Special Enrollment Period (SEP)

Enrolling in Medicare or changing Medicare coverage happens typically during Medicare’s ordinary enrollment periods. Still, you can enroll in Medicare or change your Medicare coverage outside of Medicare’s general enrollment periods if certain qualifying events happen in your life. These occasions for making changes are called Special Enrollment Periods (SEPs). There are two types of Medicare Special Enrollment Periods, and the rules about when you can make changes and the type of changes you can make are different for each kind of Special Enrollment Period.

The first type of SEP is for people who already have Medicare and are enrolled in a Part C Medicare Advantage Plan or a Part D Prescription Drug Plan who experience a qualifying life event. If a qualifying life event is triggered, a person has a two-month Special Enrollment Period for switching to a different Part C Medicare Advantage Plan or a Part D Prescription Drug Plan.

Examples of Qualifying Life Events:

• The Medicare Advantage (MA) Trial Period - The ability to disenroll from a MA plan, revert to original Medicare, and obtain a Medicare supplement insurance plan without medical underwriting, within 12 months of enrolling into the MA plan for the first time since being eligible for Medicare.
• Maintaining Medicare financial assistance such as Medicaid, Medicare Savings Program (MSP), or Extra Help (LIS), or newly eligible for the aid or losing eligibility for the assistance.
• Gaining or losing eligibility for any Medicare Advantage Special Needs Plan (SNP).
• If enrolled in or lose eligibility for a qualified State Pharmaceutical Assistance Program.
• Enrolling in or leaving the Program of All-Inclusive Care for the Elderly (PACE).
• Moving into or out of a qualified institutional facility, like a nursing home.
• Moving out of the plan’s service area.
• The plan closes or stops serving the area it should cover.
• The plan significantly reduces its provider network.
• The plan consistently receives low Medicare star ratings.
• A 5-star plan is available to enroll in.

The second type of SEP is for people who currently do not have Medicare because they were qualified to delay their Medicare Part A and/orPart B due to having creditable coverage, usually from an employer group health insurance plan or union plan. If you delayed enrolling into Medicare Part A and/or Part B, there is an eight-month window for enrolling in Medicare Part A & Part B and a two-month window for enrolling into a Medicare Part D plan without incurring late penalties.

This is where things get confusing! People have a whole eight months from the time their credible coverage ends to enroll in Medicare Part A and/or Part B without incurring a penalty. Still, they only have two months from when their credible coverage ends to enroll in a Medicare Prescription Drug Part D Plan without incurring a penalty, either as a stand-alone plan or combined with a Part C Medicare Advantage Prescription Drug plan (MAPD).

To qualify for this Special Enrollment Period, you must prove that you have recently had creditable employer health coverage or a union plan based on employment by having your Human Resources department head fill out and sign one of two CMS forms, form L-564 or form 40B. CMS form 40B must be filled out and signed if you did not delay enrolling in Medicare Part A and only delayed enrolling into Medicare Part B. CMS form L-564 must be filled out and signed if you delayed enrolling in Medicare Part A & B.