As a Medicare agent, you are familiar with Medicare’s three main enrollment periods each year. These are the times when most people make changes to their Medicare coverage:
- Initial Enrollment Period
- Annual Enrollment Period
- Open Enrollment Period
CMS also allows Medicare beneficiaries to make changes to their Medicare Advantage and Part D plans outside these enrollment periods under certain circumstances. However, your clients may be less familiar with these Special Enrollment Periods (SEPs) and may not know when they’ve had a qualifying life event that triggers their eligibility. SEPs can also allow for late enrollment in Part A and/or B without penalty when a beneficiary missed a Medicare enrollment period in specific circumstances.
You play an important role in helping your clients understand the different SEPs and the timelines associated with each one. When you check in with your clients throughout the year, ask them about any changes in their situations.
There are many different SEPs that cover a variety of circumstances – the following is a quick overview of the most frequently used. Being familiar with these SEPs will help you determine when one is applicable to a client’s situation. In all cases, coverage begins the first of the month after the plan receives an enrollment application.
Change of Address
If your client moves to an address outside the plan’s service area, he or she can switch to a different Medicare Advantage or Part D plan.
Timeline: If the client informs the plan before moving, the SEP begins the month before and continues for two full months after the client moves. If the client informs the plan after moving, the SEP begins the month the client informs the plan and lasts for an additional two full months.
Change in Employment Status
This is a SEP for individuals who did not enroll at age 65 because they were still working and had coverage through their employer’s large group health insurance. It also applies to individuals who had coverage through their spouse’s health insurance when they turned 65. Beneficiaries may enroll in Original Medicare, Medicare Advantage, or a Part D plan.
Timeline: Begins the month following the end of employer coverage and lasts eight months.
Eligibility or Loss of Eligibility for a Special Program
There are multiple SEPs for individuals who become eligible for a special program as well as for those who lose eligibility. These special programs include Medicaid, CSNP plans, Extra Help, and State Pharmaceutical Assistance Programs. The timelines and rules vary. You can reference the details for each program on the Medicare website.
If there are 5-star Medicare Advantage or Part D plans available in your area, your clients can use the 5-star special enrollment period to change plans.
Timeline: Beneficiaries can use this SEP once between December 8 (right after the annual enrollment period) and November 30 of the following year.
CMS also allows for SEPs due to extraordinary events, such as FEMA-declared emergencies and disasters.
Timeline: The SEP begins on the date the emergency or disaster is declared and ends six months after the emergency declaration ends.
Social Security can also grant an SEP on an individual basis if beneficiaries missed an enrollment period due to circumstances outside their control. Your client may need to provide proof of the exceptional circumstance.
New for 2024
Starting January 1, 2024, anyone who signs up for Part A or B in an exceptional situation will have two months to join a Medicare Advantage plan or Part D plan.
Medicare Trial Period
The trial period gives Medicare beneficiaries time to see if a Medicare Advantage plan is right for them. Anyone who enrolled in a Medicare Advantage plan when they were first eligible for Medicare has the right to switch back to Original Medicare within the first year of enrollment without penalty. They can also purchase a Medigap plan with no medical underwriting.
Anyone who was already enrolled in a Medigap plan and enrolled in a Medicare Advantage plan for the first time but is unhappy with their Advantage plan has 12 months to return to Original Medicare. They will have the same Medigap policy as before, provided the insurer still offers the plan.
Your Clients Count on You
Your clients rely on your expertise and guidance to ensure they have the right coverage. Encourage them to make you aware of any changes in their circumstances. When you advocate on their behalf, you become a trusted partner in their healthcare decisions.
Questions? The dedicated support team at Western Asset Protection is here to help. Contact us today.