How Do Medicare Special Enrollment Periods Work?

Open Enrollment is not the only time you can change Medicare plans

Special Enrollment Periods for Medicare

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Unlike Original Medicare (Part A and Part B), Medicare Advantage (Part C) plans do not include a nationwide network of providers. Instead, plans are tailored to a local network. Whether your Medicare Advantage plan is of the health maintenance organization (HMO) or preferred provider organization (PPO) variety, there are a number of logistical reasons you may need to leave your network. That's when a Medicare Advantage Special Enrollment Period (SEP) comes into play.

Special Enrollment Periods for Original Medicare

Signing up on time for Medicare is important to avoid paying late penalties. If you are approaching your 65th birthday, you will need to understand how the Initial Enrollment Period and Special Enrollment Period for Part B work.

Initial Enrollment Period for Medicare

The traditional Initial Enrollment Period for Medicare starts three months before and ends three months after your 65th birthday. Signing up after this time will result in late penalties. Part B penalties, in particular, last as long as you remain on Medicare.

Special Enrollment Period for Part B

Not everyone will want to sign up for Medicare when they turn 65, especially if they have a good health plan through their employer. In this case, they can use the Special Enrollment Period for Part B to delay their initial enrollment. They have eight months from the time they leave their employer or lose their health benefits, whichever comes first, to sign up for Medicare before facing potential late penalties. Keep in mind that to be eligible for this enrollment period, your employer must hire the equivalent of at least 20 full-time employees.

Special Enrollment Periods for Medicare Advantage

Special Enrollment Periods for Medicare Advantage are different that the Special Enrollment Period for Part B. First of all, they do not result in late penalties. Second, they are used to change from one plan to another. The Centers for Medicare and Medicaid Services (CMS) understands that there are circumstances that will affect your coverage when your plan is on a limited network. It is simply not always an option to wait for Medicare Open Enrollment (October 15 to December 7) to change your plan.

Changing Medicare Plans When You Move

In the following situations, you have two months to choose a new Medicare Advantage plan.

  • You move outside of your plan's network.
  • You move within your plan's network but to an area address that has more plan options.
  • You move back to the United States from a foreign country.
  • You are released from jail/prison.

You have more options if you are moved into or currently reside in a nursing home, long-term care hospital, or other medical institution. In that case, you can change your Medicare Advantage plan at any time or even change back to Original Medicare. When you move out of the facility, however, you only have a two-month window in which to change plans.

Changing Medicare Plans When You Lose Other Health Coverage

Losing access to other health care coverage puts you in a bind. You are given an opportunity to sign up for a Medicare Advantage plan in the following circumstances:

  • You are no longer eligible for Medicaid.
  • Your employer, union, or COBRA coverage ends.
  • You are no longer enrolled in a Program of All-Inclusive Care for the Elderly (PACE).

With the exception of Medicaid eligibility, you have two months to choose a Medicare Advantage plan. In that case, you have three months to choose a plan, although you can also opt for Original Medicare.

Changing Medicare Plans When You Gain Access to Other Health Coverage

When you get access to certain health benefits, you may no longer need a Medicare Advantage plan:

  • You become eligible for Medicaid.
  • You become eligible for an employer or union-sponsored health plan.
  • You enroll in a Program of All-Inclusive Care for the Elderly (PACE).

With the exception of Medicaid, you can disenroll as soon as you enroll in a new plan. Although there is no time limit, it's in your best interest to do this sooner than later. Otherwise, you will end up paying unnecessary monthly premiums.

When it comes to Medicaid, you can make a change once during one of the following three periods: January to March, April to June, and July to September. To change plans from October to December, you would defer to Medicare Open Enrollment.

Changing Medicare Plans When Your Medicare Advantage Plan Changes

You cannot be faulted if there is a change in your plan that violates Medicares rules and regulations and/or results in termination from the Medicare program:

  • Medicare places a sanction on your plan that affects you.
  • Medicare terminates its contract with your plan's contract.
  • Your plan is not renewed by Medicare.

Sanctions are addressed on a case-by-case basis. You can change Medicare Advantage plans two months before and up to one month after your plan's contract is terminated by Medicare. If your plan isn't renewed, however, you have a limited time to change plans between December 8 and February 28/29.

Special Enrollment Periods for Part D

The Special Enrollment Periods for Medicare Advantage above apply for Part D prescription plans as well. Other considerations for Part D coverage include the following:

  • You were not notified that your current drug coverage was not creditable.
  • You involuntarily lose coverage to prescription drug coverage that was creditable.
  • Your current health plan changes and your drug coverage is no longer creditable.

In these cases, you have two months to change plans after you lose creditable coverage.

Similar to the Special Enrollment Periods for Medicare Advantage that occur when you gain access to other health coverage, you have a right to change or cancel your Part D coverage.

You can drop your plan anytime when you sign up for a new plan that has creditable coverage. To change plans when you enroll in Extra Help, you are given the same timelines you do when you change plans based on Medicaid eligibility. Part D plans can be changed once a year when you are on a SPAP.

A Word from Verywell

Medicare Open Enrollment is not the only time you can change Medicare plans. Understanding how Special Enrollment Periods work for Medicare Advantage and Part D prescription drug plans will get you on the right plan sooner.

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