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Special Enrollment Periods
Article Abstract
For the rest of 2008, most people with Medicare are allowed to join or switch Part D plans or Medicare Advantage plans only if they have a Special Enrollment Period (SEP).
So with that in mind, it’s time to review the most commonly used SEPs.
In This Article:
- Medicare Advantage SEPs for Low-Income Beneficiaries
- Medicare Advantage SEPs to Remedy Erroneous Enrollments
- Medicare Advantage SEPs Based on Residence
- Medicare Advantage SEPs That Coordinate With Part D
Medicare Advantage SEPs for Low-Income Beneficiaries
Dual and Extra Help SEP
What
The dual SEP can be used by anyone with Medicare who has any kind of Medicaid, including full Medicaid, Medicaid Savings Programs, Medicaid waiver programs and Medicaid surplus income entitlement. The Extra Help SEP is for people who applied and were found eligible for Extra Help. Both of these SEPs allow people who are dually entitled or who get Extra Help to enroll, disenroll or switch to another Medicare Advantage plan at any time, with the new plan becoming effective as of the first day of the following month. Remember that duals are not allowed to join Medicare Savings Account plans (MSAs).When
These SEPs start when an individual becomes dually entitled or is found eligible for Extra Help by Social Security Administration and ends two months after the person loses Medicaid entitlement or Extra Help.More Info from CMS
- MA Dual SEP (Word document)
- MA LIS SEP (Word document)
SPAP SEP
What
This SEP may be used in the states with State Pharmaceutical Assistance Programs (SPAPs) by participants to enroll or switch to another Part D plan.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. They may join a Part D plan for the first time, switch from an MA-PD to a PDP, from a PDP to an MA-PD, or from an MA-Only plan to an MA-PD.
Once they make one election this SEP has been used up for the current calendar year. This SEP was intended to give new SPAP participants an opportunity to join or switch to another Part D plan when their SPAP enrollment takes effect.
When
This SEP may use this SEP once per calendar year, with the new plan taking effect on the first day of the month following enrollment.More Info from CMS
Medicare Advantage SEPs to Remedy Erroneous Enrollments
Two Special Enrollment Periods (SEPs) might help some of your clients deal with erroneous Medicare Advantage enrollment. (Two similar SEPs cover Part D plan enrollment.) One of these SEPs covers incomplete and unintended enrollments; the other covers enrollments caused by the action, inaction or error of a federal employee.
These SEPs can be used by your clients to disenroll out of a plan they never wanted to be in, to undo a disenrollment action that kept your clients from enrolling in a plan (so that an enrollment period election can to be used to join a plan), and even to secure retroactive enrollment into another plan. Usually this would mean reenrollment into the plan your client was in before the unintended or erroneous enrollment.
Medicare Advantage Enrollment Not Legally Valid
What
This SEP may be used when a Medicare Advantage 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 Medicare Advantage 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.More Info from CMS
Medicare Advantage 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 decides on a case-by-case basis whether or not to approve this SEP, which permits enrollment into or disenrollment from a PDP.When
This SEP begins in the month CMS tells a beneficiary the SEP has been granted and ends two months later. It allows that person to enroll or disenroll from a Prescription Drug Plan.More Info From CMS
Medicare Advantage SEPs Based on Residence
Medicare Advantage 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.
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 MA-PD 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 Medicare Advantage or PDP plan, even if her old Medicare Advantage plan was a Regional MA-PD and would still be available to her.
Note that since Mrs. J had been in an MA-PD prior to her move she must elect an MA-PD or a PDP in her new home state. This SEP does not allow her to change her Part D status by either picking up or completely dropping out of Part D.
What would happen if beneficiaries such as Mrs. J in the example above did not notify her current MA-PD plan about her move in advance? If she moved outside of the area served by her MA-PD 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 plan following her move. 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
Open Enrollment Period for Institutionalized Individuals
What
The Medicare Advantage Open Enrollment Period (or OEPI) that allows nursing home residents and others residing in residential long term care facilities to enroll or switch Medicare Advantage plans is similar to the PDP SEP for institutionalized beneficiaries.
The OEPI allows beneficiaries with Medicare Parts A and B who move into, reside in, or are discharged from certain long term care facilities to join or disenroll out of a Medicare Advantage plan. People eligible for the OEPI may join a Medicare Advantage plan, switch to a different Medicare Advantage plan or disenroll out of Medicare Advantage and go to Original Medicare. They are not allowed to change their Part D status using the OEPI. If they previously had Part D D they must join an MA-PD or a PDP and if they did not previously have Part D they are not allowed to join an MA-PD Or a PDP by use of the OPEPI.
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).The OEPI also is applicable to individuals who are admitted to a nursing facility in which they can join a Special Needs Plan (SNP) for institutionalized individuals. The SEP may be used to enroll or disenroll from an applicable institutional SNP.
When
This SEP begins in the month of admission and continues for up to two months following discharge. Unlike the PDP SEP for institutionalized persons, the OEPI may be used repeatedly to switch plans as frequently as monthly (although this would not be a recommended practice)
More Info from CMS
Medicare Advantage SEPs That Coordinate With Part D
SEP 65
What
This SEP allows people who join a Medicare Advantage plan during their Medicare Initial Enrollment Period at age 65 to disenroll to Original Medicare. If they join an MA-PD they may exercise this SEP by enrolling in a PDP. The PDP enrollment automatically effects the disenrollment from the MA-PD. Younger people who have Medicare due to a disability also get a Medicare Initial Enrollment Period when they turn 65 and may join a Medicare Advantage plan at that time. They may use this SEP to get out of the Medicare Advantage plan.
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.
When
This SEP may be used at any time within the first calendar year after joining a Medicare Advantage plan at age 65. 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.
Medicare Advantage Trial Period Part D SEP
What
This SEP is for people who join a Medicare Advantage plan for the first time after age 65. The SEP is only for people who had a Medigap policy before they enrolled to try out Medicare Advantage. 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. This SEP allows them to join a PDP.
When
This SEP may only be used 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 the trial period SEP have a right guaranteed by federal law to get back the Medigap policy they had before they tried Medicare Advantage for the first time. If that Medigap plan is no longer for sale they are allowed to buy any Medigap plan A,B, C, F, K, or L that is for sale in their state.
