Medicare Special Enrollment Periods

Medicare Special Enrollment Period

At times an individual may enroll in Medicare outside of the regular Medicare enrollment periods due to extenuating circumstances. These are known as the Medicare Special Enrollment Periods (SEP). If you qualify for a Medicare Special Enrollment Period, you may enroll in Medicare outside of your Initial Enrollment Period (IEP) and the General Enrollment Period (GEP).

If you are 65 or older and are covered under a group health plan, your or your spouse’s current employment, you have a Special Enrollment Period during which you can sign up for Medicare Part B. This means that you may delay your decision to enroll in Medicare Part B without having to wait for the General Enrollment Period and without having to pay the 10% premium penalty for late enrollment.

Most people get Medicare Part A without paying a premium if they’ve worked at least 40 quarters (10 years) and paid their Medicare taxes. However, if you don’t have enough work history to get premium-free Medicare Part A and delay Medicare enrollment when you turn 65 because you have employer-sponsored coverage, you can also use your Special Enrollment Period to sign up for Part A. Otherwise, a late-enrollment penalty may apply for Medicare Part A if you don’t enroll when you’re first eligible and need to pay a premium.

Under such circumstances, you may:

• Enroll in Medicare Part A and/or Part B any time while you’re covered under the group health plan based on your current employment.
• Enroll in Medicare Part A and/or Part B during the eight months that begins with the month your group health coverage ends or the month your employment ends, whichever comes first. Medicare Special Enrollment Period rules do not apply if employment or employer-provided group health plan coverage ends during your Initial Enrollment Period.

If you do not enroll in Medicare by the end of the eight months, you will end up having to wait until the next General Enrollment Period, which begins January 1 of the next year. You also may have to pay a higher premium for Medicare Part B. If you don’t qualify for premium-free Medicare Part A, you may also owe a late-enrollment penalty for Part A as well.

People who receive Social Security disability benefits and are covered under a group health plan, from either their own or a family member’s current employment, also have a Medicare Special Enrollment Period. For more information on situations that may qualify you for a Special Enrollment Period, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week; TTY users can call 1-877-486-2048.

Medicare Advantage State Pharmaceutical Assistance Program (SPAP)

This SEP may be used in the states with State Pharmaceutical Assistance Programs (SPAPs). SPAP participants can use this SEP to join or switch to another Part D plan (a PDP or an MA-PD). This SEP was intended to allow new SPAP participants to join or switch to another Part D plan when their SPAP enrollment takes effect. This SEP may be used once per calendar year, with the new plan taking effect on the first day of the month following enrollment.

Medicare Advantage SEP to Coordinate with Part D

Medicare Advantage 65

This SEP allows people who join a Medicare Advantage plan (excluding a Medical Savings Account) at age 65 during their Medicare Initial Enrollment Period (IEP) to disenroll from that MA plan and go to Original Medicare. If they joined a Medicare Advantage plan with prescription drug coverage (an MA-PD), they may exercise this SEP by enrolling in a stand-alone Prescription Drug Plan (PDP).

Note: Those who use this SEP should also consider supplementing Medicare, either by applying for the Qualified Medicare Beneficiary Program (QMB) if they are eligible or by purchasing a Medigap policy. They have a right guaranteed by federal law to purchase any Medigap policy since this SEP has the effect of extending their Medigap Open Enrollment Period. 

This SEP may be used at any time within the first calendar year (12 months) after joining a Medicare Advantage plan at age 65. Original Medicare and the PDP enrollment (if applicable) take effect on the first day of the month following the month in which the SEP was used.

Medicare Advantage SEP to Coordinate with Subsequent Part D Initial Enrollment Period (IEP)

People who are under 65 and have Medicare because of disability get an additional Part D Initial Enrollment Period (IEP) when they turn 65. This SEP allows them to coordinate with the additional Part D IEP. They can use this SEP to disenroll from an MA-only or an MA-PD and return to Original Medicare or enroll in an MA-only plan, regardless if they use the Part D IEP to enroll in a PDP. The SEP begins and ends concurrently with the additional Part D IEP.

Medicare Advantage SEPs to Remedy Erroneous Enrollments

There are two Special Enrollment Periods that may help some of your clients deal with erroneous Medicare Advantage enrollment. One of these SEPs covers incomplete and unintended enrollments; the other covers enrollments caused by the action, inaction, or error of a federal employee. These SEPs can be used by your clients to disenroll from a plan they never wanted to be in but were enrolled through the abuse or fraud of MA plan marketers. It is used to undo a dissenrollment action that kept your clients from enrolling in a plan (so that an enrollment period election can be used to join a plan), and even to secure retroactive enrollment into another plan. Usually, this would mean re-enrollment into the plan your client was in before the unintended or erroneous enrollment.

Medicare Advantage Enrollment Not Legally Valid

This SEP may be used when a Medicare Advantage plan enrollment is not complete. An enrollment might not be complete, for example, if it was not signed by the beneficiary. One of the most notable examples of an incomplete and consequently invalid enrollment is one your client did not intend to make.

For example, if your client thought she was buying a Medigap policy or enrolling in a Medicaid managed care plan with a similar name, she never had the intent to join the Medicare Advantage plan. She should be able to use this SEP. 

Generally, this SEP involves a dis-enrollment from the plan into which the person was mistakenly enrolled and re-enrollment back into the prior Part D plan. To prevent a gap in Part D coverage, the re-enrollment might be made retroactive by the Centers for Medicare & Medicaid Services (CMS)to place your client back in the situation she never intended to switch out of.

This SEP usually involves SMS using its discretion to decide whether enrollment is incomplete. The timing of the disenrollment and re-enrollment will be determined by CMS. In general, once somebody establishes that the enrollment was not complete, including decisions that enrollments were not intended, CMS will time disenrollment and re-enrollment back to the prior plan so that the individual experiences no gap in Part D coverage.

Medicare Advantage Federal Error

Nobody is perfect —federal employee error can cause a Part D plan enrollment that should not have happened. Federal errors might also prevent an intended enrollment into a Part D plan.CMS decides on a case-by-case basis whether to approve this SEP, which permits enrollment into or dis enrollment from a Medicare Advantage plan with prescription drug coverage (MA-PD). This SEP begins in the month CMS tells a beneficiary the SEP has been granted and ends two months later. Enrollment in the new plan is effective on the first day of the month following enrollment.

Easing enrollment into Medicare Advantage plans:

Medicare allows pre-approved health insurance plan sponsors to automatically move individuals enrolled in one of their plans into that sponsor’s MA plan once the individual becomes eligible for Medicare. This process is called “seamless conversion.” This default enrollment is only for Medicaid managed care enrollees who are newly eligible for Medicare and who are enrolled into a Dual Eligible Special Needs Plan (D-SNP)or a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) administered by an MA organization (under the same parent organization that operates the Medicaid managed care plan). Plans are required to inform the individual at least 60 days before the conversion, and persons who do not wish to enroll in the MA plan must actively opt out of the seamless conversion.

Additionally, CMS in consultation with Medicaid may passively enroll full-benefit duals enrolled in a non-renewing integrated D-SNP into a comparable D-SNP. Individuals enrolled through passive enrollment, have a three-month SEP to disenroll from their assigned plan and enroll in a different plan.

Medicare Advantage SEPs Based on Residence

There are two commonly used Special Enrollment Periods for people enrolled in Medicare Advantage related to where they live or relocate to.

Medicare Advantage Relocation 

This SEP is for Medicare beneficiaries who, as a result of a permanent move, are no longer eligible to belong to their Medicare Advantage plan, or even if they are still eligible to remain in the plan, they will have new MA or PartD plan options available to them as a result of the move. (Generally, new plan options become available only upon moves to another state.)

Generally, plan members are responsible for notifying the current plan about a permanent move. Upon such notification, the SEP begins the month before the move and continues until two months after the move. Upon selecting a new plan, the beneficiary can choose an effective date of up to three months after the month the enrollment was submitted.

Medicare Advantage SEP for Individuals Affected by a FEMA-Declared Weather-related Emergency or Major Disaster 

This SEP allows individuals affected by a weather-related emergency or major disaster who were entitled to but unable to complete a valid election to enroll, disenroll, or switch Medicare Advantage plans. This SEP is also available to individuals who do not live in the affected areas but rely on help making healthcare decisions for friends or family members who live in the affected areas.

The SEP is available from the start of the incident period (i.e. when the emergency was declared) and for four full calendar months thereafter.

Medicare Advantage SEP for Institutionalized Individuals

The Medicare Advantage Open Enrollment Period (or OEPI) allows nursing home residents and others residing in residential long-term care facilities to enroll or switch Medicare Advantage plans similar to the Part D SEP for institutionalized beneficiaries.

The OEPI allows beneficiaries with Medicare Parts A and B who move into, reside in, or are discharged from certain long-term care facilities to join or disenroll from a Medicare Advantage plan. People eligible for the OEPI may join a Medicare Advantage plan, switch to a different Medicare Advantage plan or disenroll from Medicare Advantage and go to Original Medicare. They are not allowed to change their Part D status using the OEPI. If they previously had Part D, they must join an MA-PD or a PDP. If they did not previously have Part D, they are not allowed to join an MA-PD or a PDP.

Specifically, this SEP can be used by people in nursing homes, psychiatric hospitals, rehabilitation hospitals, long-term care hospitals, and swing beds. The OEPI also applies to individuals who are admitted to a skilled nursing facility in which they can join a Special Needs Plan (SNP) for institutionalized individuals. The SEP may be used to enroll or disenroll from an applicable institutional SNP.

This SEP begins in the month of admission and continues for up to two months following discharge. Unlike the PDP SEP for institutionalized persons, the OEPI may be used repeatedly to switch plans as frequently as monthly (although this would not be are commended practice).