What Is a Medicare Special Enrollment Period?

What Is a Medicare Special Enrollment Period?

A special enrollment period allows you to enroll in or change your Medicare coverage outside the regular Medicare open enrollment period and Medicare Advantage open enrollment period. You can qualify for a special enrollment period if you experience certain life events, such as moving or losing workplace health coverage. Changes you can make and deadlines depend on the life event and the Medicare coverage type. Here’s a look at the circumstances that can trigger a special enrollment period.

Special Enrollment Periods for Original Medicare (Parts A and B)

Many people enroll in Original Medicare (Parts A and B together) along with a Medigap plan to help pay for out-of-pocket costs from A and B, such as deductibles and copays. You may be penalized in some situations if you miss your initial enrollment period. But if you qualify for a SEP, you won’t have to pay a late enrollment penalty.  

If you have employer-based health coverage, you may be able to delay Medicare enrollment and avoid late enrollment penalties. So, losing the coverage you get through your job or your spouse’s job is one common reason for a SEP. Speak to your employer’s benefits administrator about coordinating your Medicare and employer benefits. 

Other qualifying situations include: 

• Losing Medicaid coverage
• Being impacted by a natural disaster
• Receiving inaccurate or misleading information from an employer or health plan
• Being in jail
• Having TRICARE 
• Finding out you’re no longer eligible for Extra Help
• Volunteering and serving in a foreign country 
• Experiencing other exceptional conditions that prevent you from enrolling

For example, if you lost your Medicaid coverage, you can enroll in Medicare Part A or Part B from the day you’re told you’re losing Medicaid coverage until six months after your coverage ends. 

Your SEP’s length depends on the qualifying event. It generally ends six to 12 months after the trigger event. 

The Medicare Trial Right Period

Suppose you have Original Medicare plus a Medigap policy and want to try out a Medicare Advantage Plan. You have one 12-month period to switch back to your original Medigap policy if you don’t like your new Medicare Advantage plan. You can only get your Medigap policy back if it’s still available from your insurer; otherwise, you must choose another plan. 

There are a few other situations in which you can switch your Medicare Supplement plan, and some states offer more rights to switch or enroll in plans than others.

Special Enrollment Periods for Medicare Advantage (Part C) and Part D Drug Plans

Medicare Advantage or Medicare drug plans have more circumstances that can trigger a SEP than Medicare Part A and Medicare Part B do. A special enrollment period can also allow you to drop Medicare Advantage and return to Original Medicare outside the usual open enrollment periods.  Here’s a general overview of the more than 30 reasons that could qualify you for Part C (Medicare Advantage) and Part D (drug coverage) plan SEPs.

Your Address Changes

Several relocation situations, including moving states, can trigger a SEP and allow you to make changes, including enrolling in a Medicare Advantage plan, Part D plan, or potentially, a Medicare supplement plan. In most cases, you have two months after the event to make changes or enroll.

Here are moves that could qualify you for a SEP.

• Moving to a new state or area: If your MA plan doesn’t offer services in your area or if it offers new plan options you prefer, you can choose a new MA plan or Part D plan. Or you can return to Original Medicare. 
• Moving back to the U.S. from abroad: You can join a MA plan or Part D plan during the two months after the month you return to the U.S. 
• Moving in or out of an institution: If you’ve just moved into or out of a nursing home or rehab hospital, you can join or switch MA plans, return to Original Medicare, or drop Medicare Part D.
• Being released from jail: You can join a MA or Part D plan for up to two full calendar months if you missed enrollment on or after Jan. 1, 2023.

You Lose Other Coverage

You could qualify for a special enrollment period if you lose employer-sponsored insurance or Medicaid coverage. Other reasons include: 

• Losing Medicaid eligibility: You can join or switch to another MA plan with drug coverage, return to Original Medicare, or drop your Medicare Part D within three months after losing your eligibility or being notified.
• Losing drug coverage: If you lose creditable drug coverage, you can switch to a MA or Part D plan. 
• Losing Extra Help: You have three months from the date you become no longer eligible for Extra Help, during which you can join, switch, or drop a Part D plan or a Medicare Advantage plan with drug coverage.

You Qualify for New Coverage

New coverage may qualify you for new plan options, including:

• Becoming eligible for Medicaid or Extra Help: For example, qualifying for Medicaid or being diagnosed with a chronic condition could allow you to enroll in a customized Special Needs Plan (SNP) via several more enrollment windows. If you qualify for Extra Help, you can also join, switch, or drop drug coverage. You can change plans during special periods throughout most of the year. 
• You develop a new severe or chronic health condition: If a C-SNP (Chronic Needs Special Needs Program, a type of Medicare Advantage plan) is available to you, you may be able to join that C-SNP.
• Employer or union coverage: You can drop your Medicare Advantage or drug plan to join employer or union coverage whenever they allow you to enroll.
• Other creditable drug coverage: You can drop your current Medicare Advantage with or without a drug plan or your Part D plan at any time if you enroll in other drug coverage, such as TRICARE or VA drug coverage. 

Your Plan Changes or Has Problems 

In some rare cases, your Medicare Advantage or Part D plan may face serious problems, which will allow you to change Medicare Advantage plans. These include: 

• Medicare takes official action regarding your plan: You can switch to a new one until the sanction is lifted or you change plans.
• The state takes over your plan due to financial issues: You can switch to another plan until the state’s involvement ends or enroll in a new one.
• Misrepresentation happened: If a plan representative provides you with misleading or incorrect information, you may be able to switch plans, return to Original Medicare, or drop your Part D coverage. 
• Medicare or your plan ends its contract: You can switch from a MA plan or drug plan to another plan two months before the contract ends and one month after. 
• Your plan’s contract hasn’t been renewed. You can switch your MA, Part D, or Medicare Cost Plan to another plan between Dec. 8 and the end of February the following year.  
• Your Medicare Advantage or Part D plan is performing poorly: If you’re in a plan that’s received less than three stars in the Medicare star rating system for the last three years, you can switch at any time. 

You Fall Into Another Special Category

Another half-dozen or so situations, including federal employee error or having incorrect information provided to you, could qualify you for a Medicare Advantage or Part D SEP. 

One of the more helpful SEP options is the ability to switch to a 5-star-rated MA or Part D plan during the 5-star special enrollment period. You can only use this SEP once between Dec. 8 and Nov. 30 of the following year, and only if you qualify for the MA plan. But if you do so, make sure you understand how your drug coverage would be affected. 

Frequently Asked Questions (FAQs)

The Bottom Line

Medicare special enrollment periods (SEPs) allow you to change your Medicare coverage outside regular enrollment periods. A SEP is triggered by specific life events, such as moving, losing other health coverage, or changes to your Medicare plan’s contract. 

Understanding the life events that qualify for a SEP and the timing for making changes ensures you can maintain or adjust your coverage as needed. Be sure to act within the time frames associated with your SEP to avoid gaps in your healthcare coverage.