By Dana Barrett

Seniors enrolled in Medicare can add, drop, or change their Medicare Advantage coverage when certain unexpected life events occur. These changes are made during a Special Election Period or SEP. There are a variety of circumstances that create eligibility for a Special Election Period. Let’s take a look at some of the most common ones.

Medicare Advantage SEP 65

If you initially enroll in a Medicare Advantage Plan at age 65, the first 12 months of enrollment are considered a trial period. During this time, you can switch to a different Medicare Advantage Plan or you can disenroll from Medicare Advantage and enroll in Original Medicare. If you choose to enroll in Original Medicare, you also qualify for a “guaranteed issue right” to purchase a Medigap supplemental plan at the same time. The beneficiary can exercise the issue right for 63 days after leaving their Medicare Advantage Plan.

Special Enrollment Period for the Working Senior

If you are over 65 and retiring from a job where you had private health insurance, you have 8 months from either your last day of work or the last day your private insurance coverage ends to enroll in Medicare Parts A and B. You must be enrolled in Medicare Part B and be paying your Part B premiums to enroll in a Medicare Advantage Plan. 

There is a 2 month “Special Enrollment Period” from the month that your private health coverage ends during which you can enroll in a Medicare Advantage Plan. You are also eligible to enroll during the fall Open Enrollment Period, from October 15 to December 7 each year.

Relocation

There are several circumstances involving relocation that trigger a SEP. 

• Moving to a new state or county
• Moving into or out of a skilled nursing facility or hospital
• Moving back to the U.S. after living abroad 
• If you were recently released from jail

Medicare Advantage plans are managed by private insurance providers regionally. So, if you move out of your current Advantage Plan region, you’ll need to find a plan in the area where you currently live. Similarly, if you move back to the U.S. from another country, or you’ve been released from a nursing home or rehabilitation facility you can change Medicare plans to a local Advantage Plan that suits your needs.

Special Election Period for Relocation:

Notifying your plan before your move, will give you 1 month prior to moving and up to 2 months after you’ve moved. If you notify your plan after you move, then you will have 2 months from the date of notification.

If you move into a skilled nursing facility, psychiatric hospital, or rehabilitation facility, the SEP begins the month you are admitted and continues for up to 2 months after you’ve been discharged.

Medicare Advantage SEP – Dual Enrollment

Dual enrollment refers to beneficiaries who are enrolled in both Medicare and Medicaid, or full Medicaid with a Medicare savings plan. If you are dually qualified, you can enroll, disenroll, or switch to another Medicare Advantage plan during the Dual Enrollment SEP. This Special Election Period is one time per quarter during the first 3 quarters of the calendar year. The enrollment change will be effective on the first day of the following month after you make the change.

Medicare Advantage Extra Help or Low-Income Subsidy SEP

This SEP also applies to dually enrolled beneficiaries but is specific to individuals who are approved by the Social Security Administration for the Medicare Part D low-income subsidy (LIS) also called Extra Help. The LIS Special Enrollment Period starts the month you are approved for Extra Help and ends 2 months after you lose Extra Help status. Changes are active on the first day of the month following enrollment.

5-Star Special Enrollment Period

Medicare evaluates the overall performance of Medicare Advantage Plans using customer satisfaction surveys. Each plan is given a rating of 1 to 5 stars. Plan ratings are updated and published every fall for the coming year. The 5-star Special Enrollment Period allows you to switch to a 5-star plan in your region only one time between December 8 and November 30. 

Default Enrollment/Seamless Conversion SEP

There is a Medicare enrollment process called “default enrollment” (previously called “seamless conversion”). This process allows pre-approved Medicare Plan sponsors to automatically transfer the enrollment of a beneficiary into a Medicare Advantage Plan under certain circumstances. 

If you are a senior in a Medicaid Managed Care plan, the plan manager or Centers for Medicare and Medicaid Services (CMS) can transfer your enrollment to a Dual Eligible Special Needs Plan (D-SNP) or a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) when you initially become eligible for Medicare.  

If you are a Medicare recipient that has been transferred into a Medicare Plan but would prefer different coverage, you have a 3-month SEP to disenroll from your assigned plan and enroll in a different plan. The SEP starts from the month your request the change and continues for 2 months after.

Federal Employee Enrollment Errors

Occasionally your Medicare enrollment choices are incorrectly processed by a federal employee. If this happens, there is an SEP during which you can join, switch to, or drop a Medicare Advantage Plan. You can also switch back to Original Medicare or drop your Medicare prescription drug coverage. The Special Enrollment Period allows you to change coverage for 2 full months after you are notified of the error by Medicare.

State Pharmaceutical Assistance Program (SPAP) SEP

As of 2020, 16 states offer State Pharmaceutical Assistance Programs (SPAP) to help people pay for their medication. Eligibility for this service is usually tied to having a specific medical condition. If you are a SPAP participant, you have the option to join or switch to a different Medicare Part D Prescription Drug Plan one time during the calendar year. You can also join a Medicare Advantage Prescription Drug Plan during this SEP.

As you can see, Medicare Special Election Periods provide enrollment flexibility to accommodate various situations for Medicare members. If you need to change your Medicare coverage because of special circumstances, be sure to review the guidelines for Medicare SEPs to determine when you’re eligible to make those changes.