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| Medicare Part D Special Enrollment Periods (SEP)
Publish On 2008-03-29 , 6:17 AM
In certain situations, people with Medicare may be eligible for a Special Enrollment Period (SEP) to join a plan that provides Medicare prescription drug coverage, or switch to a different plan. A Special Enrollment Period is a period of time when an individual can enroll in or switch plans outside of the annual enrollment period (the next AEP is October 15th through December 7th). The chart below describes the different situations in which an individual may be eligible for a Special Enrollment Period. [Updated August 2012]
| 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 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. |
| 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. |
| |
| | Comment
| | 1. | I have had Medicare part A since age 65. I was employed and had creditable health and medicine coverage through my employer until July 30, 2010. I applied for and received part B, effective August, 2010. How long can I wait to apply for Part D, before I will be faced with a penalty? I am unable to find the clear answer to this question. Thanks.
- by D. Sherrill, 2010-08-19, 12:00 AM
| | 2. | My wife and I had Medicare part A for many years already. I am now 78 years old, and my wife is 76. However, since I was employed and we both had creditable health and medicine coverage through my employer only until June 30, 2010, I applied for and received part B, effective May, 2010.
How long can I wait to apply for Part D, before I will be faced with a penalty?
- by Ervin Y. Rodin, 2010-07-05, 11:44 AM
| | 3. | i just retired and I have employer group coverage through June 30 2010. My Medicare part B and Medigap policies start July 1, 2010. How long do I have before I have to decide on a part D plan before penalty sets in?
- by AK, 2010-05-13, 1:43 PM
| | 4. | My wife and switched Medicare Advantage plans because our previous company was terminating the program where we live. We signed up for the program including drug coverage but I discovered in January that the company had my wife on the drug program but not me for some reason. Since I didn't catch the error when they sent us our material, they told me I would have to now do that and is this something that would qualify for a SEP?
[Online Editorial Team Note]
Yes. The Centers for Medicare and Medicaid Services (CMS) extended the December 31, 2009 Annual Enrollment Period deadline for people who were previously enrolled in a now-discontinued Medicare plan until February 28, 2010.
For example, if you were enrolled in a 2009 Medicare Part D plan or Medicare Advantage plan and that 2009 plan is not being offered in 2010, you will be granted additional time to enroll into a 2010 Medicare Part D or Medicare Advantage plan that includes prescription drug coverage (MA-PD). CMS should have mailed a notice of this enrollment extension to all people who were enrolled in a 2009 Medicare plan that was not re-newed in 2010.
- by Ken, 2010-01-16, 12:00 AM
| | 5. | I am a veteran, will this cover my prescriptions from the VA medical center?
[Online Editorial Team Note]
No. Medicare Part D prescriptions drug plans work independently to your VA prescription drug benefits - so you would not use your Medicare Part D plan at the VA Medicare Center.
You would simply use your VA benefits.
If you have VA benefits, the prescription drug coverage is considered "creditable" and you do not need to purchase a Medicare Part D plan if you find that all of your medications covered by your VA benefits.
However, you may find that a Medicare Part D plan may cover additional medications or provide more convenient / affordable prescription coverage - so you are able to also join a Medicare Part D plan if you so choose. Your Medicare Part D plan can be used to purchase some medications and your VA benefits can be used for other medications. This is one of the rare cases where your two types of prescription coverage actually can work together.
- by Martha, 2009-09-10, 12:00 AM
| | 6. | when I went to apply for medicare they would not let me enroll but said I had to wait until next january. I just returned from the middle east where I lived for 10 years. I have depleted my savings drastically because I have had to have one procedure after another and cannot cover them with any insurance, and also I have a lot of medications that are also depleting my savings. I have almost none left. I am 69 years old. I did not find the people in the social security office sympathetic or friendly or even helpful in recommending what to do next. I have been on social security, but no one advised me that I could have enrolled automatically at age 65, and I did not get the information sent to me either. I have to have a root canal on tuesday and pay up front 1200 before I can get a treatment. what am I supposed to do?
[Online Editorial Team Note]
You should have been granted a Special Enrollment Period and allowed to join a Medicare Part D plan when you moved into your new Medicare Part D region.
If you are finding that your finances are depleted, you can contact either the Social Security Administration or your state Medicaid office and ask for more information about the Medicare Part D "Extra Help" program. This program was established to assist people with paying for their Medicare Part D prescription drug coverage.
As to the dental work, usually expensive dental work is not covered by a Medicare plan and Dental insurance usually does not cover pre-existing conditions - as probably is true in your case. Some Medicare Advantage plans include limited dental coverage, however expensive procedures are usually not covered.
- by Raymond, 2009-08-09, 12:00 AM
| | 7. | We were forced to join the Medicare family on March 1,2009 because of loss of job. We had company insurance until February 28,2009. We are both 66 yrs old. We are having continued problems with the Part D monthly premium. They are accessing both of us late enrollment fees as well as additional late charges. We have called them, wrote them, sent them an appeal letter. I will not pay additional fees because I have proof of insurance until February 28th until my husband was laid off. Does anyone else have any other suggestions regarding similar situations? Life is stressful enough without additional help from Government intervention.
- by Barbara, 2009-05-12, 12:00 AM
| | 8. | I receve medicare part A and B and I would like to enrole in medicare part B. I am disabled and receive disability of $645. per month. I live in Virginia. Could you please tell me how to enroll. I was never given the option when I became disabled. Thank you M.M. B.
- by margaret, 2009-04-19, 7:01 AM
| | 9. | I qualified for help with drugs from five individual Patient Assistance Programs %28sponsored by Big Drug Companies%29, therefore I did not sign up for any Medicare Part D drug plan. On January 1, 2009, these companies discontinued any assistance to me and will no longer include me in their Patient Assistance Programs. They say I am no longer eligible for any free medication from them. Because of this, I have missed the open enrollment eligibility period that closed on December 31, 2008. Can I qualify for a one-time Special Enrollment Period, so I can make arrangements to be included in a Medicare Part D Program?
- by Lenore , 2009-01-18, 1:46 AM
| | 10. | I have a patient who started dialysis three and a half months ago. He is 78. He has a drug discount card and thought that it was sufficient to cover his drugs. He did not consider a Medicare drug plan because he thought what he had was OK. With all the drugs for dialysis he is drowning in the copays. His income is only $1400.00 a month but this overqualifies him for Medical Assistance. When I called Social Security, they said he could not enroll til 11/15/09. Help!
- by RoxAnna Anthony, 2009-01-12, 8:39 AM
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