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Can I change my Medicare Part D plan at any time if I qualify for Extra Help or the Low-Income Subsidy?

Category: Extra Help - LIS - Medicaid
Updated: Jul, 06 2023


No, whether you qualify for full- or partial*-Extra Help - you can only change Medicare plans three times a year.  If you are eligible for the Medicare Part D Extra Help or the Low-Income Subsidy (LIS) program, you are granted a Special Enrollment Period (SEP) that allows you to change Medicare Part D or Medicare Advantage plans once per quarter any time during the first nine (9) months of the plan year.

*Note: 2023 is the last year for partial-Extra Help.  For plan year 2024 and beyond, the Inflation Reduction Act (IRA) of 2022 increases full-Extra Help benefits to people at or below 150% of FPL and consequently, the current partial Extra Help (135% to 150% of FPL) designation will be eliminated.

Using the SEP - You can use the SEP to change Medicare plans by telephoning a Medicare representative at 1-800-633-4227 (TTY 1-877-486-2048)  - or you can contact the Medicare plan directly - or you can submit a printed enrollment application to your chosen Medicare plan.

Your new plan coverage will start on the first day of the month after your enrollment.  For example, if you decide to use the Extra Help SEP and submit an enrollment application in September, your new Medicare Part D or Medicare Advantage plan coverage will begin on October 1st.

Important reminder: The Dual-Eligible SEP is no longer continuous.

Since January 2019, Medicare beneficiaries who are dual-eligible (Medicare/Medicaid) or eligible for the Medicare Part D Extra Help program [LIS] no longer have a "continuous" month-to-month Special Enrollment Period (SEP).  Instead, as noted above, the Dual-Eligible or Extra Help SEP “may be used only once per calendar quarter during the first nine months of the year.”

Extra Help recipients and Dual-Eligibles automatically qualify for the SEP

Remember, if you are eligible for both Medicare and Medicaid (Dual-Eligible) then you are automatically qualified for Medicare Part D Extra Help and the quarterly Special Enrollment Period.


Why would I want to enroll into a new Medicare Part D plan?

Even if you stay with the same Medicare plan from last year, you may find that your Medicare Part D or Medicare Advantage plan coverage is different than last year.  So, you may decide to change Medicare plans in the middle of the year if:
  • Your medications are no longer covered by your plan and you have not been able to have your plan approve your Formulary Exception request.  (Your plan has not agreed to cover your non-formulary drugs.)
  • You now have a monthly premium for your Medicare Part D plan because your plan no longer qualifies for your state's LIS $0 premium.

  • Your local pharmacy is no longer included in your plan's pharmacy network - or your plan no longer offers a mail-order option.

  • Your Medicare Advantage plan no longer includes some of your healthcare providers (doctors or local hospitals) within the plan's network.

  • Another Medicare Advantage plan is available in your area that covers all your prescriptions, healthcare providers, and adds some additional benefits such as health club memberships, hearing coverage, and/or vision coverage.
Tip:  Choosing your SEP when completing a printed enrollment application

If you are filling out a printed enrollment application to change Medicare plans during the year, you will use the application section for Special Enrollment Periods and then choose the SEP that applies to you.  You will probably read something like the following text on the enrollment application:
"Typically, you may enroll in a Medicare Prescription Drug Plan only during the annual enrollment period from October 15 through December 7 of each year. Additionally, there are exceptions that may allow you to enroll in a Medicare Prescription Drug Plan outside of the annual enrollment period."
...
  • I have both Medicare and Medicaid or my state helps pay for my Medicare premiums.

  • I get extra help paying for Medicare prescription drug coverage.
...
Guidance from Medicare to help you determine your eligibility for this SEP

Full and Partial Dual Eligible
- Do you currently have Medicaid coverage?
- Did you recently receive a yellow letter from CMS?
- Does your state pay for your Medicare premiums?
- Have you recently lost coverage under Medicaid?

Other Low-Income Subsidy
- Have you recently been approved for [Medicare Part D] extra help?
- Have you recently received a green letter from CMS?
- Do you receive SSI cash benefits without Medicaid?
- Did you receive a letter from Medicare letting you know that you automatically qualify for extra help?
- How much do you pay for your prescriptions?


More guidance from the Medicare Prescription Drug Benefit Manual:

"There is an SEP for individuals who have Medicare Part A and/or Part B and receive any type of assistance from the Title XIX (Medicaid) program. This includes both full benefit” dual eligible individuals as well as individuals often referred to as “partial duals” who receive cost sharing assistance under Medicaid (e.g. QMB-only, SLMB-only, etc.) and individuals who qualify for LIS
(but who do not receive Medicaid benefits).

This SEP begins the month the individual becomes dually-eligible and exists as long as he or she receives Medicaid benefits); however, there are limits in how often it can be used.

This SEP allows an individual to enroll in, or disenroll from, a Part D plan once per calendar quarter during the first nine months of the year. This SEP can be used once during each of the following time periods:
• January – March,
• April – June, and
• July – September.
[The SEP] may not be used in the 4th quarter of the year (October – December).
The SEP is considered “used” based on the month in which the individual makes the election (i.e., application date of the enrollment request). I f the plan receives an election in March (which would be effective April 1st), this counts as “using” the SEP for the 1st quarter, not the 2nd quarter.

The effective date of an enrollment request made using this SEP is the first of the month following receipt of an enrollment request." [emphasis and formatting added]


Source:
Chapter 3 - Eligibility, Enrollment and Disenrollment, Updated: August 19, 2011 (Revised: November 16, 2011, August 7, 2012, August 30, 2013, August 30, 2014, July 6, 2015, September 1, 2015, September 14, 2015, December 30, 2015,May 27, 2016, August 25, 2016, June 15, 2017, July 31, 2018 & August 12, 2020), Section 30.3.2 – SEP for Dual- and Other LIS-Eligible Individuals 42 CFR 423.38(c)(4) (Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)





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