Like any other health insurance plan in the U.S., Medicare has fixed enrollment periods (called Annual Enrollment Periods or AEP) where you can enroll and disenroll in plans. Special Enrollment Periods (SEPs) allow you to switch your Medicare plan outside of the standard AEP.
SEPs are the only available time windows during which Medicare recipients can make urgent changes to their coverage plans. This makes it crucial to understand how SEPs are triggered and how you can apply for changes during them.
What are Special Enrollment Periods?
Special Enrollment Periods are designated intervals when individuals can enroll in or change their health insurance coverage outside the regular open enrollment period. The need for SEPs is typically triggered by specific life events, such as getting married, having a baby, losing other health coverage, or moving to a new location.
SEPs are windows that allow individuals to enroll in a health insurance plan, switch to a different one that better meets their needs. In the context of Medicare, an SEP simply allows individuals to change their Medicare plans to better fit their changed living conditions or other major life changes.
SEPs are designed to provide flexibility and ensure that individuals retain access to health insurance through major life events that impact their coverage needs. SEPs typically happen once every year, allowing beneficiaries to make much-needed adjustments to their coverage outside the usual open enrollment period.
Qualifying life events
SEPs can become necessary because of several qualifying life events. They include:
- Getting married, divorced, or legally separated (which results in you leaving employer-provided insurance when you are over 65).
- Losing existing health coverage due to job loss, aging off of a parent’s plan, or expiration of COBRA coverage.
- Changing residence or moving to a new location that is not within the coverage area of the current plan.
- Gaining citizenship or lawful residential status in the country.
- Dropping a Medigap policy to engage in Medicare Advantage for the first time. One has a 12 month SEP to disenroll and return to the original plan.
Different types of SEPs
The type of Special Enrollment Period depends largely on the reason that makes it necessary. Some of those reasons are:
- Medicaid eligibility: If an individual becomes eligible for Medicaid, they may qualify for a SEP to enroll in a health insurance plan.
- Errors or misconduct: If an error or misconduct affects an individual’s ability to enroll in or change their coverage during the initial enrollment period, a SEP may be granted to rectify the situation.
- Other exceptional circumstances: Some health insurance programs and marketplaces provide additional SEPs based on exceptional circumstances such as natural disasters, public health emergencies, or other significant events that impact access to healthcare coverage.
Who is eligible for a SEP?
Here are some common scenarios that may lead to an individual qualifying for a SEP:
Moving to a new location
This involves an individual moving to a new area that is not within the coverage area of their current health insurance plan. In such cases, they may be eligible for a SEP to enroll in a plan that serves their new location.
A change of address that qualifies for a SEP can also be a result of:
- Moving back to the US after living abroad.
- Moving in, being admitted to, or moving out of a facility such as a nursing home or long-term care institution.
- Getting out of jail after a period of incarceration.
Losing current coverage
If an individual loses their existing health coverage due to factors such as job loss, aging off a parent’s plan, expiration of COBRA coverage, or the discontinuation of a qualified health plan, they may qualify for a SEP to enroll in a new plan.
A few other circumstances that amount to losing current coverage include:
- The ending of employer or union health insurance coverage.
- Losing creditable prescription drug coverage or change in coverage.
- Dropping out of coverage under a Program of All-Inclusive Care for the Elderly (PACE) plan.
Gaining or losing Medicaid eligibility
If an individual becomes newly eligible for Medicaid or CHIP or loses their eligibility for these programs, they may be eligible for a SEP to enroll in a health insurance plan.
Additional scenarios that qualify individuals for a SEP include:
- Getting married, divorced, or legally separated.
- Gaining citizenship or legal residency in the country.
- Experiencing exceptional circumstances like natural disasters or public health emergencies.
Please remember that SEP eligibility can be subjective, depending on applicable rules and circumstances. You should consult the Medicare program guidelines or contact a healthcare professional, Social Security office, or insurance representative to understand the specific SEPs available to you.
How do SEPs Work?
Understanding how SEPs work involves consideration of their timing and duration, the process of enrollment during a SEP, and the potential penalties for failing to enroll during a SEP. Let’s discuss these aspects one by one.
Timing and duration of SEPs
The timing and duration of SEPs can vary depending on the particular health insurance program or marketplace covering an individual. As we’ve mentioned before, the need for SEPs is occasioned by specific life events or circumstances that affect a person’s health insurance coverage. Most SEPs typically kick in at the time of the qualifying event and last for up to 60 days.
However, the duration of a SEP can extend over several months in some cases, depending on the specific reason for it and the policies set by the health insurance program concerned. Make sure to read up on the specific timeframes associated with each qualifying event to ensure timely enrollment or changes to health insurance coverage.
How to enroll during a SEP
To join, change, or leave a Medicare plan during a SEP, you need to take the following steps:
- Identify the qualifying event: Determine the specific qualifying event that makes you eligible for a SEP. As indicated above, examples include getting married, losing other health coverage, or moving to a new location. If you fulfill any of the Medicare SEP eligibility criteria, you can consult your local social security office or a registered Medicare broker to confirm your eligibility.
- Gather documentation: Collect all necessary documentation or proof of the qualifying event. That may include marriage certificates, birth certificates, proof of loss of coverage, or proof of new address.
- Contact an expert: Reach out to an independent insurance agent who represents the plans you want to enroll in or change your coverage to. Typically, you can do this through their website, by phone, or in person. Trusted organizations like CoverRight act as a comprehensive one stop shop for all your Medicare needs, assisting you throughout the process from determining your Medicare eligibility to applying for a change during and SEP.
- Provide required information: Be prepared to provide all necessary information including personal details, documentation of the qualifying event, and any other information requested.
- Enroll or make changes: Follow the instructions the health insurance program or marketplace provides to enroll in or change your health insurance coverage. This may involve selecting a new plan, updating personal information, adding or deleting dependents, or making changes to existing coverage.
Potential penalties for not enrolling during a SEP
Failure to enroll in or change Medicare when you are eligible can result in potential penalties or delays in obtaining coverage. Such penalties and delays vary depending on the health insurance program under which an individual is covered.
Here are some potential penalties to consider:
- Late enrollment penalty: If you are eligible for a SEP but do not enroll during the designated time frame, you can face a late enrollment penalty. This penalty is often associated with Medicare Part B and Part D and certain private health insurance plans. The late enrollment penalty can result in higher monthly premiums for the remainder of your coverage.
- Coverage gaps: By not enrolling during a SEP may leave you exposed to gaps in health insurance coverage. In case that happens, you will not have access to insurance benefits and may have to pay out-of-pocket for healthcare services during the period without coverage. Coverage gaps can lead to severe financial strain and limit access to much-needed medical care.
- Limited enrollment opportunities: Not taking advantage of a SEP when eligible may result in having to wait until the next available SEP to enroll or make changes to your health insurance coverage.
If you happen to miss multiple SEPs, it can leave you without coverage for an extended period. Having limited enrollment opportunities can significantly impact your ability to receive timely healthcare services and protect yourself from huge medical bills.
Frequently asked questions about SEPs
Can I change my Medicare plan during a SEP?
Yes, you can change your Medicare plan during certain SEPs. If you have Original Medicare (Part A for Hospital Insurance and Part B for Medical Insurance ), you can switch to a Part C or Medicare Advantage plan or vice versa. You can also change your Medicare Advantage plan during certain SEPs.
What documents do I need to provide to enroll in Medicare during a SEP?
The documents required to enroll in Medicare during a SEP can vary depending on the specific qualifying event or circumstance. First, you’ll likely have to provide documentation or proof of the qualifying event. Examples of other documents you may need include birth certificates, marriage certificates, proof of loss of other health coverage, proof of address change, or proof of gaining or losing Medicaid or other healthcare coverage.
Can I enroll in Medicare Advantage during a SEP?
You can enroll in a Medicare Advantage (Part C) plan during certain SEPs. If you are eligible for a SEP due to a qualifying event such as moving to a new location or losing other health coverage, you’ll have the opportunity to enroll in a Medicare Advantage plan.