More About Special Enrollment Periods

Q: I didn’t change my insurance coverage earlier this year, but now I want to. Do I have any options open to me?

A: (Remember, this is a continuation of last time’s question.) Enrollment Periods are the timeframes during which you are allowed to enroll in something. For the purposes of this discussion, I am sticking with Medicare Part D because that is what you asked about. There are different Special Enrollment Periods (SEPs) for Medicare Part D, Medicare Advantage Plans and Medicare Part B.

There are at least 16 different qualifying situations that enable you to have a Special Enrollment Period. I will use this week’s article to cover the second half of the 16 SEPs.

1. You have creditable drug coverage or lose creditable coverage through no fault of your own.

2. You choose to change employer/union coverage (through either current or past employment).

3. You are institutionalized.

4. You are enrolled in a State Pharmaceutical Assistance Program (EPIC for New York, PACE for Pennsylvania).

5. You have Medicaid, Medicare Savings Program, Supplemental Security Income or Low Income Subsidy (Extra Help).

6. You want to disenroll from a Medicare Private Health Plan with drug coverage (HMO & PPO).

7. You enroll in or disenroll from PACE.

8. You permanently change your home address.

9. You have had Medicare eligibility issues.

10. You are eligible for a Special Needs Plan (SNP).

11. You experience contract violations or enrollment errors.

12. Your plan no longer offers Medicare Drug Coverage.

13. You disenroll from your Medicare Advantage plan during the Medicare Advantage Disenrollment Period.

14. You qualify for a new Part D initial enrollment period because you are turning 65.

15. You want to enroll in a five-star Medicare Advantage or Part D plan.

16. You experience an “exceptional circumstance.”

9. An individual may have Medicare eligibility issues because they may not have joined when they were first eligible, or they were out of the country. Your enrollment may be an issue because you received retroactive enrollment. Another situation is that you are not eligible for premium free Medicare Part A and are joining Part B later. Your enrollment period for Medicare Part D begins when you are notified you are eligible for Part A and B and continues for two months. If you are joining Medicare Part B during January to March, and Part B will begin July 1, then you are eligible for Medicare Part D enrollment April 1 to June 30. This SEP also applies to those individuals who have lost Part B for some reason and therefore involuntarily disenrolled from your Medicare Advantage Plan. When you learn of your disenrollment you have a two-month SEP to enroll in a Stand Alone Drug plan. This is a SEP that is not very common either.

10. This SEP involves joining or losing a Special Needs Plan (SNP). A SNP plan is a health plan that requires a particular diagnosis or chronic condition. If you become eligible for this SNP because of a change in your health status, you have a SEP to join that SNP. If you develop another chronic condition, you will get another SEP to join a different SNP plan. If you join a SNP plan and it is later determined you do not qualify for that plan, (you don’t have the required diagnosis or illness), you have an SEP to enroll in an alternative Medicare Part D plan. There are not a lot of individuals who are currently enrolled in SNPs in our area, so you may not be aware of the types of plans available.

11. This SEP has a number of different conditions for you to qualify. You could qualify for this SEP if your Medicare Part D plan did not provide you with benefits promised or required by Medicare rules. You could qualify if you feel you were misled in joining a Medicare Advantage plan. You could qualify if you feel a federal employee made a mistake in your enrollment or disenrollment process. You could qualify for this SEP if CMS sanctions a plan, or determines a plan is not creditable and all enrollees are disenrolled from the plan. This is an SEP that we have helped seniors with, particularly those seniors who have joined a Medicare Advantage Plan and did not understand what they were joining and therefore want out. We have also seen plans sanctioned by Medicare, but currently I do not know of any plans meeting this part of the criteria with CMS in our region.

12. If your plan no longer offers Medicare Part D, you must switch plans. This usually happens during the annual open enrollment. Some of you have already had this happen. You were in a plan that chose to not offer its coverage for the next year, and you were required to switch. It can happen at other times of the year, but it has not in our region. If your plan terminates its coverage or CMS decides to terminate their contract, the plan must give you notice (between 30 to 90 days depending on the circumstances) and you have two months after that notice to switch to a new plan. If it is an immediate termination, CMS will help you to find a new plan mid month. This has not happened that I am aware of with Medicare Part D.

13. This SEP actually just ended on Feb. 15. This is a new SEP which allows you to disenroll from a Medicare Advantage plan with drug coverage and go back to Original Medicare with a Stand-Alone Drug plan. This SEP runs from Jan. 1 to Feb. 14 each year. Your new plan begins the first of the following month.

14. This SEP applies to those individuals who received Medicare benefits prior to age 65. Once the individual reaches age 65, they have their “initial enrollment period” (IEP) lasting for seven months, the three months before, the month of your 65th birthday and three months after. This IEP also erases all previous premium penalties for late enrollment into Part B or Part D benefits.

15. This SEP runs all year long and allows anyone in any type of plan to switch into a five-star Medicare Part D or Medicare Advantage Plan. Each year Medicare announces the five-star plans in each region of the country. Currently our region has one five-star plan – BlueCross BlueShield Rx PDP. This is a stand-alone drug plan, so it would be paired with Original Medicare coverage for most individuals. This is a SEP that applies to everyone and could be used to get you out of a plan that isn’t working for you.

16. If you experience an “exceptional circumstance,” Medicare can grant you a SEP based on your particular case. I have talked with individuals who I do not feel qualify for one of the previous 15 SEPs, but instead of telling them there is nothing that can be done, I redirect them to CMS staff. It is my opinion that everyone should have the right to plead their case as to why they feel they qualify for a Special Enrollment Period. This is the SEP that allows you to do just that.

For most of these SEPs you must work with Medicare staff to help determine if you qualify and when your SEP begins and ends. I have provided this list as a guide to those who feel they want to switch outside of the normal annual enrollment periods available. Most of these SEPs are special exceptions, special circumstances that don’t apply to everyone. The one SEP that anyone can use is No. 15, joining a five-star Medicare Plan. Remember, CMS staff is there to help you with questions and concerns. You can call 1-800-medicare or the Medicare Rights Center at 1-800-333-4114 to get help with any of these issues and much more.