In certain situations, people with Medicare may be eligible for a Special Enrollment Period (SEP) allowing them to join a Medicare Advantage plan or Medicare Part D prescription drug plan , or switch to a different Medicare plan during the plan year.
A Special Enrollment Period is a period of time when an individual can join or switch Medicare Part D or Medicare Advantage plans outside of the annual Open Enrollment Period (also called the OEP or Annual Coordinated Election Period or AEP). The annual Open Enrollment Period for Medicare Part D and Medicare Advantage plans begins each year on October 15th and continues through December 7th - with coverage beginning January 1st of the next year.
The chart below describes some of the different situations when an individual may be eligible for a Special Enrollment Period allowing them to join or change Medicare Advantage plans (MA), Medicare Advantage plans that includes prescription drug coverage (MAPD), or stand-alone Medicare Part D prescription drug plans (PDP).
|Special Enrollment Period||Who is eligible?|
|Special Enrollment Period (SEP) to Switch to 5-star Medicare Advantage plan AND Medicare Part D prescription drug plans||Beneficiaries currently enrolled any MA, MAPD or PDP plan (including those that already have a 5-star rating) and Beneficiaries who are enrolled in Original Medicare and meet the eligibility requirements for Medicare Advantage. The 5-star rating SEP can only be used one time during the plan year. See more details here.|
|Dual-eligibles (Medicare / Medicaid) beneficiaries and those who lose their dual eligibility||Individuals who receive any type of assistance from the Medicaid program or who lose their Medicaid eligibility. This SEP is ongoing for dual eligibles and provides a one-time election for individuals who lose their dual eligibility.|
|Contract violations||Individuals in a MA, MAPD, or PDP that violates its contract. This is a one-time SEP for individuals to select a new MA, MAPD, or PDP.|
|Non-renewals or termination of Medicare plan (or Service Area Reduction (SAR))||Individuals affected by MA, MAPD, or PDP non-renewals or plan terminations. If an annual contract is not renewed and the Medicare plan members are not consolidated or cross walked to another plan, then these people have a SAR SEP that starts December 8 and continues until the end of February.|
|Involuntary loss of creditable coverage||Individuals who involuntarily lose creditable coverage, including a reduction in the level of coverage so that it is no longer creditable. This is a one-time SEP for individuals to select a new MA, MAPD, or PDP.|
|Not adequately informed about creditable prescription drug coverage||Individuals who were not adequately informed of the creditable status of drug coverage provided by an entity required to give such notice or who were not adequately informed of a loss of creditable coverage. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment.|
|Enroll in or maintain other creditable coverage||Individuals may disenroll from a Medicare plan (including MA, MAPD, or PDPs ) to enroll in or maintain other creditable drug coverage (such as TRICARE or VA coverage).|
|Error by a Federal employee||Individuals whose enrollment or non-enrollment in a MA, MAPD, or PDP is erroneous due to an action, inaction or error by a federal employee. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment.|
|Employer Group Health Plan||Individuals enrolling in employer group/union sponsored Part D plans, individuals disenrolling from a Part D plan to take employer/union-sponsored coverage of any kind, or individuals disenrolling from employer/union-sponsored coverage (including COBRA coverage) to enroll in a Part D plan.
|CMS sanction||Individuals who want to disenroll from a MA, MAPD, or PDP as a result of a CMS sanction of the Part D sponsor. This SEP is granted on a case-by-case basis.|
|Cost plan||Enrollees of HMOs or CMPs that are not renewing their cost contracts (if the individual is also enrolled in a Part D benefit through that cost plan).|
|PACE||Individuals enrolling in PACE. This is a one-time SEP for the individual to disenroll from a PDP.|
|Institutionalized individuals||Individuals who move into, reside in, or move out of an institution such as a SNF, long-term care hospital, etc.|
|Medicare entitlement determination is made retroactively||Individuals whose Medicare entitlement determination is made retroactively and who should have been provided the opportunity to enroll in a PDP during their Initial Enrollment Period (IEP).|
|Individuals who enroll in Part B during the Part B General Enrollment Period (GEP)||Individuals who are not entitled to premium-free Part A and who enroll in Part B during the General Enrollment Period for Part B (January – March).|
|New LIS Eligibles||Individuals who are not currently enrolled in a Part D plan and who newly qualify for LIS because they have SSI or applied for LIS at SSA or State.|
|SPAP||Individuals who belong to a qualified SPAP may make one enrollment choice at any time through the end of each calendar year (i.e. once per year).|
|Full-benefit dual eligible Medicare beneficiaries with retroactive uncovered months||Full-benefit dual eligibles who voluntarily enroll in a Part D plan in the month(s) before the individual would otherwise have been auto-enrolled.|
|MA coordinating SEPs||There are a number of SEPs that were established to coordinate with MA election period (e.g., SEP65, OEPI, OEPNEW, etc).|
|Change of Residence||Beneficiaries who move outside of their plans service area.|