What are Special Enrollment Periods for Medicare Part C & Part D?

Sep 12, 2011
Carol Finch

What can You do in a Medicare Special Enrollment Period? - Image by awottawa

The times when you can join, switch, change or drop Part C & Part D coverage may be limited. In some instances, you can use a Special Enrollment Period.

Not all seniors can alter their Part C Medicare Advantage or Part D prescription drug plans when they like. There are general rules in place that limit when you can join, leave or amend your coverage. These are known as enrollment periods. In certain circumstances, however, you may be eligible to make changes outside of standard timescales by using Special Enrollment Periods (SEPs). When do these apply?

Change of Location May Give You More Part C and Part D Options

A change of location may make you eligible for a SEP if it forces a change of coverage on you or gives you different plan options. So, for example, you may move to an area that isn't covered by your current provider. Even if your existing company does operate in your new location, you may still be able to make changes if it offers new options to the ones you have now. This rule can also apply if you relocate back to the country after living abroad, move into, live in or move out of an institution or are newly released from jail.

Loss of Coverage Can Allow You to Switch Medicare Plans

There are times when you may lose health insurance coverage and will need to put it back in place. You could, for example, lose Medicaid eligibility, leave an employer or union plan, come out of a Medicare Cost Plan (with drug coverage) or drop a PACE plan. You may also be given some flexibility in cases of involuntary loss of/plan changes to creditable coverage for prescription drugs – this describes an option that pays on average as much as standard Medicare drug plans.

Changing Medicare Plans Because of New Coverage Options

There may come a time when you want to drop your current coverage because new options become available to you. So, for example, you may become eligible to join a private plan through your employer or union or may enrol in a PACE plan. Or, you could be offered comparable prescription drug options such as VA/TRICARE coverage.

Changes Made to Your Plan by Medicare

In some instances, your coverage can be affected by issues that your provider has with Medicare rather than by changes to your circumstances. Examples of when this might affect your coverage include sanctions because there is a problem with a plan and the termination or non-renewal of a contract with Medicare.

Special Situations When You Can Change Parts C and D Coverage

In addition to the classifications above, there are also other times when you can make changes under SEP rules. For example, this could apply if you:

Are eligible for both Medicare and Medicaid.
Can claim Extra Help for prescription drugs.
Qualify to join a SPAP (State Pharmaceutical Assistance Program).
Came out of a Medigap policy when you enrolled in Advantage for the first time.
Have a condition that qualifies you for a (SNP) Chronic Care Special Needs Plan or a condition that is no longer managed by this kind of coverage.
Enrolled/did not enrol in a plan following an error made by a Federal employee.
Were not correctly informed that the private drug coverage you chose was not as good as the Medicare alternative or that you were losing private coverage that was as good.

If you cannot make changes under SEP rules, it may also be worth investigating whether you can make them at other times such as during open enrollment periods.

What Can You do in a SEP?

Do remember that each individual type of circumstance here may trigger specific options that are not always the same. The flexibility you are given in terms of what you can and cannot do with your Part C or Part D coverage can vary. For example, you may need to meet certain conditions, including:

Timescales – you may have a limited time to make a change, may be able to amend at any time or may have to work within specific dates or on a per-year limit.
Coverage options – you may be restricted to what you can actually do with coverage in terms of joining, switching or dropping a plan.

If you think that you might be eligible for Special Enrollment, you can call 1-800-MEDICARE to find out more. The conditions given to each criteria are also available in a PDF download ( Publication 11219 – Understanding Medicare Enrollment Periods) on the service's website.