Yes. The Centers for Medicare & Medicaid Services (CMS) provide case-by-case Special Enrollment Periods allowing a person to change Medicare Part D or Medicare Advantage plans outside of the annual Open Enrollment Period based on exceptional or extraordinary circumstances (the annual Open Enrollment Period or AEP begins October 15 and continues only through December 7).
As guidance, the CMS Medicare Part D and Medicare Advantage plan Manuals include sections for "SEPs for Exceptional Conditions" specifically addressing extraordinary SEPs that are considered by CMS representatives on an individual basis and note:
As guidance, the CMS Medicare Part D and Medicare Advantage plan Manuals include sections for "SEPs for Exceptional Conditions" specifically addressing extraordinary SEPs that are considered by CMS representatives on an individual basis and note:
"CMS will establish an SEP, on a case-by-case basis, for exceptional circumstances related toUnder the section 30.6 "Special Enrollment Periods (SEPs), CMS lists two "exceptional" SEPs:
enrollment into or disenrollment from an MA or Part D plan that are not otherwise captured in
regulation."
30.6.34. SEP for individuals who enroll in Medicare premium-Part A or Part B using an
exceptional condition SEP, as described in 42 CFR Parts 406.27 and 407.23 42 CFR §§ 422.62(b)(26) and 423.38(c)(34)"An SEP exists for individuals who enroll in Medicare premium-Part A or Part B using an exceptional condition SEP as described in 42 CFR §§ 406.27 and 407.23. The SEP begins when the individual submits their premium-Part A or Part B application and ends after the first two months of enrollment in premium Part A or Part B. The Part C or D plan enrollment is effective the first of the month following the month the plan receives the enrollment request."
30.6.36 – SEP for other exceptional circumstances 42 CFR §§ 422.62(b)(26) and 423.38(c)(36)
This SEP offers broader guidance for granting an SEP in extraordinary situations:"CMS will establish an SEP, on a case-by-case basis, for exceptional circumstances related to enrollment into or disenrollment from an MA or Part D plan that are not otherwise captured in regulation. Consistent with current practice, CMS will consider granting an enrollment or disenrollment opportunity in situations such as the following:CMS will review supporting details and documentation to determine eligibility for the SEP for exceptional circumstances. CMS’s review can be in response to an individual’s request for an exception to the current enrollment rules, as well as CMS’ determination that an exception is warranted for a group of beneficiaries.
- Circumstances beyond the individual’s control that prevented them from submitting a timely request to enroll in or disenroll from a plan during a valid election period. This is inclusive of, but not limited to, a serious medical emergency of the individual or their authorized representative during an entire election period, a change in hospice status, or mailed enrollment or disenrollment requests returned as undeliverable on or after the last day of an enrollment period.
- Situations in which an individual provides a verbal or written allegation that their enrollment in an MA or Part D plan was based upon misleading or incorrect information provided by a plan representative or State Health Insurance Assistance Program (SHIP) counselor, including situations where an individual states that they were enrolled into a plan without their knowledge or consent, and requests cancellation of the enrollment or disenrollment from the plan.
- An SEP may be warranted to ensure access to services, and when, without the approval of an enrollment exception, there could be adverse health consequences for the individual. This is inclusive of, but not limited to, maintaining continuity of care for a chronic condition and preventing an interruption in treatment.
The SEP begins once CMS makes its determination and the enrollee has been notified. The effective date for an enrollment or disenrollment election using an approved enrollment exception is based on the individual’s circumstances and will be effective the first of the month and may be either prospective or retroactive. The earliest prospective enrollment effective date is the first day of the calendar month following the month in which the election is made." [highlighting and emphasis added]
More from CMS about this "exceptional" SEP
A CMS blog published back on November 27, 2019, entitled, "We’re Heading into the Last Week of Medicare Open Enrollment Don’t Miss Out on Your Chance to Find Better Coverage" also addresses the issue of a discretionary Special Enrollment Period (SEP) that was available in extraordinary circumstances where people relied on false or misleading information when making an enrollment decision:
Question: How can I get this "exceptional" SEP so I can Medicare plans outside of the AEP?
Medicare beneficiaries should contact a CMS representative (by calling 1-800-633-4227) with any questions and to learn whether Medicare will grant this SEP based on their specific situation or circumstances.
Please remember that SEPs for extraordinary situations are granted on a case-by-case basis and depend on the facts surrounding your enrollment experience, so please be sure to provide the Medicare representative with as much information as possible – especially if your lack of Medicare plan coverage could adversely affect your health (for example, you suffer from a chronic health condition and rely on the continuous care and medications provided by your Medicare plan).
References:
New consolidated Medicare Advantage and Part D Enrollment and Disenrollment Guidance Updated: 2024
Medicare Prescription Drug Benefit Manual, Chapter 3 - Eligibility, Enrollment and Disenrollment, p. 34, 121, Updated: August 19, 2011 (Revised: August 15, 2023))
Medicare Managed Care Manual Chapter 2 - Medicare Advantage Enrollment and Disenrollment Updated: August 19, 2011 (Revised: August 15, 2023)
See the related Frequently Asked Question (FAQ: "Can I change Medicare plans more than once during a Special Enrollment Period (SEP)?"
Medicare Blog: https://www.cms.gov/blog/were-heading-last-week-medicare-open-enrollment-dont-miss-out-your-chance-find-better-coverage (now offline 12/15/2021, but available in internet archive).
A CMS blog published back on November 27, 2019, entitled, "We’re Heading into the Last Week of Medicare Open Enrollment Don’t Miss Out on Your Chance to Find Better Coverage" also addresses the issue of a discretionary Special Enrollment Period (SEP) that was available in extraordinary circumstances where people relied on false or misleading information when making an enrollment decision:
"Of course we want to ensure that beneficiaries are confident in their decisions and happy with the coverage they choose. We have protections such as Special Enrollment Periods in place if something happens to shake that confidence. As is the case every year, our call center representatives and staff caseworkers can help beneficiaries throughout the year if they believe they made the wrong plan choice because of inaccurate or misleading information. This process isn’t new, but this year we’re doubling down on ensuring that it’s a simple and painless experience for beneficiaries. Our staff is trained and ready to help any beneficiary who needs it. All they need to do is call 1-800 MEDICARE. Again, we’ve always had a Special Enrollment Period for people who think they made a wrong choice due to inaccurate information." [emphasis added]
Question: How can I get this "exceptional" SEP so I can Medicare plans outside of the AEP?
Medicare beneficiaries should contact a CMS representative (by calling 1-800-633-4227) with any questions and to learn whether Medicare will grant this SEP based on their specific situation or circumstances.
Please remember that SEPs for extraordinary situations are granted on a case-by-case basis and depend on the facts surrounding your enrollment experience, so please be sure to provide the Medicare representative with as much information as possible – especially if your lack of Medicare plan coverage could adversely affect your health (for example, you suffer from a chronic health condition and rely on the continuous care and medications provided by your Medicare plan).
References:
New consolidated Medicare Advantage and Part D Enrollment and Disenrollment Guidance Updated: 2024
Medicare Prescription Drug Benefit Manual, Chapter 3 - Eligibility, Enrollment and Disenrollment, p. 34, 121, Updated: August 19, 2011 (Revised: August 15, 2023))
Medicare Managed Care Manual Chapter 2 - Medicare Advantage Enrollment and Disenrollment Updated: August 19, 2011 (Revised: August 15, 2023)
See the related Frequently Asked Question (FAQ: "Can I change Medicare plans more than once during a Special Enrollment Period (SEP)?"
Medicare Blog: https://www.cms.gov/blog/were-heading-last-week-medicare-open-enrollment-dont-miss-out-your-chance-find-better-coverage (now offline 12/15/2021, but available in internet archive).
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