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• • About the Part D Benefit
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  • Medicare Advantage
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Part D Special Enrollment Periods

In This Article:

SEPs for Low-Income Beneficiaries

• Dual and Extra Help SEPs
• SPAP SEP
• Full Dual Retroactive SE

SEPs to Remedy Erroneous Enrollment

• Part D SEPs to Remedy Erroneous Enrollment

SEPs Based on Residence

• Part D Relocation SEP
• Part D Institutionalized Individuals SEP

SEPs That Coordinate With Medicare Advantage Disenrollment

• Part D Enrollment With SEP 65
• Part D Enrollment With Trial Period SEP

          SEP to Coordinate with the Part B General Enrollment Period

• Part B GEP SEP

Part D and Low Income SEPs DuPart D and Low Income SEPsal and xtra Help  SEPs

Four Part D SEPs and three Medicare Advantage SEPs can be used by low-income Medicare beneficiaries who want to join, drop or switch to another Part D or Medicare Advantage plan. 

Part D Low-Income SEPs

What
The dual SEP can be used by anyone with Medicare who has any kind of Medicaid – whether it’s full Medicaid or simply enrollment in a Medicare Savings Program.  The Extra Help SEP is for people who applied and were found eligible by the Social Security Administration for Extra Help/Low-Income Subsidy (LIS). These SEPs allow your clients who are either dually entitled or who receive Extra Help because they applied and Social Security Administration found them eligible for it to enroll, disenroll or switch to another Part D plan at any time.  Enrollment in the new plan is effective as of the first day of the following month.

When
This dual SEP starts when someone becomes dually entitled and the Extra Help SEP starts as of the month someone is found eligible for Extra Help.  Both SEPs end  two months after the person loses Medicaid entitlement or Extra Help.

More Info from CMS

• Dual SEPs (Word document)
• LIS SEP (Word document)

SPAP SEP

What
This SEP may be used in the 23 states with  State Pharmaceutical Assistance Programs (SPAPs), by participants to enroll or switch to another Part D plan.

This SEP is intended to give new SPAP participants an opportunity to join or switch to another Part D plan when their SPAP enrollment takes effect. 

When
Beneficiaries may use this SEP once per calendar year whether or not they are new to their SPAP, with the new plan taking effect on the first day of the month following enrollment.  Once they make one election this SEP has been used up for the current calendar year.

More Info from CMS

• SPAP SEP (Word document)

Full Dual Retroactive SEP

What
This SEP is for people who had full Medicaid and then get Medicare (Parts A and B). 

As of the month they become entitled to Medicare, these new duals lose their Medicaid drug coverage because Medicaid is not allowed to cover drugs that Part D covers. In addition, Part D plan enrollment doesn’t take effect until the first day of the month following enrollment.

Without this SEP new duals who select and enroll in a Part D plan before CMS auto-enrolls them (called a “voluntary enrollment) would experience a gap between losing their Medicaid drug coverage and getting drug coverage through a Part D plan..   This SEP makes such voluntary enrollments retroactive to the first month people with full Medicaid became entitled to Medicare in order to avoid any months with no drug coverage.

When
Part D plans can make enrollments by people with full Medicaid who become eligible for Medicare retroactive to the first day of the month their Medicare went into effect.

More Info from CMS

• Full Dual Retro SEP (Word document)

Part D SEPs to Remedy Erroneous Enrollment

There are two SEPs that cover erroneous Part D plan enrollment and two similar SEPs that cover Medicare Advantage enrollment. MedicareAdvantageEnrollmentAndDisenrollment.php One SEP covers unintended enrollments and the other covers enrollments caused by the action or inaction of a federal employee. Additionally, we will look at how several of these SEPs may be used when your clients disenroll out of a plan instead of effecting disenrollment by enrolling in a new plan. CMS can “undo” a disenrollment so that the beneficiary can two of the Part D SEPs that can be used in conjunction with the Medicare Advantage SEPs that can be used by your clients who try Medicare Advantage for the first time.

Part D Plan Enrollment Not Legally Valid SEP

What
This SEP may be used when a Part D plan enrollment was not complete. An enrollment might not be complete, for example, if it was not signed by the beneficiary. One of the most notable examples of an incomplete and consequently invalid enrollment is one your client did not intend to make. For example, if your client thought she was buying a Medigap policy or enrolling in a Medicaid managed care plan with a similar name, she never had the intent to join the Part D plan. She should be able to use this SEP.

Generally this SEP involves a disenrollment from the plan into which the person was mistakenly enrolled and reenrollment back into the prior Part D plan. In order to prevent a gap in Part D coverage, the re-enrollment might be made retroactive by CMS when needed to place your client back in the situation she never intended to switch out of.

CMS also has the discretion to void a disenrollment so that a beneficiary can enroll into a new plan, thereby automatically disenrolling out of the previous plan. This can become important when your clients have only one election right during an enrollment period. If they use it to disenroll they would not be able to enroll in a new plan.

When
This SEP will usually involve CMS using its discretion to decide whether an enrollment is incomplete. The timing of the disenrollment and reenrollment will be determined by CMS. In general, once somebody establishes that the enrollment was not complete, including decisions that enrollments were not intended, CMS will time dis-enrollment and re-enrollment back to the prior plan so that the individual experiences no gap in art D coverage.

More Info from CMS

• Enrollment Not Legally Valid

Part D Federal Error SEP

What
Nobody is perfect -- federal employee error can cause a Part D plan enrollment that should not have happened. Federal errors might also prevent an intended enrollment into a Part D plan. CMS uses this SEP to CMS decide on a case-by-case basis whether or not to approve this SEP, which permits enrollment into or disenrollment from a PDP, depending on the circumstances and the scope of the SEP granted by CMS.

When
This SEP begins in the month CMS tells the individual the SEP has been granted and ends two months later.

More Info From CMS

• Fed Error SEP

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Part D SEPs Based on Residence

Part D Relocation SEP

What

This SEP is for Medicare beneficiaries who, as a result of a permanent move are no longer eligible to belong to their PDP, or even if they are still eligible to remain in the PDP, but will have new Medicare Advantage or Part D plan options available to them as a result of the move. Note that such new PDP or health plan options would most likely become available only upon moves to another state.

This SEP also is for beneficiaries who were not previously eligible for Part D, either because they permanently resided outside the U.S. and have relocated to a home within the U.S., or because they had been in prison and have been released from custody.

This SEP allows one PDP election and  once the election has been made, the SEP is over. This SEP may, or may not protect beneficiaries against the imposition of late enrollment penalty premiums.  Whether or not a late enrollment penalty is imposed depends upon whether or not beneficiaries were previously eligible for Part D and for those who were, depending upon whether or not they had other creditable drug coverage. Click here for more on creditable drug coverage.

When

Generally Part D plan members are responsible for notifying the current Part D plan about a permanent move.  Upon such notification, the SEP begins the month before the move and continues until two months after the move.  Upon selecting a new plan, the beneficiary can choose an effective date of up to three months after the month the enrollment was submitted.    

            Examples:

Mrs. J. is moving from New Jersey to Utah.  In May 2008 she notifies her New Jersey PDP that she will be moving on July 6, 2008.  She also researches her options, picks a Utah PDP and designates July as the month she wants the Utah PDP to make her plan enrollment effective. She should receive her new plan enrollment materials, including her membership card, before July 1st.  Remember that she will be able to get transition fills if she needs these once she arrives in Utah in July.

If Mrs. J was relocating from Massachusetts to New Hampshire then new plan options would become available to her. She could decide to use this SEP to enroll in a new plan, even if her old plan would still be available to her. 

For expatriates returning to the U.S. and newly released ex-inmates, the Part D plan election may be made the month before the beneficiary will be residing in a Part D plan area so that the plan enrollment can take effect in the first month the beneficiary is eligible for the Part D plan

Examples:

Mr. K. has lived in Ireland for the past 2 years, but is relocating to Iowa in August 2008. He may enroll in the Part D plan of his choice in July 2008, and he may designate August 2008 as the month he wishes the plan to become effective. 

Ms. B. was released from prison on April 2, 2008, but knew nothing about Part D.  Her change-of-residence SEP extends two months beyond the month of her release, or through June 2008.

What would happen if beneficiaries such as Mrs. J in the example above did not notify her current plan about her move in advance?  If she moved outside of the area served by her Part D plan, the plan is required to involuntarily disenroll her once she has been permanently residing elsewhere and gone from her previous home for 6 months.   The plan would likely learn of the relocation either from the Postal Service, due to returned mail, or from CMS if a beneficiary succeeded in enrolling in a PDP in her new home. The plan must notify beneficiaries about involuntary disenrollments, but note that the plan may not have access to a current address. The SEP begins in the 6th month, when the prior plan disenrolls the beneficiary and lasts through the 8th month following the move.

More info from CMS

• Part D Relocation SEP

Part D Institutionalized Individuals SEP

What

This SEP allows beneficiaries who move into, reside in, or are discharged from certain long term care facilities to join or disenroll out of a PDP.  Specifically, this SEP can be used by people in nursing homes, psychiatric hospitals, rehabilitation hospitals, long term hospitals and swing beds (that hospitals can use as either acute care or skilled nursing beds for Medicare billing purposes).

When

This SEP begins in the month of admission and continues for up to two months following discharge. 

More Info from CMS

• Part D Institutionalized Individuals SEP

SEPs That Coordinate With Medicare Advantage Disenrollment

SEP 65 Part D SEP

What

This SEP is for people who elect a Medicare Advantage plan immediately upon becoming entitled to Medicare at age 65. It’s important to note that this includes people who had Medicare prior to age 65 (due to receipt of Social Security disability benefits); when they turn 65 they have the same rights as people who are new to Medicare at age 65. This SEP can be used to join a PDP which would automatically disenroll them from the MA-PD they joined when they turned 65.

When

This SEP is available at any time during the first calendar year that follows the month in which the Medicare Advantage plan enrollment was effected at age 65. Generally, Original Medicare and the PDP enrollment take effect as of the first day of the month of the moth after the SEP was used.

Note: When your clients use SEP 65 they should also consider supplementing Medicare, either by applying for the Qualified Medicare Beneficiary Program (QMB) if they are eligible, or by purchasing a Medigap policy.  They have a right guaranteed by federal law to purchase any Medigap policy, since this SEP has the effect of extending their Medigap Open Enrollment Period.

More Info from CMS

Medicare Advantage Trial Period SEP

What

This SEP is for people who join a Medicare Advantage plan for the first time after age 65. They are allowed to disenroll from the Medicare Advantage plan to return to Original Medicare. If they were in a MA-PD they must join a PDP and by joining the PDP they will automatically be disenrolled from the MA-PD.   

When

This SEP must be used at any time within the first calendar year after they joined the Medicare Advantage plan. Original Medicare and the PDP enrollment if applicable take effect on the first day of the month following the month in which the SEP was used.

Note: Your clients who use SEP 65 should also consider supplementing Medicare, either by applying for the Qualified Medicare Beneficiary Program (QMB) if they are eligible, or by purchasing a Medigap policy.  They have a right guaranteed by federal law to purchase any Medigap policy, since this SEP has the effect of extending their Medigap Open Enrollment Period.

More Info from CMS

SEP to Coordinate with the Part B General Enrollment Period

Part B General Enrollment Period SEP (GEP SEP)

 

What

Every year, from the beginning of January through the end of March, there is a Medicare General Enrollment Period (GEP) during which people who did not enroll in Medicare Part B when they were first eligible to do so can go to their Social Security Administration office to enroll in Medicare Part B.  Their Part B enrollment becomes effective in July. This Part D SEP is tied to the GEP.

 

Certain individuals who enrolled in Part B during a GEP for Part B between January and March can use this Part D SEP to select a Part D plan. People who got Part A automatically because they had a sufficient work history, however, cannot use this SEP.  It is only for people who must pay for their Part A, due to a lack of sufficient work quarters.

 

When

The SEP begins April 1st and ends June 30th.  The Part D plan into which someone using this SEP enrolls this SEP becomes effective on July 1st to coincide with the start of their Part B coverage.

 

More Info from CMS

 

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