Understanding Medicare Special Enrollment Periods

In the United States, Medicare benefits help provide health care coverage for more than 60 million people, from beneficiaries turning 65 to individuals with qualifying medical conditions. Enrollment periods guide when Medicare beneficiaries are able to enroll, disenroll or change their Medicare plan.

Since you can incur lifetime penalties if you miss enrollment deadlines, it’s often best to enroll when you first qualify for Medicare, which typically is when you’re turning 65 during your Initial Enrollment Period. Once you’re enrolled in, say, a Medicare Advantage Plan, you’re able to annually change your coverage during either the Medicare Advantage Open Enrollment Period (January 1 – March 31) or the Annual Enrollment Period (October 15 – December 7). However, for both newly eligible beneficiaries and those already enrolled in plans, extenuating circumstances may prevent you from enrolling on time or changing your coverage during these annual enrollment periods.

Special Enrollment Periods

If, for some reason, you fail to join, leave or change your Medicare Advantage plan during the three aforementioned enrollment periods, you can only do so during a Special Enrollment Period (SEP). However, you have to qualify for an SEP to be allowed to join or make changes to your Medicare Advantage plan or Medicare Part D Prescription Drug plan. The Centers for Medicare and Medicaid Services (CMS) determines whether or not you qualify for an SEP. You may qualify for a Special Enrollment Period under the common circumstances detailed below.

When You Lose Creditable Drug Coverage

If you lose your coverage for a prescription drug plan or your plan fails to meet the minimum standard requirements of the Medicare Part D program, you may qualify for an SEP. However, the loss and changes should be through no fault of your own. A financial circumstance, such as your inability to pay your drug coverage premiums, does not qualify you for an SEP, unless you applied for and were approved for Low-Income Subsidy assistance for Part D.

When you lose Part D drug coverage, you can join a stand-alone Part D plan or a Medicare Advantage plan that includes Part D benefits within 63 days of notification that your prescription drug coverage ends. You can also enroll in Medicare during the next two months after you lose your prescription drug coverage or the two months after you’re formally notified of the loss of your coverage. Your Medicare coverage will begin on the first day of the month after you submit a completed application.

When You Join or Drop Employer’s Coverage

If your employer or union offers a Medicare Advantage plan or Part D plan, you qualify for a Special Enrollment Period when you enroll in their health plan. Additionally, if you drop your employer’s Medicare Advantage coverage or Part D coverage, you also qualify for special enrollment. After your employer’s plan coverage ends, you have up to two months to enroll in a Medicare plan. Your coverage will begin within three months after the month you formally submit a duly-filled enrollment application.

When You Move Into or Out of a Care Facility

If you move into or out of a qualified care facility, or you’re already a resident, you qualify for an SEP. These facilities include an intermediate care facility, skilled nursing facility, swing-bed hospital, rehabilitation hospital, long-term care hospital or a psychiatric hospital. You can enroll in Medicare Advantage or Part D one month after you move into the facility, or if you’re already a resident. After submitting your completed application, your coverage will begin on the first day of the following month.

When You Change Your Home Address

If you permanently move out of your current residence that is under the service area of a specific Medicare Advantage plan or Part D Prescription Drug plan, you qualify for an SEP. The timeline for disenrolling and joining a new Medicare Advantage Plan depends on the time you notify the Medicare Advantage plan of your move. You’re advised to notify Medicare as soon as possible. After submitting your application, your coverage may begin on the first day of the month that you move, or within three months after your application time of your move. You can apply for a new plan 30 days prior to your move and up to 60 days after your move. Should you miss this window, you could be forced to wait to enroll in the future and this could result in penalties as well as a period of time with limited or no benefits.

These are the most common circumstances that may qualify you for an SEP, but this is not an exhaustive list. To determine if your situation qualifies you for an SEP, consult with a local Medicare insurance agent who is knowledgeable about SEP regulations and the plans available in your area. It’s important that you know your options, enroll on time and obtain coverage suited to your evolving needs and situation. If you are anticipating changes in your life in the coming months, contact us today to speak to a certified Medicare insurance agent. Our team at Medicare Portal stands ready to assist you.

Scroll to Top