What is the Medicare special enrollment period?

Medicare Advantage plans, also known as Medicare Part C, are private health plans that cover the same services as Original Medicare in addition to services and items that Original Medicare does not normally cover. While you can enroll in a Medicare Advantage plan upon becoming eligible for Medicare, there are limitations on how often you can join, change, or leave a Medicare Advantage plan. Here is how the Medicare Advantage special enrollment period works and which circumstances and life events are eligible.

The Medicare special enrollment period allows you to make changes to Medicare drug coverage and Medicare Advantage plans when certain events occur. Moving is one of the most common triggers for a Medicare Advantage special enrollment period, but there are several other situations that qualify.

When these situations occur, the special enrollment period allows you to enroll in or switch Medicare plans without being penalized. You also don’t have to wait for the next open enrollment period if a special enrollment period applies.

What life events qualify for a Medicare special enrollment period?

Eligible life events for a Medicare Advantage special enrollment period include, but are not limited to, the following:

Moving

If you move and your new residence isn’t in your current plan’s service area, you can change your coverage without penalty. Even if your new residence is still in the plan’s service area, you can also qualify for a special enrollment period if there are new plan options available upon moving.

Moving in or out of a skilled nursing facility or assisted living community also counts for a special enrollment period if your new residence is out of your current plan’s service area or new plan options become available.

Losing Current Health Coverage

If you had Medicaid and lost your eligibility, you have three months from your ineligibility date to enroll in Original Medicare or a Medicare Advantage plan.

For all other losses of existing health coverage, including termination from employer, union, or COBRA coverage, you have two months from your termination date to choose a Medicare Advantage plan or enroll in Original Medicare.

Current Plan Changes Its Contract with Medicare

If Medicare terminates your current plan’s contract, you can change to another Medicare Advantage plan two months before, and up to one full month after, the contract ends. However, if Medicare sanctions your plan and you are affected by it, your ability to switch is decided by Medicare on a case-by-case basis.

If your Medicare Advantage plan contract isn’t renewed, you have from December 8 to the last day of February to enroll in a different Medicare Advantage plan.

Dual Eligibility and Navigating Coverage

There are several different federal, state, and private supplemental coverage programs such as Medigap, Medicaid, State Pharmaceutical Assistance Program (SPAP), Extra Help, and Medicare Chronic Care Special Needs Plan (SNP). Since eligibility for these programs can quickly change, enrollment or losing eligibility can trigger a special enrollment period.

If you are eligible for both Medicaid and Original Medicare, there are three periods throughout the year that you can opt for Original Medicare or a Medicare Advantage plan over Medicaid. January-March, April-June and July-September are the windows in which you can change your coverage; and it will take effect the first day of the following month. If you miss the September 30 cutoff, you would need a different eligibility factor, such as moving, to change your coverage without waiting until January.

If you are enrolled in a SPAP, you can enroll in a Medicare Advantage plan with drug coverage once during the calendar year. However, if you lose your eligibility for SPAP, you can switch the earlier of the month you’re notified you lost eligibility or the date you actually became ineligible. You have until two months after the later of these two dates.

Enrollment in SNP can be done at any time provided that you have a condition severe enough to qualify. Once you join the SNP, you cannot make any more changes during the special enrollment period created.

5-Star Medicare Advantage Plans

 If a Medicare Advantage plan, Medicare drug plan or Medicare Cost plan receives a 5-star rating and becomes available in your area, the Medicare Advantage 5-star special enrollment period kicks in. If you are not already on a 5-star plan, you can only switch to one if it becomes available in your area. Not all 5-star plans have prescription drug coverage, so there may be a Part D late enrollment penalty if a standalone drug plan is not purchased.

This special enrollment period is only allowed once between December 8 of the current year and November 30 of the following year.

Why special enrollment periods matter to you

Special enrollment periods only come up in very specific circumstances, such as moving or experiencing changes to your existing coverage. Not all Medicare Advantage special enrollment periods are the same. Many only allow you up to two months to make changes to your coverage while other special enrollment periods are more lenient. Since many special enrollment periods occur as a result of circumstances beyond your control, such as Medicare canceling contracts or issuing sanctions, it is crucial to learn the difference between the different types and timelines of special enrollment periods and how to determine a qualifying event.

For more information on special enrollment periods for Medicare Advantage plans, or to learn about Baylor Scott & White Health Plan Medicare Advantage plans, call 1.800.782.5068 (TTY: 711).