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



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

Answer: Usually, most seniors or other Medicare beneficiaries can only change their Medicare Part D or Medicare Advantage plan coverage during the annual Open Enrollment Period (AEP or Annual Enrollment Period or Annual Coordinated Election Period) that starts on October 15th and continues through December 7th with coverage starting on January 1st.  After the close of the AEP, most people are "locked" into their Medicare plans for the entire calendar year.

However, In certain situations, Medicare beneficiaries may be eligible for a Special Enrollment Period (SEP) allowing them to join or switch Medicare Part D prescription drug plans or Medicare Advantage plans outside of the annual enrollment period.  If you are eligible for an SEP, your coverage will be effective on the first day of the month following your new Medicare plan enrollment.

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


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 ongoing* for dual eligibles and provides a one-time election for individuals who lose their dual eligibility.
See more details here
*Beginning in 2019, this SEP will no longer be ongoing.  "Extra Help" recipients will be able to change plans once per quarter from January through September.

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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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
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  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.