As a Medicare agent, you are familiar with many of Medicare’s Special Enrollment Periods (SEPs), but are you familiar with all of them? You should be. Your clients rely on your knowledge and expertise. With your guidance, they can act at the right time. In some cases, this can even prevent late penalties and gaps in coverage.
Each SEP addresses a special circumstance – the timeframes depend on the situation. As there are too many SEPs to list here, you should check Medicare.gov for a complete list. The following are some of the more commonly used SEPs:
Change in Employer Coverage
- Purpose: For individuals who did not enroll in Medicare at age 65 because they (or their spouses) were still employed and covered under their employer’s (or spouse’s employer’s) health insurance to enroll in Original Medicare, MA, or PDP plans.
- Timeframe: Begins the month that follows the end of employer coverage and lasts eight months.
- Coverage begins: The first day of the month following enrollment. Individuals should try to time their enrollment to avoid gaps in coverage.
- Additional note: Medicare does not consider COBRA active employer coverage. Those on COBRA should plan to enroll during their Initial Enrollment Period; otherwise, they may face late enrollment penalties.
Change of Address
- Purpose: For individuals who permanently move outside their plan’s coverage area or move to an area with more plan choices to switch to a new MA or PDP plan.
- Timeframe: For those that notify their plan before they move, the SEP begins as early as the month before the move and lasts up to two months after the move. For those that notify their plan after they move, the SEP begins the month the plan becomes aware of the move and continues for two more months.
- Coverage begins: Any time between the first day of the month of the move and up to three months after, depending on the submission of the enrollment application.
- Additional note: Anyone who fails to enroll in a new MA plan during this timeframe will be disenrolled from their plan and enrolled in Original Medicare.
Changes in Eligibility for SNP
- Purpose: For individuals who become eligible to enroll in an SNP and for individuals who lose eligibility for an SNP to join another MA or PDP plan.
- Timeframe: Individuals who become eligible to join an SNP can leave an MA or PDP plan at any time to enroll in an SNP. Individuals with an additional chronic condition will have another SEP to join a different SNP for that condition. For individuals who lost eligibility, the SNP must continue coverage for at least one month after the individual becomes ineligible – up to six months if it’s likely the individual will requalify. Individuals can join another MA or PDP plan beginning the month they no longer qualify for the SNP and ending either three months after their continued period of enrollment ends or when they enroll in another plan, whichever comes first.
- Coverage begins: In both scenarios, coverage begins the first day of the month after submitting an enrollment application.
Currently Have Medicaid, a Medicare Savings Program (MSP), or Extra Help
- Purpose: For individuals who currently have Medicaid, MSP, and/or Extra Help to join, disenroll from, or switch MA or PAP plans.
- Timeframe: Once per calendar quarter for the first nine months of the year. It is not possible in the fourth quarter.
- Coverage begins: The first day of the month after submitting an enrollment application.
Gain Eligibility or Lose Eligibility for Medicaid, MSPs, or Extra Help
- Purpose: For individuals who become eligible for any of these programs. Also for individuals who lose eligibility to disenroll from or switch MA or PDP plans.
- Timeframe: One-time SEP lasts for three months after notification of the change in eligibility.
- Coverage begins: The first day of the month after submitting an enrollment application.
Exceptional Circumstances
CMS will also issue SEPs as the result of extraordinary events, such as the COVID-19 pandemic and FEMA-declared emergencies. Individuals who have been impacted by exceptional circumstances have the right to contact CMS to request a SEP.
One of the many benefits of staying in frequent contact with your clients is you are more likely to be aware of events in their lives that could make them eligible for a SEP. When you advocate for your clients, you become a valued partner in their healthcare decisions.
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