Medicare Special Enrollment Period (SEP) 2020
You can get coverage through a Medicare Special Enrollment Period if you meet certain qualifying requirements.
What is the Medicare Special Enrollment Period (SEP)?
Medicare offers people the chance to enroll in Medicare during a Special Enrollment Period (SEP) that can take place at any time throughout the year, depending on your specific circumstances.
When you qualify for a SEP, you don’t have to pay a late enrollment penalty that might otherwise be due if you did not sign up during your IEP.
Many people choose to delay enrolling in coverage during their IEP for a variety of reasons, such as if they are still working and already have employer group health coverage, including COBRA.
People that are younger than 65 who are eligible for Medicare due to a disability but who also have coverage through an employer (or spouse’s employer) can also delay coverage and later qualify for a SEP.
Qualifying for a Special Enrollment Period
There are several instances when a qualifying life event will make you eligible for a Special Enrollment Period.
You changed where you live:
- Moved to a new address that isn’t in your plan’s service area.
- Moved to a new address that is still in your plan area, but you now have other options to choose from.
- Moved back to the U.S. after living in a foreign country.
- You were released from jail.
- You moved in or out of an institution such as a long-term care hospital or skilled nursing facility. Anyone who is in a skilled nursing facility, nursing home, psychiatric unit, ICF/ID, rehabilitation facility, or long-term care hospital is considered “institutionalized.” Anyone who has resided in an institution for at least 90 days or meets 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.
You lost your coverage:
- You lost coverage through your employer, including COBRA coverage.
- You’re no longer eligible for Medicaid.
- You involuntarily lost drug coverage as good as Medicare’s drug coverage (creditable coverage).
- You had drug coverage through Medicare and I left the plan.
- You dropped your coverage in a PACE plan.
You have a chance to obtain different coverage:
- You can enroll in other coverage offered by your employer or union.
- You can enroll in other coverage as good as Medicare Part D coverage.
- You enrolled in a PACE plan.
Your plan changes its Medicare contract:
- Medicare terminates your plan’s contract.
- Medicare sanctions your plan because of a problem that affects you.
- Your Medicare Part C or Part D coverage is not renewed.
You qualify under a special situation, including:
- Dual enrollment eligible for Medicare and Medicaid.
- You qualify for Extra Help for Part D coverage.
- You enroll in or lose SNAP coverage.
- You dropped a Medigap policy when you first joined a Medicare Advantage Program.
- You are enrolled in a Special Needs Plan (SNP) but it is no longer covered as such by the plan that you are in.
- I either joined or disenrolled from a plan based on misinformation or an error by a federal employee.
How long is the Medicare Special Enrollment Period?
Different circumstances dictate how long your SEP would be.
For example, delaying enrollment because you have coverage from an employer that you subsequently lose gives you an 8-month enrollment period.
Other situations will limit you to a two-month window for your SEP.
In other cases, you could qualify for a year-long SEP, allowing you to make changes to your plan once a quarter for the first three quarters of the year.
Special Enrollment Period for Medicare Part B
You can enroll in Part B at any time you are covered by you or your spouse’s employment or during the 8-month period that starts the month the coverage or employment ends.
You qualify for a SEP to enroll in Part B coverage only if you delayed enrolling when you first turned 65 because you were covered under an employer’s group coverage. This is true for both you and your spouse’s employer.
If you’re younger than 65 and become eligible for Medicare due to a disability, but you have coverage from an employer’s group health then you can delay Part B enrollment until such time that you lose coverage.
When that coverage ends, you qualify for a SEP to enroll in Part B. The SEP is an 8-month period following the end of your employer’s coverage.
People with end-stage renal disease (ESRD) are not eligible to enroll during a SEP.
Special Enrollment Period for Medicare Part C and Part D
Special Election Periods (SEPs) for Medicare Advantage Part C and Part D Prescription Drug plans may be available depending on your situation. Some of those can include:
- If you move permanently, you have a SEP to change plans or return to Original Medicare if you have different options in your new location.
- When coverage through your current or former employer or union group health plan ends, you have a two-month SEP to enroll in Part C or Part D plans.
- If you become eligible for the Part D Extra Help or a Low-Income Subsidy, you have an ongoing SEP as long as you qualify for the Extra Help. You can change Part D plans or MA plans with prescription drug coverage every month if you want.
- When you lose the Extra Help, you have a 3-month SEP beginning in the month you receive notice of losing the subsidy.
- If you live in an area with a Part C or Part D plan that has an overall plan performance rating of 5 stars, you have a SEP to join that plan from December 8 through November 30 of each year. Medicare scores Part C 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 so that beneficiaries can make educated choices based on “star ratings.” 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.
- If you enroll in Part B during the GEP but you’re not entitled to premium-free Part A, you have a SEP to enroll in a Part D plan between April 1 and June 30. Your plan would become effective on July 1.
There may be other instances that allow you to use a SEP to enroll in Part C and Part D coverage. Contact Medicare directly to see if you qualify in other ways.
Getting Other Types of Coverage Through a Medicare Special Enrollment Period
You can get a Medigap plan or a Medicare Supplement plan during a SEP as well.
You qualify for a SEP for a Medicare Supplement plan when your employer group plan ends if you apply within 63 days. You can also enroll in some Supplement plans if you canceled your Medicare Part C plan because it violated its contract with you or you canceled your existing Supplement plan because you enrolled in a Part C plan for the first time, but later canceled your Part C plan within the first 12 months.
You can also buy a Medigap plan through a SEP within 63 days of losing your employer group plan coverage. This is known as a guaranteed issue right, and an insurer must sell you a Medigap policy at the best available rate, regardless of your health status.
Also, you cannot be denied coverage. A guaranteed issue right also prevents an insurer from imposing a waiting period to cover you for pre-existing conditions.
How To Apply for Medicare Special Enrollment
Contact the Social Security Administration (SSA) at 800-772-1213 and request forms based on your particular SEP circumstances.
Once you have gathered and completed all your documents, go to your local Social Security office to drop off your application or send your application to their mailing address.
Make copies of everything before you submit them so you’ll have records in case you need them later on.
You will receive a letter back from Social Security with your enrollment decision.
What if I’m turned down for a Special Enrollment Period, but I think I qualify?
You have the right to appeal the decision. In most cases, you have 90 days from the date you receive your Eligibility Notice to ask for an appeal.
If you decide to appeal, ask your doctor or healthcare provider to give you any information that may help you make your case.
If you’re worried that a delay could severely impact your health, you can ask for a quick decision. If the plan or your doctor agrees with this claim, you can get a decision within 72 hours.
When an appeal goes against you, it si reviewed by an independent organization that works for Medicare.
The appeals process has five levels and if you disagree with a decision made at any level, you can go to the next level in most cases. You will be provided with instructions on how to level up.
Contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal.
Other Medicare Enrollment Periods
Initial Enrollment Period (IEP)
Most people enroll in Medicare when they turn 65. Your Initial Enrollment Period (IEP) begins three months before the month you turn 65, includes the month you turn 65, and the three months after you turn 65.
If you enroll before the months you turn 65, your actual coverage starts on the first day of the month you turn 65. In you enroll during your IEP after your birthday, your coverage begins the first of the following month.
If you’re already getting Social Security benefits when you turn 65, you’ll automatically be enrolled in Original Medicare (Part A and Part B). If not, then you must enroll on your own.
For most people, the first time they will enroll in Medicare is when they turn 65. Your Initial Enrollment Period (IEP) is a seven-month window that begins three months before the month you turn 65, includes the month you turn 65, and the three months afterward.
Actual enrollment takes place on the first day of the month you turn 65.
You can elect to opt out of Part B coverage to avoid paying a premium. You can also decline Part A coverage, but for the vast majority of people, Part A is free, so there’s really no downside to not enrolling.
If you don’t qualify for free Part A coverage because you haven’t worked enough quarters in your working life (40 quarters or 10 years of Medicare taxed wages), then you can still enroll, but you’ll pay a Part A premium based on how many quarters you have banked.
If you enroll in Part A and Part B coverage during your IEP, then you can also enroll in Part C Medicare Advantage coverage and Part D Prescription drug coverage as well.
General Enrollment Period (GEP)
If you don’t enroll in Medicare during your IEP, you can still sign up for Medicare Part A and Part B during the General Enrollment Period (GEP) that runs from January 1 through March 31 annually.
When you enroll during the GEP, your coverage begins the following July 1.
If you enroll during the GEP, you may be required to pay late enrollment penalties.
For Part A, penalties can increase by 10% for twice the number of years you could have been enrolled but chose not to do so. For example, if you delay signing up for Part A by two years, you would have to pay a Part A late enrollment penalty for four years.
Part B premiums can also go up 10% for every 12-month period you were eligible but did not enroll. That means if you delayed Part B enrollment for two years, you would pay a 20% enrollment penalty.
The difference between Part A and Part B penalties is that for Part B, the penalties remain in effect for as long as you’re enrolled in Part B.
Annual Enrollment Period (AEP)
The Annual Enrollment Period (AEP) takes place from October 15 through December 7 each year. Changes made during the AEP are effective on January 1 of the following year.
During the AEP, you can change, drop or add Medicare Part C and Part D coverage for the coming year.
If you didn’t sign up for a Part C and/or a Part D plan during your IEP, the AEP gives you the opportunity to make changes.
Each September, you’ll get an Annual Notice of Change letter so you know how your coverage is going to be different. This helps you determine if your Part C and Part D coverage that you currently have is still the best plan for your needs.
Specifically, you can make the following changes during the AEP:
- Change to or from a Medicare Part C plan from Original Medicare, Part A and Part B.
- Change from one Medicare Part C plan to another
- Add a Medicare Supplement Plan
- Enroll in a Part D prescription drug plan.
- Change from one Medicare Part D plan to another.
- End Medicare Part D coverage completely.
Medicare Advantage Open Enrollment Period (OEP)
The Medicare Advantage Open Enrollment Period (OEP) takes place from January 1 through March 31 annually.
This period lets people already enrolled in a Medicare Advantage Part C plan to make a one-time change. You can switch from one Part C plan to another Part C plan, or you can disenroll from a Part C Plan and return to Original Medicare (Part A and Part B) with or without a Part D prescription drug plan.
People sometimes make changes during the OEP if their current network becomes more restrictive or they are informed their doctor is leaving their network.
Medicare Advantage Disenrollment Period (MADP)
The Medicare Advantage Disenrollment Period (MADP) takes place from January 1 through February 14 each year.
During this period, beneficiaries can disenroll from their Medicare Advantage Plan and return to Original Medicare coverage. However, you cannot switch from one Medicare Advantage Plan to another during the MADP.