How does a Special Enrollment Period work for Medicare plans?

Going through life changes? You may be able to enroll in Medicare or make changes to your plan. Learn what changes qualify.  

You may have heard that you can sign up for health insurance only during a certain time of year. But when your child left their job recently, they signed up during a Special Enrollment Period (SEP). That’s a special window that opens when you have a qualifying life event that allows you to sign up for health insurance after the normal enrollment period.

That got you thinking: Is there such a thing as an SEP for older adults? Yes, there is. In many situations, you might be able to enroll or make changes to your Medicare Advantage or Part D coverage outside of the designated enrollment periods. Here’s what you need to know.

What are Medicare Special Enrollment Periods, and how do they work?

You can make changes to your Medicare Advantage (MA) or Medicare Part D prescription medication plans in certain special circumstances, explains Shelley Miller. She’s the owner and founder of S.R. Miller Consulting, a Medicare consulting firm in St. Louis.

Those special circumstances are called Special Enrollment Periods (SEPs).

(An MA plan, which you might see called Medicare Part C, is a type of Medicare plan that is administered by a private insurance company that contracts with Medicare. Medicare Part D, on the other hand, is a Medicare prescription drug plan, which you can either pay extra for as part of your Original Medicare plan or get included in your Medicare Advantage plan.)

What triggers a Medicare SEP? You may get one when certain events happen in your life, like you lose your current coverage or you move.

Another instance might be if your plan changes its contract with Medicare.

If you do qualify for an SEP, you’ll get a set period of time where you can make changes to your MA plan or Medicare Part D coverage. Here’s a look at some of the most common situations.
Have a SEP and want to make changes to your current plan? Call a licensed insurance agent at (800) 827-9990 from 8 a.m. to 8 p.m. ET, Monday through Friday, to talk about plans, or browse your options online today.

Special circumstance #1: You move

MA plans typically cover limited geographic areas. If you move out of your plan’s coverage area, you’ll have an SEP during which you can switch MA plans or switch to Original Medicare. Even if you’re still in your plan’s coverage area, you may be able to switch plans if you have new MA plan options.

If you notify your insurer ahead of time, your SEP will begin the month before you move and continue for 2 months after. (If you tell them after you move, your SEP will begin the month you tell them and last for 2 months after.)

Special circumstance #2: You lose your current coverage

You may qualify for an SEP if you’ve lost health coverage for any of these reasons:

• You’ve been on Medicaid and you’ve lost eligibility.
• Your health insurance no longer covers prescription medications.
• You had medication coverage through a Medicare Cost Plan (a form of Medicare coverage found only in certain parts of the country) and you left the plan.
• You dropped your coverage in an All-Inclusive Care for the Elderly (PACE) plan. This is a special type of health plan for people eligible for both Medicare and Medicaid who need nursing home services but can still live in the community.

Special circumstance #3: You have a chance to get other coverage

This could be because:

• You’re eligible for health insurance through your current employer or a new job.
• You become eligible for a PACE plan.

In this case, you’ll be able to change your MA or Part D plan during an SEP.

Special circumstance #4: Your plan changes its contract with Medicare

This could happen because:

• Your MA plan did not renew its contract with Medicare.
• Medicare ended its contract with your MA plan.

You’ll be able to switch to another plan during your SEP.

Special circumstance #5: You qualify for a Special Needs Plan (SNP)

Certain MA plans, called Special Needs Plans (SNPs), are designed to serve people with specific chronic conditions that need more specialized care and management. You may qualify for an SNP plan if:

• You live in an institution, such as a nursing home, or you require in-home nursing care.
• You qualify for both Medicare and Medicaid.
• You have a chronic or disabling condition. This includes:
  • Chronic heart failure
  • Dementia
  • Diabetes
  • End-stage renal disease
  • HIV/AIDS

If you develop a condition that qualifies you for an SNP, you’ll be able to enroll in one during an SEP. Similarly, if you’re enrolled in an SNP and lose your special needs status, you can switch to a regular MA plan.

Thinking about switching Medicare plans? Call a licensed insurance agent at (800) 827-9990 to talk about plans, or browse your options online today.

What are some other times you may make changes to your Medicare plans?

If you don’t qualify for a SEP, there are also enrollment periods each year during which you can sign up for Medicare or make changes to your plan. These include:

Medicare’s Annual Open Enrollment Period. This happens every year from October 15 to December 7. During this time, you can:

• Change from Original Medicare to an AM plan, or vice versa
• Switch from one MA plan to another
• Join a Medicare Part D plan, or switch from one plan to another
• Drop your Medicare Part D coverage completely

Your new coverage will start January 1 of the following year.

Medicare Advantage’s Enrollment Period. If you’re enrolled in an MA plan, you’ll have another chance to make changes to your coverage from January 1 through March 31. During this time, you can:

• Switch from one MA plan to another
• Switch from MA to Original Medicare (if you do this, you can also join a separate Medicare Part D plan)

Your coverage will start the first day of the month after you ask to join the plan.

This enrollment period is only for people with an MA plan. If you have Original Medicare, you can’t switch to an MA plan or join or switch a Medicare Part D plan during this time.

Still need more information about Medicare? Call a licensed insurance agent at (800) 827-9990 to talk about plans, or browse your options online today.