eligibility allows beneficiaries to combine Medicare and Medicaid benefits to expand coverage and assist with costs. Dual eligible people have a monthly SEP to switch to a different Medicare Part D plan plan or to leave their Medicare Advantage plan and return to Original Medicare while joining a stand-alone Part D plan.
- You qualify for Extra Help. The Extra Help (also called the Low Income Subsidy) program helps those with limited income and financial resources to lower or cut Part D costs. If you’re eligible for this subsidy, you have a monthly SEP to change Part D plans or drop a Medicare Advantage plan. If you lose eligibility for Extra Help, that also qualifies you for an SEP when you can join or drop a Medicare Advantage or Part D plan.
- You are diagnosed with a chronic condition. If there’s a Chronic Condition Special Needs Plan (C-SNP) available in your area that fits your needs, you can use an SEP to enroll at any time.
- You enroll in or leave the Program of All-Inclusive Care for the Elderly (PACE). PACE programs are available in certain areas to provide services and coverage that help people stay in their own homes. If you are already enrolled in Medicare, you may qualify for a two-month Medicare SEP.
- You were recently released from incarceration. An SEP may be available after your release to enroll in Original Medicare, join a Medicare Part D plan, or join a Medicare Advantage plan.
Some Important SEP Timelines:
Unlike the Annual Enrollment Period, Special Enrollment Periods do not occur at a specific time of year. The beginning and end dates of your Special Enrollment Period depend on your situation. Because there are also so many kinds of SEPs, check the timeline for your qualifying event:
- You move out of your current plan’s service area. If you alert your plan before the move, your SEP starts the month before the month you move and continues for two months after. If you alert your plan after the move, your SEP starts the month you tell your plan, plus an additional two months. If you do not notify your plan of your move, your plan will disenroll you after six months. You will get a SEP that lasts two months following your disenrollment.
You will have a similar SEP even if your new address is in your plan’s service area, but you have new plan options available that were not previously available at your old address.
- You moved back to the U.S. after living abroad. You have two months after the month you return to the U.S.
- You moved into a skilled nursing facility. Once you move into a skilled nursing facility, you can enroll the entire time you live there and two months after you leave.
- You lose Medicaid or Medicare Savings Program (MSP) eligibility. You will have three months to change Medicare Advantage or Part D drug plans, starting the date you are notified you will lose Medicaid or Medicare Savings Program benefits.
- Medicare ends your plan’s contract. The most common reason for ending your plan’s contract comes down to poor plan performance. If Medicare ends your plan’s contract, you will have two months before and one month after your contract ends. You can also expect to receive a notice of what has happened and what your options are.
- Your employer health coverage ends. Your SEP to join a Medicare Advantage plan or prescription drug plan lasts two months after the month your coverage ends. If you delayed Part B enrollment, for example, your SEP lasts eight months after group health coverage or employment ends, whichever comes first. The same applies if you are currently on a spouse’s health plan and either coverage ends or employment ends.
- You qualify for Extra Help. If you’re eligible for Extra Help to help pay for Medicare Part prescription drug coverage, you have a monthly SEP.
- You were recently released from incarceration. If you were formerly incarcerated and demonstrate you are eligible for Medicare, show you did not enroll or re-enroll in Medicare Part A or B during another enrollment period, and have proof you were officially released on or after January 1, 2023, you will be eligible for a 12-month SEP beginning the day of release from incarceration. If you qualify for a Medicare Advantage or Medicare Part D prescription drug plan, you will have a two-month window to enroll.
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What To Do If I’ve Received Misleading Plan Information?
If you believe you have been misled into joining a Medicare Advantage plan, you could be eligible for an SEP allowing you to switch out of a plan that you joined based on erroneous, incomplete, or ambiguous information. You must apply to Medicare for this SEP, and your case will be further investigated. If CMS decides that your claim is valid, you will be able to join another Medicare Advantage plan or switch back to Original Medicare if originally enrolled in a Medicare Advantage plan. You may also decide to join a stand-alone Part D drug plan in this case as well.
The 5-Star Special Enrollment Period
After consolidating information gathered from member satisfaction surveys, plans, and healthcare providers, Medicare shares an overall performance rating on a five-star scale. If there are any plans with five-star ratings available to you, you can switch plans once between December 8 and November 30 of the following year.
When Don’t I Qualify for a Medicare Special Enrollment Period?
For as many opportunities as there are to qualify for a Special Enrollment Period, there are certain exceptions. For example, you may have missed your eight-month window to sign up when you stopped working or lost your employer-based coverage.
Can I bundle multiple benefits into one plan?
How Do I Apply for a Medicare Special Enrollment Period?
So, do you think you qualify for one of the scenarios listed above? If you are not sure whether or not you qualify for a Medicare Special Enrollment Period, or if you believe you qualify and would like to compare competitive Medicare Advantage plans in your area, licensed insurance agents are available to answer any questions you may have about benefits, costs, and coverage.