Medicare Special Enrollment Periods (SEP)

A Special Enrollment Period (SEP) is an enrollment period that takes place outside of the annual Medicare enrollment periods, such as the annual Open Enrollment Period.

They are granted to people who were prevented from enrolling in Medicare during the regular enrollment period for a number of specific reasons.

Special Enrollment Periods exist for Original Medicare (Part A and Part B), as well as for Medicare Advantage (Medicare Part C) and prescription drug plans (Medicare Part D).

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Special Enrollment Periods for Original Medicare

There are a few scenarios that may qualify someone for a Special Enrollment for Original Medicare.

Some of these qualifications include:

#1. Employer coverage

If you did not enroll in Medicare when you turned 65 because you were still employed and were covered by your employer’s health insurance plan, you will be granted a Special Enrollment Period.

This allows you to enroll in Medicare once you leave your employer coverage, even if you work past the age of 65, the qualifying age for Medicare.

Beginning the month that follows the end of your employer coverage (whether you retired or your coverage was terminated), you will be given a Special Enrollment Period of eight months to sign up for Part A and/or Part B.

One thing to note: Medicare does not consider COBRA coverage or retiree health plans to be active employer coverage.

If you did not enroll in Medicare when you turned 65 because you were covered by COBRA insurance or a retiree health insurance plan, you will not be granted a Special Enrollment Period. You may be subject to late enrollment penalties if and when you do sign up for Medicare.

#2. Foreign volunteer work

If you failed to enroll in Medicare when you first became eligible because you were participating in volunteer work in another country, you may also be granted a Special Enrollment Period. In order to qualify, you must have:

  • Volunteered for at least 12 months outside the U.S.
  • Volunteered for a tax-exempt program
  • Had another type of health insurance for the entire duration that you were volunteering

#3. Disabled TRICARE beneficiaries

TRICARE beneficiaries who are under 65 and qualify for Medicare because of a disability, ALS (Lou Gehrig’s Disease) or End-Stage Renal Disease (ESRD) may be eligible for a Special Enrollment Period if they didn’t sign up for Medicare Part B when they first became eligible.

When does a Special Enrollment Period start?

The beginning and end dates of your Special Enrollment Period will differ from one qualifying scenario to the next.

If you have a particular situation that prevented you from enrolling in any type of Medicare coverage for which you were eligible, you are encouraged to call 1-800-MEDICARE and request a Special Enrollment Period.

Learn what to expect when you call 1-800-MEDICARE.

How do I enroll in Medicare?

You can sign up for Original Medicare one of four ways:

Changing Medicare Advantage plans or Part D plans outside of open enrollment

Many Medicare beneficiaries enroll in a Medicare Advantage plan or a Medicare Part D prescription drug plan during the Medicare Open Enrollment Period for Medicare Advantage and prescription drug plans.

During this period (also called the Annual Enrollment Period, or AEP), you can make a number of coverage changes:

  • You can change from one Medicare Advantage plan to another, whether or not either plan includes prescription drug coverage.

  • You can disenroll from your Medicare Advantage plan and switch back to Original Medicare (Part A and Part B).

  • If you switch back to Original Medicare during this period, you can join a Medicare Part D prescription drug plan.

If you don’t enroll in a Medicare plan during this annual period, you may qualify for a Special Enrollment Period.

There are many ways to qualify for a Medicare Advantage Special Enrollment Period or a Medicare Part D Special Enrollment Period.

Some of the situations that may qualify you for one of these types of Special Enrollment Periods include:

  • You lose drug coverage (through no fault of your own) that was equal to or better than that offered by Medicare, or your drug coverage is reduced to a level that is below that of Medicare’s

  • Your employer or union offers a Part C or Part D plan as part of its benefits, and you wish to either join or drop this non-Medicare coverage

  • You reside in or move in or out of an institutional facility such as a skilled nursing home or other long-term care facility

  • You’re eligible to enroll in a State Pharmaceutical Assistance Program (SPAP), or you lose SPAP eligibility

  • You have Medicaid

  • You’re enrolled in a Medicare Savings Program or Medicare Extra Help

  • You wish to disenroll from your first Medicare Advantage plan within 12 months of signing up for it

  • You enroll in or disenroll from the Program of All-Inclusive Care for the Elderly (PACE)

  • You move to a new residence

  • You were released from prison

  • You are eligible to join a Special Needs Plan, or you lose your Special Needs Plan eligibility

  • The plan in which you enrolled was in violation of marketing, benefits or enrollment rules

  • Your plan does not renew its contract with Medicare

  • You have a disability and are turning 65 and are therefore eligible for new plan options

  • You wish to enroll in a five-star Medicare plan

  • You have been enrolled in a low-performing plan

  • Your plan stops contracting with a number of providers, and Medicare determines that the number of terminations is substantial

The above list does not necessarily include every and all qualifications for a Special Enrollment Period.

Losing creditable drug coverage through no fault of your own

If you had a Medicare Advantage plan with prescription drug coverage which met Medicare’s standards of “creditable” coverage and you were to lose that coverage through no fault of your own, you may enroll in a new Medicare Advantage plan with creditable drug coverage beginning the month you received notice of your coverage change and lasting for two months after the loss  of coverage (or two months after receiving the notice, whichever is later).

Additionally, if you wish to disenroll from a Medicare Advantage plan with drug coverage and enroll in another form of creditable coverage such as VA, TRICARE or a state pharmaceutical assistance program, you may do so whenever you become eligible for enrollment in the new coverage. 

Joining or dropping employer or union health or drug coverage

If you wish to disenroll from employer or union-sponsored coverage (including a group-sponsored Medicare Advantage plan) in order to enroll in Medicare Advantage, or you wish to disenroll from Medicare Advantage in order to join an employer or union-sponsored plan, you may do so for up to two months following the end of your previous coverage.  

Being institutionalized

If you move into, out of, or currently reside in a facility of special care such as a skilled nursing home or long-term care hospital, you may enroll in, disenroll from, or change a Medicare Advantage plan one time per month.

Once you move out from the facility, you will be given two months to do the same.

Enrollment in a State Pharmaceutical Assistance Program

If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), you may join or switch Medicare Advantage plans once per year at a time of your choosing.

Enrollment in Medicaid, a Medicare Savings Program or Extra Help

If you are enrolled in Medicaid, a Medicare Savings Program (MSP) or Extra Help, you may join, disenroll from or switch Medicare Advantage plans beginning the month you first become eligible for Medicaid or MSP and may continue to switch plans once a month thereafter.

If you lose Medicaid, MSP or Extra Help benefits, you will be granted a one-time opportunity to make changes in your Medicare Advantage enrollment.

Disenrollment from your first Medicare Advantage plan

If you enrolled in a Medicare Advantage plan when you first became eligible for Medicare, you have 12 months to disenroll from the plan and transition back to Original Medicare.

If you dropped a Medicare Supplement Insurance plan to enroll in a Medicare Advantage plan but wish to revert back again, you have 12 months to do so (provided that was the first Medicare Advantage plan you had ever been enrolled in).

Enrollment in or disenrollment from PACE

You may disenroll from a Medicare Advantage plan to enroll in a PACE program at any time.

If you wish to disenroll from PACE in order to join a Medicare Advantage plan, you may do so for up to two months following your PACE disenrollment. 

Change of address

If you permanently move out of your Medicare Advantage plan’s coverage area or move to an area with more available plans, you may switch to another Medicare Advantage plan beginning the month before your move and lasting for two months.

If you moved back to the U.S. after living abroad, you may enroll in a Medicare Advantage plan within the same timeframe.

Retroactive enrollment in Medicare

If you have received a retroactive enrollment in Medicare, you may enroll in a Medicare Advantage plan for the first time beginning the month you receive notice of your Medicare eligibility and continuing for two months thereafter.

Eligibility or loss of eligibility for a Special Needs Plan

If you are eligible to enroll in a Special Needs Plan (SNP), you may leave a Medicare Advantage plan at any time in order to do so.

If you are already enrolled in an SNP but are losing your eligibility, you may join a Medicare Advantage plan beginning the month that you are no longer eligible for the SNP and lasting for three months.

Contract violations or enrollment errors

If you are enrolled in a Medicare Advantage plan that failed to provide benefits in accordance with the plan’s terms or provided misleading information about coverage or other circumstances, you may be given an opportunity to disenroll from or switch to a new Medicare Advantage plan.

The timeframe in which you may do so will depend on the situation. 

A Medicare Advantage plan that chooses not to renew its service

If your Medicare Advantage plan fails to renew its service for the next calendar year, you have from Dec. 8 through the last day in February to switch to a different plan.

If the failure to renew becomes effective mid-year, you may switch to a new Medicare Advantage plan beginning two months prior to the end of coverage and lasting a total of three months.

If your Medicare Advantage plan is terminated for other reasons, you may switch to a new plan beginning one month before termination and continuing for two more months thereafter.

Qualification for a new Initial Enrollment Period

If you enrolled in a Medicare Advantage plan prior to turning 65 because of a qualifying disability, you will be granted another enrollment period upon turning 65.

During this seven-month period, you may switch Medicare Advantage plans or revert back to Original Medicare.

Wanting to enroll in a five-star Medicare Advantage plan

If you want to enroll in a Medicare Advantage plan that has been awarded a five-star Plan Performance Rating,1 you may do so between Dec. 8 and Nov. 30 of the following year.

Enrollment in a poor-performing plan

If you are enrolled in a Medicare Advantage plan that has received a Plan Performance Rating of three stars or less for three consecutive years,1 you may enroll in a higher rated plan throughout the year.

A Medicare Advantage plan that surrenders contracts with providers

If your Medicare Advantage plan ceases contracts with many of its providers and these terminations are considered substantial, you will be granted a one-time opportunity to switch to a different Medicare Advantage plan.

The period given to make the change will begin the month you are notified of the opportunity and will continue for two months thereafter.

If your circumstances do not fit into any of the Special Enrollment Periods described above, you may ask the Centers for Medicare and Medicaid Services (CMS) for your own Special Enrollment Period based on your situation.

How do I enroll in a Medicare Advantage plan during my Special Enrollment Period?

If you are unsure about whether you qualify for a Medicare Special Enrollment Period, or if you qualify and want to compare plans in your area, you can speak with a licensed insurance agent for help.

A licensed insurance agent can answer any questions you have and help you compare benefits, costs, coverage and other details of Medicare Advantage plans that may be available in your area.

 

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Or call TTY Users: 711 24/7 to speak with a licensed insurance agent.