By Ryan Kennelly
September 9, 2017
Topics:
September 9, 2017
In certain situations, people with Medicare may be eligible for a Special Enrollment Period (SEP) allowing them to join a Medicare Advantage plan or Medicare Part D prescription drug plan , or switch to a different Medicare plan during the plan year.
A Special Enrollment Period is a period of time when an individual can join or switch Medicare Part D or Medicare Advantage plans outside of the annual Open Enrollment Period (also called the OEP or Annual Coordinated Election Period or AEP). The annual Open Enrollment Period for Medicare Part D and Medicare Advantage plans begins each year on October 15th and continues through December 7th – with coverage beginning January 1st of the next year.
The chart below describes some of the different situations when an individual may be eligible for a Special Enrollment Period allowing them to join or change Medicare Advantage plans (MA), Medicare Advantage plans that includes prescription drug coverage (MAPD), or stand-alone Medicare Part D prescription drug plans (PDP).
| Special Enrollment Period | Who is eligible? |
| Special Enrollment Period (SEP) to Switch to 5-star Medicare Advantage plan AND Medicare Part D prescription drug plans | Beneficiaries currently enrolled any MA, MAPD or PDP plan (including those that already have a 5-star rating) and Beneficiaries who are enrolled in Original Medicare and meet the eligibility requirements for Medicare Advantage. The 5-star rating SEP can only be used one time during the plan year. See more details here. |
| Dual-eligibles (Medicare / Medicaid) beneficiaries and those who lose their dual eligibility | Individuals who receive any type of assistance from the Medicaid program or who lose their Medicaid eligibility. This SEP is ongoing for dual eligibles and provides a one-time election for individuals who lose their dual eligibility. |
| Contract violations | Individuals in a MA, MAPD, or PDP that violates its contract. This is a one-time SEP for individuals to select a new MA, MAPD, or PDP. |
| Non-renewals or termination of Medicare plan (or Service Area Reduction (SAR)) | Individuals affected by MA, MAPD, or PDP non-renewals or plan terminations. If an annual contract is not renewed and the Medicare plan members are not consolidated or cross walked to another plan, then these people have a SAR SEP that starts December 8 and continues until the end of February. |
| Involuntary loss of creditable coverage | Individuals who involuntarily lose creditable coverage, including a reduction in the level of coverage so that it is no longer creditable. This is a one-time SEP for individuals to select a new MA, MAPD, or PDP. |
| Not adequately informed about creditable prescription drug coverage | Individuals who were not adequately informed of the creditable status of drug coverage provided by an entity required to give such notice or who were not adequately informed of a loss of creditable coverage. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment. |
| Enroll in or maintain other creditable coverage | Individuals may disenroll from a Medicare plan (including MA, MAPD, or PDPs ) to enroll in or maintain other creditable drug coverage (such as TRICARE or VA coverage). |
| Error by a Federal employee | Individuals whose enrollment or non-enrollment in a MA, MAPD, or PDP is erroneous due to an action, inaction or error by a federal employee. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment. |
| Employer Group Health Plan | Individuals enrolling in employer group/union sponsored Part D plans, individuals disenrolling from a Part D plan to take employer/union-sponsored coverage of any kind, or individuals disenrolling from employer/union-sponsored coverage (including COBRA coverage) to enroll in a Part D plan. |
| CMS sanction | Individuals who want to disenroll from a MA, MAPD, or PDP as a result of a CMS sanction of the Part D sponsor. This SEP is granted on a case-by-case basis. |
| Cost plan | Enrollees of HMOs or CMPs that are not renewing their cost contracts (if the individual is also enrolled in a Part D benefit through that cost plan). |
| PACE | Individuals enrolling in PACE. This is a one-time SEP for the individual to disenroll from a PDP. |
| Institutionalized individuals | Individuals who move into, reside in, or move out of an institution such as a SNF, long-term care hospital, etc. |
| Medicare entitlement determination is made retroactively | Individuals whose Medicare entitlement determination is made retroactively and who should have been provided the opportunity to enroll in a PDP during their Initial Enrollment Period (IEP). |
| Individuals who enroll in Part B during the Part B General Enrollment Period (GEP) | Individuals who are not entitled to premium-free Part A and who enroll in Part B during the General Enrollment Period for Part B (January – March). |
| New LIS Eligibles | Individuals who are not currently enrolled in a Part D plan and who newly qualify for LIS because they have SSI or applied for LIS at SSA or State. |
| SPAP | Individuals who belong to a qualified SPAP may make one enrollment choice at any time through the end of each calendar year (i.e. once per year). |
| Full-benefit dual eligible Medicare beneficiaries with retroactive uncovered months | Full-benefit dual eligibles who voluntarily enroll in a Part D plan in the month(s) before the individual would otherwise have been auto-enrolled. |
| MA coordinating SEPs | There are a number of SEPs that were established to coordinate with MA election period (e.g., SEP65, OEPI, OEPNEW, etc). |
| Change of Residence | Beneficiaries who move outside of their plans service area. |
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