What are the Medicare Part D Special Enrollment Periods (SEP)?

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Category: Special Enrollment Periods (SEPs)
Updated: May, 16 2024

A Special Enrollment Period (SEP) allows a Medicare beneficiary to join, switch, or drop their Medicare Part D prescription drug plan (PDP) or Medicare Advantage plan (MA or MAPD) outside of the annual Open Enrollment Period (AEP) that runs from October 15th through December 7th or the Medicare Advantage plan Open Enrollment Period (MA-OEP) that starts January 1st and continues through March 31st.

The chart below describes some of the different situations in which an individual may be eligible for a Special Enrollment Period.

Using an SEP . . .
You can also learn more about available SEPs by contacting a Medicare representative at 1-800-633-4227 (1-800-Medicare) or visiting with a local SHIP representative. If you find an applicable SEP, a Medicare representative can also process your Medicare plan change using the Special Enrollment Period over the telephone. If you change plans using an SEP, your new plan coverage will be effective on the first day of the month following your new Medicare plan enrollment or plan change.

Special Enrollment Period	Who is eligible?
Special Enrollment Period (SEP) to Switch to 5-star Medicare Advantage AND Prescription Drug Plans	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. See more details here.
SEP when a Medicare beneficiary changes residence, moving out of their Medicare plan's service area	If you move outside of your Medicare Part D or Medicare Advantage plan's Service Area, you will be granted a Special Enrollment Period to join a new Medicare plan located within your new service area (Part D CMS Region or ZIP code / county for a Medicare Advantage plan). Even if you move to a new address within your current plan's service are but have new plan options, you can still switch plans. See timing and evidence requirement related to the SEP when changing residences.
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. "Extra Help" recipients can change plans once per quarter* from January through September. You can click here for more information. This change took effect January 1, 2019.
SEP for Medicare plan contract violations	Individuals in a Medicare Part D plan (PDP) or Medicare Advantage plan that violates its contract. This is a one-time SEP for individuals to select a new PDP, MAPD, or MA).
SEP for Medicare plan non-renewals or Medicare plan terminations	Individuals affected by Medicare Part D or Medicare Advantage plan non-renewals or plan termination (3-month SEP).
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 (PDP or MAPD).
SEP for people who were not adequately informed about their plan's creditable prescription drug coverage	Medicare beneficiaries who were not adequately informed of the creditable status of their drug coverage (usually provided by an entity required to give such notice) or people who were not adequately informed of the loss of creditable drug coverage. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment.
SEP to enroll in or maintain other forms of creditable drug coverage	Individuals may disenroll from a Part D plan (including PDPs and MAPDs) to enroll in or maintain other creditable drug coverage (such as TRICARE or VA coverage).
SEP when there was an error by a federal employee or enrollment based on false or misleading information	Individuals whose enrollment or non-enrollment in a Medicare Part D plan is erroneous due to an action, inaction or error by a federal employee. This SEP also includes exceptional circumstances when a person's enrollment if based on false or incorrect or misleading information. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment. You can click here to read more.
Joining or leaving an Employer Group Health Plan (EGHP)	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 read more about this SEP in our FAQ "Is there a Special Enrollment Period (SEP) available to join or leave an Employer or Union Group Health Plan (EGHP)?" or you can read our Article about SEP EGHP timing.
SEP for members of Medicare plans under CMS sanctions	Individuals who want to disenroll from a Medicare Part D or Medicare Advantage plan as a result of a CMS sanction of the Medicare plan sponsor. This SEP is granted on a case-by-case basis.
Cost plan	Enrollees of HMOs or CMPs that are not renewing their cost contracts (if the individual is also enrolled in a Part D benefit through that cost plan).
PACE	Individuals enrolling in PACE. This is a one-time SEP for the individual to disenroll from a PDP.
SEP for institutionalized individuals	Individuals who move into, reside in, or move out of an institution such as a nursing home, skilled nursing facility (SNF), long-term care (LTC) hospital, etc.
Medicare entitlement determination is made retroactively	Individuals whose Medicare entitlement determination is made retroactively and who should have been provided the opportunity to enroll in a PDP during their IEP.
Individuals who enroll in Part B during the Part B General Enrollment Period (GEP)	Individuals who are not entitled to premium-free Part A and who enroll in Part B during the General Enrollment Period for Part B (January – March).
New LIS (low-income subsidy or Extra Help) eligibles	Individuals who are not currently enrolled in a Medicare Part D plan and who newly qualify for the low-income subsidy (LIS) because they have SSI or applied for LIS at SSA or State.
SPAP - State pharmaceutical assistance programs	Individuals who belong to a qualified SPAP may make one enrollment choice at any time through the end of each calendar year (i.e. once per year).
Full-benefit dual (Medicare/Medicaid) eligible people with retroactive uncovered months	Full-benefit dual eligibles who voluntarily enroll in a Part D plan in the month(s) before the individual would otherwise have been auto-enrolled.
MA coordinating SEPs	There are a number of SEPs that were established to coordinate with MA election period (e.g., SEP65, OEPI, OEPNEW, etc.).
Individuals enrolled in a plan placed in receivership	Individuals currently enrolled in a Medicare Part D plan placed in receivership can use this SEP to move to another Part D plan.
Individuals enrolled in a plan that has been identified by CMS as a "Consistent Poor Performer"	Individuals currently enrolled in a Medicare Part D plan that has been identified by CMS as a consistent poor performing plan, can use this SEP to move to another Part D plan.
SEPs for Exceptional Circumstances - Discretionary or case-by-case basis	Medicare has the legal authority to establish SEPs when an individual or group of individuals meets exceptional conditions specified by CMS, including Special Enrollment Periods on a case-by-case basis. You can click here to read more.

Sources:

Medicare Managed Care Manual, Chapter 2 - Medicare Advantage Enrollment and Disenrollment, Updated: August 19, 2011 (Revised: August 15, 2023)

Medicare Prescription Drug Benefit Manual, Chapter 3 - Eligibility, Enrollment and Disenrollment, Updated: August 19, 2011 (Revised: August 15, 2023)

Federal Register/ Vol. 85, No. 106 / Tuesday, June 2, 2020 / Rules and Regulations g. Special Election Periods (SEPs) for Exceptional Conditions (§§ 422.62, 422.68, 423.38, and 423.40)