Medicare Special Enrollment Period: What to Know
Key Takeaways
- A Special Enrollment Period (SEP) allows you to join or make changes to your Medicare coverage outside of regular enrollment periods.
- There are a number of qualifying circumstances for a Special Enrollment Period, and the length of time the period lasts will depend on the event that 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. Here, we outline an overview of these unique enrollment periods and how you may qualify.
What is a Medicare Special Enrollment Period?
Each year, there are two significant Medicare enrollment periods: Annual Enrollment, from October 15 to December 7, and Open Enrollment, from January 1 to March 31. For many, switching coverage – especially Medicare Advantage or Part D drug plans – falls outside the annual enrollment period. Our healthcare needs do not always fit neatly into these small windows of time – life is much more complex than that.
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) is a personalized period that 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 that are worth noting. If you do not adhere to these time limits, you lose your opportunity and must wait until the next open 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 a 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, and we will primarily cover some of the most common situations used to switch Medicare Advantage or Part D plans; however, some SEPs also impact traditional Medicare coverage and Medigap supplemental 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.
- Your plan changed. CMS (Center for Medicare Services) may have removed your plan option due to a reported problem or ended your plan’s contract. Under certain circumstances, plans may not renew their contract with the CMS or intend to stop providing benefits 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.
- Working past 65. You have plans to work past the age of 65 and qualify to delay Medicare with creditable employer coverage. For a plan to be considered ‘creditable coverage’ for Medicare, it must provide benefits that are equally good or better than Medicare. There are some caveats if you plan on delaying coverage, as enrollment periods vary for Original Medicare (Part A/B), Medicare Advantage (Part C), and Medicare Supplemental Plans (Part D) without penalties.
- You are eligible for both Medicare and Medicaid. This is known as dual eligibility, and it allows beneficiaries to combine Medicare and Medicaid benefits to expand coverage and assist with costs.
- You enroll in or leave the Program of All-Inclusive Care for the Elderly (PACE). If you are already enrolled in Medicare, you may qualify for a two-month Medicare SEP.
- You no longer qualify for Extra Help. The Extra Help program helps those with limited income and financial resources to lower or cut Part D costs. This assists with the costs of your prescription drugs, like deductibles and copays.
- You were recently released from incarceration. If you were released from incarceration and did not enroll (or re-enroll) in Part A or Part B, a SEP may be available for eligible beneficiaries.
Some Important SEP Timelines:
Unlike formal enrollment periods, Special Enrollment Periods do not fall under one specific, unchangeable time of year. The beginning and end dates of your Special Enrollment Period will depend on the qualifying scenario you’re using to enroll. Because there are also so many kinds of SEPs, it is best to run through some average timelines for some of the life events:
- You move to a spot that is not in your 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 will 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. Under a specific Extra Help Special Enrollment Period where there is a loss, gain, or change, this period will last three months. You will have an opportunity to change plans once during the following time periods:
- January – March
- April – June
- July – September
- 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 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 will have a SEP allowing you to switch out of a plan that you joined based on erroneous, incomplete, or ambiguous information of the kind that is intended to confuse Medicare beneficiaries through unclear language. You must apply to Medicare for this Special Enrollment Period, and your case will be further investigated. If the investigating party (Medicare) decides that your claim is valid, you will be able to join another Medicare Advantage plan or switch back to traditional 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 will share an overall performance rating with plans on a five-star scale. Five-star ratings are considered the health plan, and these ratings can help Medicare consumers compare plans based on quality and performance.
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 that you should be aware of:
- You miss your 8-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 relating to benefits, costs, coverage, and other key information for competing Medicare Advantage plans.