What are the Medicare Special Enrollment Periods (SEP)?


Medicare Special Enrollment


A Medicare Special Enrollment period is a time in which a Medicare beneficiary is allowed to join, switch, or drop their Medicare Part D plan, or Medicare Advantage plan  outside of the annual Open Enrollment Period. Normally, individuals are only allowed to change plans during AEP, which runs from October 15th through December 7th or during the Medicare Advantage plan Open Enrollment Period that starts January 1st and continues through March 31st every year.

If you are eligible for an SEP and you get properly enrolled, the plan will go into effect on the first day of the following month following.

Here is a list of common situations in which you may be eligible for a SEP.

Special Enrollment Period (SEP) to change to 5-star Medicare Advantage or Prescription Drug Plan:

Beneficiaries currently enrolled any MA, MAPD or PDP plan (including those that already have a 5-star rating) and Beneficiaries who are enrolled in Original Medicare and meet the eligibility requirements for Medicare Advantage. The 5-star rating SEP can only be used one time during the plan year.

SEP when changing residences or moving out of a service area:

Moving or changing residences counts as an SEP eligible time frame. You will be granted a Special Enrollment Period to join a new Medicare plan located within your new Service Area or ZIP Code area / County for a Medicare Advantage plan.

SEP for individuals who are joining or leaving an Employer Group Health Plan (LEGHP):

Individuals enrolling in employer group/union sponsored Part D plans, individuals disenrolling from a Part D plan to take employer/union-sponsored coverage of any kind, or individuals disenrolling from employer/union-sponsored coverage (including COBRA coverage) to enroll in a Part D plan. You can learn more on this topic here. 

SEP for Dual-Eligible Medicare/Medicaid beneficiaries and those who lose their dual-eligibility status:

Individuals who receive any type of assistance from the Medicaid program or who lose their Medicaid eligibility. This SEP is available to dual eligibles and provides a one-time election for individuals who lose their dual eligibility.

SEP for Medicare plan Non-renewals or Medicare plan terminations:

Individuals affected by Medicare Part D or Medicare Advantage plan non-renewals.

SEP for people who involuntary lose their “creditable” prescription drug coverage:

Individuals who involuntarily lose creditable drug coverage, including a reduction in the level of prescription drug coverage so that coverage is no longer creditable. This is a one-time SEP for individuals to select a new Medicare prescription drug plan or MAPD plan.

There are many additional instances in which you could be eligible for an SEP which is why it’s important to work with a local agent to determine all of your plan options.