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.
|Dual-Eligibles (Medicare/Medicaid) 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 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*.
See more details here.
*This change took effect January 1, 2019.
|Contract violations||Individuals in a PDP that violates its contract. This is a one-time SEP for individuals to select a new PDP.|
|Non-renewals or terminations||Individuals affected by PDP non-renewals or plan terminations.|
|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 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 Part D plan (including PDPs and MA-PDs) 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 Part D 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 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 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 eligibles 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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