15 Ways to Qualify for a Medicare Special Enrollment Period

Medicare Special Enrollment Periods: What You Need to Know

A Special Enrollment Period allows you to make changes to your Medicare plan outside of the regular sign-up windows.

Most of the time, you can make changes to your Medicare coverage only during the Annual Enrollment Period (AEP) or Medicare Advantage Open Enrollment Period. But life can be unpredictable. What if you need to move across town — or across the country — in May, and the relocation causes you to lose your current coverage?

Well, there’s a fail-safe for that. It’s called the Special Enrollment Period (SEP). It works similarly to the change-of-life exceptions offered by many employer-sponsored group insurance plans.

“SEPs allow individuals in certain circumstances to be eligible for Medicare coverage and enroll in a Medicare Advantage or Medicare Prescription Drug Plan outside of the AEP,” says Ryan Urgo. He’s a managing director at Avalere Health, a healthcare consulting firm in Washington, D.C.

The purpose of SEPs is to prevent lapses in healthcare coverage, adds Urgo. And unlike the AEP, there’s no set time period for SEPs. They will differ depending on your situation.

There are literally dozens of special circumstances that can qualify you for an SEP. Here, we dive into 15 that may apply to you.

Reason #1: You become eligible for both Medicare and Medicaid

You can sign up for Medicare three months before you turn 65 (or earlier if you have a disability). Medicaid is a state-level program that helps those with certain disabilities, family size, and income limits. Each state differs, so use this tool to find your state and see if you qualify.

If you’re eligible for both Medicare and Medicaid, you can use an SEP to join, switch, or drop your Medicare Advantage Plan or Medicare prescription drug coverage (Part D). You can do this once during each of these three time periods:

  • January–March
  • April–June
  • July–September

Everyone who has Medicare, including those who also have Medicaid, can make changes to their coverage during the Annual Enrollment Period (AEP). This runs from October 15 to December 7.

Reason #2: You qualify for Extra Help

Anyone who has Medicare can get Medicare prescription drug coverage (Part D). But some people need extra help affording this drug plan, whether it’s the monthly premiums or prescription payments.

Enter: Extra Help. This is a program that helps people with limited income gain more affordable access to prescription drug coverage (Part D), says Urgo. If you receive Extra Help, you may be able to join, switch, or drop Part D coverage once during each of the time periods above.

To find out if you qualify, contact one of our qualified insurance agents today. Just call the number listed at the top of the page.

Reason #3: You enter or leave a care facility

You also qualify for an SEP if you move into or leave one of Medicare’s qualified institutional facilities. These include long-term care hospitals and skilled nursing facilities.

Reason #4: You gain or lose eligibility for a Special Needs Plan

Medicare Special Needs Plan (SNP) is a type of Medicare Advantage Plan (like an HMO or PPO). It’s typically for people living with certain chronic conditions, and the benefits are tailored to those needs. If your SNP status changes, an SEP can help you find the most appropriate coverage.

Reason #5: You enroll in or leave the Program of All-Inclusive Care for the Elderly (PACE)

PACE programs give people access to healthcare professionals while living in a community setting, rather than at a nursing home or other type of care facility. You have two months after you drop your PACE plan to join another Medicare Advantage plan penalty-free.

Reason #6: You work past age 65

Some people continue working past 65. In that case, they may maintain their employer’s coverage and delay Medicare (assuming their current coverage is creditable). If that’s you, you can qualify for an SEP when you finally leave your employer’s plan. Like with PACE, you have two months after your previous coverage ends to join a Medicare plan.

Reason #7: You moved

Some Medicare Advantage or Part D plans limit membership based on where its members live. So if you’re moving, it’s important to check to see if you’re still in your plan’s service area. (If you can, try to do this before you make the move, to give yourself the most time to shop around for a new plan.) Depending on your new location, you may lose your current coverage, but you will likely gain new options, says Urgo.

Reason #8: You have or lose eligibility for a State Pharmaceutical Assistance Program (SPAP)

Some states offer a SPAP to help residents pay for costly prescription drugs. If you become enrolled, or subsequently lose your eligibility, you can qualify for an SEP.

Reason #9: You want to disenroll from your first Medicare Advantage Plan

If this is your first time in a Medicare Advantage Plan, you’re able to switch back to Original Medicare anytime during the 12 months after your health plan coverage started.

Related readingWhat is Medicare Advantage?

Reason #10: You lose your Medicaid coverage

As with people who lose insurance coverage through an employer, those who lose coverage from Medicaid can also qualify for a Special Enrollment Period. “An SEP in this circumstance can prevent lapses in coverage,” says Urgo.

Reason #11: Your Medicare Advantage Plan terminates a significant number of its network providers

Unfortunately, this can happen if you have a Medicare Advantage Plan (which is offered by private companies, rather than Medicare itself). And if it does, you qualify for an SEP and are able to join another Medicare Advantage Plan.

Reason #12: You have been in a consistently low-performing Medicare Advantage or Part D plan

Medicare scores plans with a rating between 1 and 5 based on quality and performance. You can qualify for an SEP if your current plan has failed to achieve at least a 3-star quality rating for three straight years.

Reason #13: There are changes to a plan’s contract with the Centers for Medicare & Medicaid Services (CMS)

“For example, if CMS takes action to sanction a plan, terminates the plan’s contract, or the plan’s contract is not renewed, an SEP in these instances allows for continuity of coverage in a comparable Medicare Advantage or Part D plan,” says Urgo.

Reason #14: You moved back to the United States after living outside the country

If you recently moved back to the United States, you could qualify for an SEP. In this circumstance, you have two months after you move to join a Medicare Advantage or prescription drug plan.

Reason #15: There’s a top-rated plan available to you

“There is also an SEP for individuals to switch from their current plan to a 5-star rated Medicare Advantage Plan or Part D prescription drug plan, if one resides in their area,” says Urgo. This SEP is designed to reward the highest-performing plans and to give you the opportunity to find the best coverage for your needs.

If none of these situations apply to you, you may have to wait for one of Medicare’s other election periods. Learn more here: When Can I Change My Medicare Plan?

Additional resources

Gloria Alcius
Gloria Alcius has been a Licensed Health Insurance Advisor since 2011. She enjoys building relationships with her clients and helping them better understand their Medicare options. Gloria’s goal is giving each customer peace of mind, knowing they have the right health insurance for their unique needs. In her spare time, Gloria enjoys spending time with her family, cooking, and traveling.


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