What is a Special Enrollment Period?

During a Medicare Special Enrollment Period, often known as a Special Election Period or SEP, Medicare beneficiaries can change their existing Medicare Advantage or Part D coverage outside the normal annual open enrollment time frame.

People who already have Medicare may qualify for a Special Enrollment Period with certain qualifying events. This Special Enrollment Period lets you switch to a different Medicare Advantage or Part D prescription drug plan. Rules about when you can make changes and the type of changes differ for each SEP.

What qualifies for a Medicare Special Enrollment Period to switch plans?

You move out of your plan’s service area:

Moving to a new address can be an exciting experience, but it can also cause some stress if you’re enrolled in a Medicare Advantage Plan (or Prescription Drug Plan) and the new address is outside your plan’s service area. Fortunately, there are options available for those in this situation. One option is to switch to a different Medicare Advantage Plan or Medicare Prescription Drug Plan that covers the new address. If you don’t enroll in a new plan during the specified time period, you will automatically be enrolled in Original Medicare when you are disenrolled from your old plan. But you will not be automatically enrolled in a Medicare Supplement Plan.

If you had a Medicare Advantage Plan, you’ll also have a Guaranteed Issue Period to enroll in certain Medicare Supplement Plans (meaning the insurance company cannot refuse to cover you) if you lose coverage because you moved out of a Medicare Advantage Plan service area.  If you want to use this option, be careful that your former carrier doesn’t enroll you in a new Medicare Advantage Plan when you call them to update your address.

Your plan changes its contract with Medicare:

If your plan closes, discontinues serving the area where you live, significantly reduces its provider network, or consistently receives low Medicare star ratings, you could be eligible for a SEP. If a problem with the plan affects an individual, Medicare may take an official action called a “sanction”. If this is the case, the individual can elect to switch from their current plan to an alternative one.

The timing of when an individual can change plans is determined by Medicare on an individual basis. It is essential to remember that changing plans may not always be an option, so it is advised to consult a doctor or other healthcare provider before making any adjustments. Individuals should be mindful of the expenses that may come with making a change and research all their choices and talk with the Medicare Broker before deciding.

You drop your first Medicare Advantage plan within 12 months of enrolling:

This is called trial rights. I dig into this deeper in another article which you can read HERE.

Generally, if you join a Medicare Advantage Plan for the first time, THE FIRST TIME YOU ARE ELIGIBLE FOR MEDICARE, and you aren’t happy with the plan, you have a “trial right” under federal law to buy a Medigap policy and a separate Medicare drug plan if you return to Original Medicare within 12 months of joining the Medicare Advantage Plan.

You also have a 12-month trial right if you drop a Medicare Supplement Plan and join a Medicare Advantage Plan for the first time.

You move into or out of a qualified institutional facility:

If you move into, out of, or currently reside in a facility of special care, such as a skilled nursing home or long-term care facility, you may enroll in, disenroll from, or change a Medicare Advantage plan one time per month. Once you move out of the facility, you will be given two months to change plans.

You’re enrolled in a State Pharmaceutical Assistance Program (SPAP)

If you are enrolled in an SPAP, once a year, at any time during the year, you can join a Medicare Advantage plan or Part D plan for the first time or change to another Medicare Advantage plan or Part D plan. This includes joining one that works with your SPAP. If you’re automatically enrolled in a Part D prescription drug plan through your SPAP, you won’t be eligible for the special enrollment period.

Should you lose your SPAP eligibility, you can take advantage of a SEP to join or change to another Medicare Part D plan or Medicare Advantage plan with drug coverage.

You are eligible for both Medicare and Medicaid:

If you are eligible for both Medicare and Medicaid or qualify for Extra Help paying for Medicare drug coverage, there are special enrollment periods that apply to your situation. During these SEPs, you can join, change or quit your Medicare Advantage plan or prescription drug coverage. This means that if you find yourself in need of additional assistance with your medical expenses, you have the opportunity to make changes to your coverage during certain times of the year.

The SEPs occur three times a year: January to March, April to June, and July to September, you can make one change to your coverage during each of these periods if needed. This allows those who require Extra Help with their medical costs the chance to adjust their plans accordingly without having to wait until the end of the year when open enrollment begins again. With this flexibility, individuals can ensure they have the best coverage for their needs throughout the year.

You enroll in or leave PACE:

Enrollment or disenrollment from The Program of All-Inclusive Care for Elderly, also called PACE, provides a SEP. If you enroll in PACE, you can disenroll from your Medicare Advantage or Part D plan at any time

If you disenroll from PACE, your SEP to join another Medicare Advantage Plan or Part D plan lasts up to two months after the effective date of your disenrollment from the PACE program.

Enrollment into a Special Needs Plan (SNP)

If you meet the requirements, you may be eligible for a Special Enrollment Period (SEP) to join a Medicare Advantage Special Needs Plan (SNP).

• Have Medicare and Medicaid. The SEP lasts as long as you have Medicare and Medicaid.
• You suffer from a severe, disabling, or chronic condition. You can join a Special Needs Plan (SNP) that caters to those diagnosed with a certain condition.
• Are entering an institution that qualifies you for SNP coverage, or develop the need for a nursing home-level of care.

In addition, after you move out of the facility, you have two months to enroll in or disenroll from a Medicare Advantage Plan or Part D plan or to switch to another plan.

Enrollment into a 5-star plan 

It is known as the 5 Star special enrollment period. A star rating system is used to assist Medicare enrollees in selecting the most appropriate Medicare Advantage or Prescription Drug Plan for their individual needs and preferences. Five stars is considered excellent. Medicare updates these ratings each fall for the following year. These ratings may vary from year to year.

If there is a Medicare Advantage Plan or stand-alone Medicare Prescription Drug Plan with 5-star ratings available in your area, you can take advantage of the 5-star special enrollment period to switch to a top-tier plan with or without prescription drug coverage.

You can use the 5-star special enrollment period only once between Dec. 8 through Nov. 30.

It should be noted that if you decide to make a change from your current Medicare plan to a 5-star plan, some of your healthcare benefits may be lost. For instance, if you switch from a 4-star Medicare Advantage plan that includes prescription drug coverage to a 5-star plan without it. If that’s the case, you might not have prescription drug coverage anymore. If you want to get prescription drug coverage again, you’ll need to wait until the next enrollment period to make the change. ii

What is a FEMA Special Election Period?

Did you know a FEMA emergency might qualify you for a Medicare Special Enrollment Period?

If you are impacted by a disaster or emergency, you can take advantage of the Special Election Period (SEP) to enroll in, disenroll from or switch Medicare health or prescription drug plans, even if you’ve missed the other election periods. This SEP is available only in areas where the Federal, state, or local government has declared an emergency or disaster.

The specifics vary depending on which state or county you reside in, among other factors. FEMA stands for the United States Federal Emergency Management Agency. When there’s an event like a severe storm, wildfire, pandemic illness, or other disaster, FEMA might declare an emergency.

If you’re affected by a FEMA emergency, Medicare takes into consideration that you may miss the chance to sign up for a Medicare Advantage plan or a stand-alone prescription drug plan.

There are also some situations not listed here that may qualify for a SEP as well. Call your State Health Insurance Assistance Program for help if you have questions about your personal situation.

Sources:

• medicare.gov
• ⁱⁱ “5-Star Special Enrollment Period,” Centers for Medicare and Medicaid Services, Medicare.gov, https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/5-star-special-enrollment-period