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Medicare Advantage plan and Medicare Part D prescription drug plan Special Enrollment Periods(SEP)




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Medicare Advantage plan and Medicare Part D prescription drug plan Special Enrollment Periods(SEP)

Published on 2014-09-26 06:17:42Category: Special Enrollment Periods SEP

In certain situations, people with Medicare may be eligible for a Special Enrollment Period (SEP) allowing them to join a Medicare Advantage plan or Medicare Part D prescription drug plan , or switch to a different Medicare plan during the plan year.

A Special Enrollment Period is a period of time when an individual can join or switch Medicare Part D or Medicare Advantage plans outside of the annual Open Enrollment Period (also called the OEP or Annual Coordinated Election Period or AEP).  The annual Open Enrollment Period for Medicare Part D and Medicare Advantage plans begins each year on October 15th and continues through December 7th - with coverage beginning January 1st of the next year.

The chart below describes some of the different situations when an individual may be eligible for a Special Enrollment Period allowing them to join or change Medicare Advantage plans (MA), Medicare Advantage plans that includes prescription drug coverage (MAPD), or stand-alone Medicare Part D prescription drug plans (PDP).

Special Enrollment Period Who is eligible?
Special Enrollment Period (SEP) to Switch to 5-star Medicare Advantage plan AND Medicare Part D 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.
Dual-eligibles (Medicare / Medicaid) beneficiaries and those who lose their dual eligibility Individuals who receive any type of assistance from the Medicaid program or who lose their Medicaid eligibility. This SEP is ongoing for dual eligibles and provides a one-time election for individuals who lose their dual eligibility. See more details here.
Contract violations Individuals in a MA, MAPD, or PDP that violates its contract. This is a one-time SEP for individuals to select a new MA, MAPD, or PDP.
Non-renewals or termination of Medicare plan (or Service Area Reduction (SAR)) Individuals affected by MA, MAPD, or PDP non-renewals or plan terminations.  If an annual contract is not renewed and the Medicare plan members are not consolidated or cross walked to another plan, then these people have a SAR SEP that starts December 8 and continues until the end of February.
Involuntary loss of creditable coverage Individuals who involuntarily lose creditable coverage, including a reduction in the level of coverage so that it is no longer creditable. This is a one-time SEP for individuals to select a new MA, MAPD, or PDP.
Not adequately informed about creditable prescription drug coverage Individuals who were not adequately informed of the creditable status of drug coverage provided by an entity required to give such notice or who were not adequately informed of a loss of creditable coverage. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment.
Enroll in or maintain other creditable coverage Individuals may disenroll from a Medicare plan (including MA, MAPD, or PDPs ) to enroll in or maintain other creditable drug coverage (such as TRICARE or VA coverage).
Error by a Federal employee Individuals whose enrollment or non-enrollment in a MA, MAPD, or PDP is erroneous due to an action, inaction or error by a federal employee. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment.
Employer Group Health Plan 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.
See more details here.
CMS sanction Individuals who want to disenroll from a MA, MAPD, or PDP as a result of a CMS sanction of the Part D 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.
Institutionalized individuals Individuals who move into, reside in, or move out of an institution such as a SNF, long-term care 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 Initial Enrollment Period (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 Eligibles Individuals who are not currently enrolled in a Part D plan and who newly qualify for LIS because they have SSI or applied for LIS at SSA or State.
SPAP 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 eligible Medicare beneficiaries 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).
Change of Residence Beneficiaries who move outside of their plans service area.  See Timing and Evidence Requirements.



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