Medicare Special Enrollment Period (SEP)
Most people can only enroll in Medicare or change Medicare plans during one very specific time of year, but SEPs are different. If you are eligible for a SEP, or Special Enrollment Period, you can enroll in or change Medicare plans during different times of the year (or even all year long)!
What are the Different Medicare Enrollment Periods?
There are five Medicare enrollment periods that you may be eligible for:
Who Qualifies for a Medicare 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)
- Be enrolled in a SNP (Special Needs Plan)
- Have a chronic illness or disability & receive Social Security benefits
- In a Medicare Savings Program or LIS (Extra Help)
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
- 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
If any of those circumstantial events apply to you, you will have 60 days from the event to change your health care plan.
What are Medicare Special Enrollment Periods (SEPs)?
Some Medicare beneficiaries are eligible for a SEP. You can either have a SEP for a set period of time, or you can have a lifelong SEP. A SEP allows you to enroll in a new Medicare plan or make changes to your current coverage outside of the normal enrollment periods. Remember that those who do not have a SEP can only make changes during AEP (October 15 - December 7) every year. If you qualify for a SEP, you should take advantage of your ability to get yourself into a better plan.
Medicare Part B Special Enrollment Period and Employer Coverage
The Part B SEP is a form of SEP for people who are eligible for Medicare according to their age but who have continued to work and have employer health coverage. If you are over 65 and you leave your job (and by extension, your employer healthcare plan), you will have an eight-month SEP during which you can enroll in a Medicare plan. Even though you will have eight months, it is best to enroll as soon as possible to avoid a lapse in coverage.
To start your Medicare enrollment process, you’ll want to contact Social Security or visit your local SS office. To select a Medicare Advantage plan and get more benefits or a Medicare Supplement plan and get more financial coverage, you’ll want to speak to an agent who can offer you plans from all the major carriers.
Facilities and Institutionalization
Anyone who is in a skilled nursing facility, nursing home, psychiatric unit, ICF/ID, rehabilitation facility, or long-term care hospital is considered “institutionalized.” Institutionalized beneficiaries have a SEP from the day they move into a qualified institution. They will also have two months from the day they move out of the facility to make a plan change. Additionally, those who have resided in an institution for at least 90 days or meet the guidelines for requiring at least 90 days of institutionalized care can qualify for an ISNP, or Institutional Special Needs Plan, which automatically grants a SEP.
SPAP (State Pharmaceutical Assistance Programs)
Some states (not all) have an SPAP program. State Pharmaceutical Assistance Programs help state residents pay for prescription drugs, but each state works differently. Some states have SPAPs that coordinate with Medicare Part D, so you are required to have Part D before you are accepted into the SPAP program. These programs might help you pay for your Part D plan costs. Other SPAP programs work exclusively with Medicaid, so you must qualify for Medicaid in your state to get SPAP. In some states, qualifying for an SPAP will automatically qualify you for a SEP.
Part D and Medicare Advantage Special Enrollment Period
If you qualify for any type of Special Enrollment Period, you can enroll in a Part D or Medicare Advantage plan. For example, you will qualify if you have a disabling condition or financial need that allows you to qualify for a Special Needs Plan (Special Needs Plans are types of Medicare Advantage plans). You can also qualify if you become eligible for Medicaid as well as Medicare, or if a 5-Star Medicare Advantage plan becomes available in your area.
5 Star Medicare Advantage Plans Enrollment
There is one other way that you can qualify for a SEP: through a new 5 star Medicare Advantage plan! Medicare scores Medicare Advantage and Part D plans in categories like care quality, customer service, complaints, responsiveness, available preventative health benefits, etc. Every year, scores are released before AEP (the Annual Enrollment Period) so that beneficiaries can make educated choices based on “star ratings.” How does this apply to enrollment periods?
If you do not currently have 5-star Medicare Advantage plans available in your zip code, and then a new 5-star plan becomes available, you have the right to switch from your plan into the 5-star option even if it is not AEP. You will have from December 8 through November 30 of the following year to make that change into a 5-star plan. This period is for 5 star plans ONLY. You would not be able to switch from one three or four-star plan into another three or four-star plan during this time.
Extra Help and Part D Automatic Enrollment
If you have Extra Help, you will automatically be enrolled into a Part D plan because you cannot have one without the other. Once you are enrolled, you will have a three month SEP during which you can change into a different Part D or Medicare Advantage plan.
What changes can be made during a Special Enrollment Period?
During your SEP, you can:
- Switch to a new plan in your area
- Move from one Medicare Advantage plan to another
- Add Medicare Advantage to your existing coverage
- Switch from Medigap to Medicare Advantage
- Change or add a form of prescription drug coverage
SEPs are NOT for those enrolling in Medicare for the first time. If you are about to turn 65, you should instead enroll during your Initial Enrollment Period. If you already turned 65 and you missed your Initial Enrollment Period, you need to enroll during the General Enrollment Period.
When can you Enroll in Medicare?
We know that the different enrollment periods can be confusing. If you aren’t sure whether or not you qualify for a Medicare Special Enrollment Period, 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 1-844-431-1832.