Medicare SEP Changes 2020: When You Can Enroll If You’re Eligible for a DSNP or LIS
DSNPs (Dual Special Needs Plans) are Medicare Advantage plans for people who are eligible for both Medicare and Medicaid. LIS (Low Income Subsidy), or Medicare Extra Help is a federal program that helps Medicare beneficiaries save money on prescription drugs.
If you are eligible for either DSNPs or LIS, your enrollment periods might be a bit different from others.
Am I Eligible for LIS?
If you’re eligible for Medicare and you make less than 150 percent of the Federal Poverty Level, you may qualify for LIS. You can also automatically qualify for Extra Help if you’re already on SSI or you qualify for a DSNP.
What Does LIS Cover?
LIS helps qualifying people pay for prescription drugs and it covers items such as Part D premiums, deductibles, and the “Donut Hole”.
LIS coverage is offered on a sliding scale. That means the subsidy provides more or less help depending on your qualifications.
For example, if you’re single and you qualify for full LIS and Medicare only, you’ll pay no more than $3.40 for covered generic drugs and $8.50 for covered brand-name drugs. You will have no copay once you spend $5,000 out-of-pocket for covered prescription drugs.
What are Medicare DSNPs (Dual-Eligible Special Needs Plans)?
DSNPs cover your Original Medicare premiums and services, and, since they’re Medicare Advantage plans, they can offer additional benefits* such as:
Many DSNPs have $0 monthly premiums, and if you see healthcare providers in your plan’s network, you shouldn’t have to pay Medicare deductibles and copays.
*Plan benefits and availability depend on many different factors such as location and carrier. Talk to your licensed agent to learn about available plans and covered services.
What Are the Changes to My SEP?
In the past, if you qualified for a lifelong SEP, you could enroll in a new DSNP, Medicare Advantage, or Part D plan up to once a month for the entire year.
In 2019 and 2020, if you’re eligible for a DSNP, LIS, or you only qualify for Medicare Savings Programs (MSPs) such as the Qualified Medicare Beneficiary (QMB) program or the Specified Low-Income Medicare Beneficiary (SLMB) program, the 2019-2020 CMS guidelines state that you can enroll in a new plan or drop coverage once per quarter for the first three quarters of the year (January – September).
Any changes you make during this time will become effective on the first of the month following the date you made the change. For example, if you enroll in a new DSNP plan on February 10, that change will become effective on March 1. You would not be able to make another change until the next quarter.
Q1: January – March
Q2: April – June
Q3: July – September
Q4: October – December
So, what does that mean for the rest of the year? Well, it means that you’ll fall into the AEP like everyone else.
The Annual Enrollment Period (AEP), which is October 15 to December 7, is a time when anyone can make changes to their existing Medicare coverage. Any AEP changes will take effect on January 1 of the following year. For example, if you make a change during AEP on November 15, that change will become effective on January 1.
Get the Medicare Health Insurance You Need Today
A licensed agent with Medicare Plan Finder may be able to help you find the coverage you need to stay in optimal health. Our agents are highly trained and they can find out what’s available in your area and help you make the right decision.
Our agents focus on the individual and offer an unbiased approach to helping you enroll in Medicare plans. To schedule a no-cost, no-obligation appointment, call 833-431-1832 or contact us here now.
Special Enrollment Period Medicare
Most people are only eligible to enroll in Medicare during their Initial Enrollment Period (three months before and after your 65th birthday) or during the Annual Enrollment Period (October 15 – December 7). However, there are several circumstances that may allow you to enroll in a Special Enrollment Period Medicare plan, including Part B, Medicare Advantage, Medicare Supplements, or Part D, outside of the initial and annual enrollment periods!
If you qualify for a SEP, you should take advantage of your ability to get yourself into a better plan. This includes:
Switching to a new plan in your area
Moving from one Medicare Advantage plan to another
Enrolling in Medicare Advantage for the first time
Switching from a Medicare Supplement plan to Medicare Advantage
Adding or changing prescription drug coverage
Different Types of SEPs
There are two main types of SEPs – lifelong and circumstantial. Lifelong SEP means you qualify for a SEP every year, unless your eligibility changes. For example, if you were eligible for Medicaid, but your income increased drastically, you may no longer be eligible. Circumstantial SEP means you qualify for a special enrollment period one time, depending on your circumstances. For example, if you move to a new service area, you will be able to make changes one time, unless you qualify for a different reason at a later date.
Another way you can qualify for a SEP is through a 5 star Medicare plan. If you are not currently enrolled in a 5 star Medicare plan, but one becomes available in your area, you can enroll in a better plan without being penalized. To learn more, click here.
Lifelong SEP
To qualify for a lifelong SEP, you must fall into at least one of the following categories:
Be eligible for Medicaid or a Medicare Savings Program
Part of SPAP (State Pharmaceutical Assistance Program)
Many people who qualify for a lifelong SEP are eligible for a Special Needs Plan. You must live in an area that supports a SNP plan as they are not available everywhere. Then, to be eligible, you must have a special need. In the case of SNPs, special needs can mean Medicaid-eligible/low-income (D-SNP), institutionalized (I-SNP), or diagnosed with a severe or disabling chronic condition (C-SNP).
Circumstantial SEP
To qualify for a circumstantial SEP, you must:
Move to a new service area
Involuntarily lose your coverage (for example, if your plan stops accepting Medicare assignment)
Find a contract violation with your plan
Lose or gain a job with group health insurance
Move into or out of a facility
Leave imprisonment
Enter or leave a health facility
Gain or lose Medicaid eligibility
Gain or lose Medicare Savings Program or LIS eligibility
Have been automatically enrolled in Part D
Special Enrollment Period Medicare Part B
In some cases, you may have a Special Enrollment Period for Medicare Part B (and Part A). If you are covered by a group health plan from your employer (and you are still employed), you may be granted a Special Enrollment Period. This SEP will begin the month after your group health plan or your employment ends and will generally last for eight months.
In most cases, this means that even though you are passing your Initial Enrollment Period, you will not face a late enrollment penalty fee (due to your employer coverage still being active).
How long does the special enrollment period last?
Special enrollment periods typically last 60 days. This means you have roughly two months to change or enroll in a different plan. However, depending on your circumstances, you may be limited to the changes you can make and the time frame could differ. Your best bet is to speak with a licensed agent and discuss eligibility and plan options. To ask any questions or to speak with a licensed agent, fill out this form.
Is being eligible for Medicare a qualifying event?
Being eligible for Medicare is not a qualifying event for a special enrollment period. If you are about to turn 65, you are eligible to enroll through your initial enrollment period, not a special enrollment period. The only events that qualify you for a SEP are listed above. If you have any questions on if your situation applies, fill out this form, and we will be in touch with you.
Do I qualify for a Special Enrollment Period Medicare Plan?
We get it, enrollment periods can be confusing, and it can be difficult to know if you qualify. If you aren’t sure whether or not you qualify for a special enrollment period medicare plan, or which enrollment period you need to use to enroll, we can help you. We can also help you figure out if you are eligible for a SNP Medicare Advantage plan, LIS (otherwise known as Extra Help) or another health care savings program, which will allow you to change plans at any time. To set up a free appointment with a licensed agent in your area, call 844-431-1832. As always there is no cost to you and no obligation to enroll.
This blog was originally published on 4/17/17, but was updated on 3/29/19.
