By Dana Barrett

What is Special Enrollment?

Special circumstances in life can create an opportunity for you to make changes to your Medicare Advantage plan or your original Medicare coverage outside of the regular annual enrollment period.

Special Election Periods (SEPs) exist to provide consumers with the flexibility to change, add, or drop Medicare coverage due to relocation, job loss, or any of several other special circumstances that might trigger the need to make an unexpected policy change. Rules about when you can make changes and the type of changes you can make differ based on each circumstance. Let’s take a look at some specific reasons you would need to make Medicare or Medicare Advantage plan changes during a SEP.

What life changes are covered under a SEP?

A Special Election period most commonly applies in your being eligible to enroll in or change original Medicare or a Medicare Advantage plan because you are relocating.

I just moved to a new home but it’s in the same state, am I eligible?

The answer is yes. Even if you stay within a few miles of your old home, moving to a new address may put you in a service area or in a new county that gives you access to Medicare Advantage plans you weren’t eligible for at your old address. This is because Medicare Advantage plans are offered by private insurers on a regional basis. 

Other relocation situations that make you eligible for a SEP include moving back to the U.S. after living abroad, or moving into or out of a skilled nursing facility. 

When is the SEP if I am moving?

Notifying your plan before you move:

  • 1 month before your move and up to 2 months after

Notifying your plan after you move:

  • The moment you let them know, and for the next 2 months

If I lose my non-Medicare coverage but I’m over 65, do I qualify for special enrollment?

There are a variety of reasons you could find yourself without medical coverage if you aren’t currently enrolled in Medicare. You may be retiring from a job where you had private insurance through your company and are over 65 years of age. As someone who suddenly finds themselves without insurance but eligible for Medicare, it makes sense to research original Medicare vs. Medicare Advantage plans to see if there is a Medicare Advantage plan available in your area that comes close to matching your prior insurance coverage, or that might better fit your current budget and needs. 

Do I need a Medigap plan if I sign up for Medicare?

If you are considering enrolling in original Medicare, you should also look into Medigap vs. Medicare Advantage. A Medigap plan is designed to reduce your out-of-pocket expenses by bridging any “gaps” above and beyond what original Medicare covers. You aren’t able to purchase a Medigap plan if you choose a Medicare Advantage plan.

Medicare Advantage plans are also designed to reduce your medical costs, but they do so by providing more comprehensive policies with copayments that are far less than the standard 20% you’re required to pay with original Medicare coverage. Unlike original Medicare, Medicare Advantage plans provide an annual spending cap and they usually include dental and vision care.

Both Medicare Advantage and Medigap plans are sold regionally, and you’ll have access to the best rates and policy provisions if you sign up during your initial enrollment window. 

 What other losses of coverage situations qualify for a SEP?

  • You lost your Medicaid coverage.
  • You left a Program of All-inclusive Care for the Elderly (PACE) program.
  • Changes to or loss of another prescription drug program.
  • You left a Medicare Cost plan.

My Advantage Plan changed its contract with Medicare, do I qualify for special enrollment?

Medicare Advantage plans are sold by private insurers who are required to follow the rules and regulations set by Medicare. Sometimes the private insurance companies offering an Advantage plan choose to end that specific plan or decide to leave Medicare altogether. Alternately, Medicare can also choose to end a contract with a private insurer.

If you are enrolled in a Medicare Advantage plan that is being terminated for any of these reasons, you qualify for a special election. In this case, the special election period starts 2 months before coverage ends and continues one month after.

It’s important to note the insurance company managing your plan is required to notify you in writing if your plan is being terminated, and they have to continue your coverage until the end of the calendar year in which you are enrolled. 

What is a 5-star Special Enrollment Period?

A 5-star special enrollment period only applies to Medicare Advantage plans. Medicare collects member satisfaction ratings to evaluate overall performance for Medicare Advantage plans. As a result, they issue 5-star ratings to certain plans that are exceptional. Consumers can use these ratings to compare the pros and cons of Medicare Advantage plans in the same way we use Yelp to evaluate a new restaurant. If the area where you live has a 5-star Medicare Advantage plan or drug plan then you can use a SEP to switch to the 5-star plan. Be aware you are only allowed to make that change once between December 8 and November 30th.

Are there other specific situations that are SEP eligible?

There are many personal situations and life circumstances that fit the SEP bill. For instance, if you qualify for extra medical support through the Medicaid program or the low-income subsidy program you qualify for a special election period. Additionally, if you find yourself with a chronic health condition you may be able to find a Chronic Needs plan that is available in your area. The case may also be that you are currently enrolled in a special needs plan, but the medical condition that qualified you for the plan no longer exists.

As mentioned earlier, the specific time period for the SEP will differ in each of these cases based on the special circumstances you are faced with. A full list of Special Enrollment Periods and the circumstances that trigger them can be found on the  Medicare site.