Medicare SEPs
If you are in Medicare sales, you know there are several opportunities to enroll a client in a Medicare plan, that is why Medicare SEPs are so important to understand. There are times when a beneficiary qualifies for an SEP such as; if they move or lose their current coverage through no fault of their own. If they lose coverage for non-payment, they do not qualify for an SEP.
As of January 1, 2024, beneficiaries who sign up for Part A and/or Part B due to an exceptional situation, have a 2 month period to enroll in either a Medicare Advantage Plan (MA or MAPD) or a Medicare Part D (PDP). Plan coverage begins on the first day of the month after the plan receives your application for enrollment.
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Below we list some common reasons for an SEP
Your client moves to a new location:
If the beneficiary’s new address is outside the PDP or MA/MAPD plan’s service area, they qualify for a special election period. When this happens, the beneficiary must notify the plan’s carrier. If the beneficiary notifies the plan before they move, they can change plans anytime the month before they move and up to 2 months after the move. When the beneficiary does not tell the plan before they move, they can change plans starting the month they notify the plan and continues for 2 full months after the move.
If the beneficiary does not choose another Medicare Advantage plan, they will be enrolled in Original Medicare once they are disenrolled from their previous plan. The enrollee can decide to use this election period to return to Original Medicare and add a Medicare Supplement and PDP plan.
The client moves back to the U.S. after living outside the country
There is also an SEP available for qualified U.S. citizens who lived outside the country and recently moved back. This SEP last for 2 full months after the month they move back.
Clients recently moved out of a nursing home or rehabilitation facility
When this is the case, the client is eligible to enroll in a MA/MAPD, PDP or Original Medicare and a Med Supp. This SEP is available to individuals any time during their stay in the facility and last for up to 2 full months after they leave the facility.
Individuals who are released from incarceration
Those who were incarcerated and released qualify for an SEP as long as they kept paying for their Part A & Part B coverage while incarcerated. They have 2 full months to enroll in a Medicare plan form the date they are released. Please note: Part A & Part B must be in place before they can enroll in coverage.
Loss of current coverage
There are a few times this may be the case including; they are no longer eligible for Medicaid or lose their employer or union coverage. When this happens, the beneficiary can then switch to Medicare Advantage, drop the Medicare Advantage plan and return to Original Medicare and a PDP plan. If this happens, it is important to enroll in a new plan to avoid a lapse in creditable coverage which can result in a penalty.
Chance to enroll in other coverage
Beneficiaries can drop their MA/MAPD or Part D plan if they have a chance to enroll in another plan offered by a union or employer. This SEP is available anytime during the year, although it is important to be sure there is no lapse in coverage. This can also be the case if a beneficiary qualifies for Tricare or VA coverage.
Plan changes its contract with Medicare
There are circumstances when Medicare takes an official action called a sanction to protect beneficiaries. If this happens, the contract the insurance carrier has with Medicare is changed and the differences can affect the plans that beneficiaries enrolled in. When this is the case, the beneficiary can enroll in another MA/MAPD or PDP plan offered by either the same or a different carrier.
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Some special circumstances
There are several other circumstances that allow beneficiaries a special enrollment period. Here are a few examples:
If the beneficiary is eligible for both Medicare and Medicaid.
When the beneficiary qualifies for the Extra Help, they may qualify for a Special Needs Plans that provides additional benefits. In the event they lose Extra Help, this also provides a SEP.
If the beneficiary dropped a Medicare supplement to join a Medicare Advantage plan, they have a “trial right” period they can use to drop the MA/MAPD plan and go back to Original Medicare if they change their mind. This period last for 12 months.
More special circumstances
When there is a 5 Star plan available, beneficiaries can drop their current coverage and enroll in the 5 Star plan anytime from December 8th through November 30th of the following year. In the event, a beneficiary is enrolled in a plan that is rated less than 3 Stars for the last 3 years, the beneficiary is qualified to switch to a higher rated plan.
If the beneficiary has a specific disabling condition, there are CSNP plans available to provide extra care to those individuals. Individuals can enroll in this plan anytime, although you cannot use this election to make any further changes.
There are also opportunities to change plans if a beneficiary misses their chance to change plans due to a Weather related or other FEMA disaster that occurs during a valid election period.
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As you can see, there are many qualifying life events that results in a special enrollment period. If you have questions or need to look at plan options, you contact your Medicare agent or if you are a Medicare agent with questions on SEPs, contact your upline for help. For more assistance; call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.