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Special Enrollment Periods for Medicare

Like employer group plans, Medicare has enrollment periods; seniors cannot enroll in or switch Medicare plans anytime they want. Most kupuna sign up for Medicare benefits during their Initial Enrollment Period (IEP) and may make changes to their Medicare plan during the Annual Enrollment Period (AEP). But there are also Special Enrollment Periods (SEPs) for special circumstances. Medicare allows seniors to enroll in or switch Medicare plans during SEPs when they have qualifying life events.

What counts as a qualifying life event for a Medicare Special Enrollment Period?

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. Rules about when you can make changes and the types of changes you can make are different for each SEP. What special circumstances qualify seniors for a special enrollment period?

According to the Medicare rights center, seniors may qualify for a special enrollment period for these and other specific circumstances:

1. If you have creditable drug coverage or lose creditable coverage through no fault of your own, your SEP begins the month you are told your coverage will end and lasts two months after you lose your coverage; or two months after you receive notice, whichever is later. During this window you can join a Medicare Advantage plan with drug coverage or a stand-alone Medicare Part D drug plan.

2. If you join or drop employer/union coverage you have a two-month SEP after the month in which your employer or union coverage ends to switch, join, or disenroll from a Medicare Advantage Plan or Part D plan.

3. If you become institutionalized, you can change, enroll in, or disenroll from a Medicare Advantage Plan or Part D plan once a month. If you move out of a facility, you have two months to make changes to your plans.

4. If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), you have an SEP to join or switch to a different Medicare Advantage Plan or Part D plan once per year, at any time during the year.

5. If you have Extra Help, Medicaid, or a Medicare Savings Program (MSP), you will get an SEP to join, disenroll from, or switch Medicare Advantage plans or Part D plans once per calendar quarter during the first nine months of the year.

6. If you gain, lose, or have a change in your Medicaid, MSP, or Extra Help eligibility status, you have a one-time SEP to disenroll from or switch your Medicare Advantage Plan or Part D plan for three months after you are notified.

7. If you want to disenroll from your first Medicare Advantage plan, you can do so (and switch back to Original Medicare) anytime during the 12 months after your coverage started.

8. If you disenroll from PACE (Program of All-Inclusive Care for the Elderly), your SEP to join another Medicare Advantage plan or Part D plan lasts up to two months after the date of your disenrollment from the PACE program.

9. If you move (permanently change your home address) and notify your Medicare plan of the address change, you have an SEP to switch to another Medicare Advantage or Part D plan as soon as the month before your move that lasts up to two months after the move.

10. If you have had trouble qualifying for Medicare, your enrollment period to join a Medicare

Advantage or Part D plan for the first time starts the month that you receive notice of your Medicare entitlement and continues for an additional two months after the month the notice is received.

11. If you become eligible for a Special Needs Plan (SNP), you can disenroll from your current plan and enroll in a SNP at any time.

12. If CMS auto-enrolls you into a Part D plan or Dual-eligible SNP (D-SNP), you have three months to switch to another plan, beginning after you are notified of the enrollment or after its effective date, whichever is later.

13. If you experience contract violations or enrollment errors, your SEP to switch to another Medicare

Advantage Plan or Part D plan begins once the regional CMS office has determined that a violation has occurred and lasts for 90 days.

14. If your plan no longer offers Medicare coverage, you have an SEP from December 8 of that year through the last day of February of the following year to switch to another Medicare Advantage plan or Part D plan. This acts as an extension of the AEP that runs from October 15 through December 7.

15. If you have been in a consistently low-performing Medicare Advantage or Part D plan, you have an SEP to enroll into a higher quality plan throughout the year.

16. If your Medicare Advantage plan terminates a significant number of its network providers, you have an SEP to switch to a new Medicare Advantage Plan, or to join Original Medicare with a Part D plan from the month you get notified of the network change and two additional months after that.

17. If you experience an “exceptional circumstance”, you have the right to ask CMS to grant you an SEP

based on your particular exceptional circumstances. In 2021, for example, seniors qualified for a special enrollment period if they lived in a “disaster area,” as declared by the Federal Emergency Management Agency (FEMA).

Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.

At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.

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