By Maura O’Toole
BALDWINSVILLE – Suppose you are enrolled in Medicare Advantage or Medicare Part-D. In that case, you may qualify for a Special Enrollment Period (SEP) when certain events happen that require a change in Medicare coverage. There was some confusion during 2020 concerning the Covid-19 pandemic and SEP’s, and in addition to reviewing general SEPs, we will address that issue as well. In most cases, when you qualify for a SEP, it is for something routine like you moved out of a plan’s service area or lost other health care coverage. However, there are a host of other SEPs, some very clearly defined and others that are less clearly defined, which allow for flexibility for unique circumstances.
The rules about when you can make changes and the type of changes you can make are different for each SEP. The following are some of the most common reasons for SEP’s:
You changed where you live:
- You moved to a new address, not in your plan’s service area
- You moved to a new address that’s still in your plan’s service area, but you have new plan options in your new location
- You moved back to the US after living outside the country
- You just moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital)
- You were just released from jail.
You lost your current coverage:
- You are longer eligible for Medicaid
- You left coverage from an employer or union (including COBRA coverage)
- You involuntarily lost other creditable drug coverage or their other drug coverage changes and is no longer creditable
- You had drug coverage through a Medicare Cost Plan and left the plan
- You dropped their Program of All-inclusive Care for the Elderly (PACE) plan
Other special situations:
- You become eligible for both Medicare and Medicaid
- You qualify for Extra Help paying for Medicare prescription drug coverage (Low Income Subside – LIS)
- You are enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility
- You have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with your condition
- You live in an area where a Federal disaster occurred (hurricane, flood, etc.)
Covid-19 SEP and other Special Circumstances
In 2020 when the Covid-19 pandemic was declared a Federal disaster, a Covid-19 SEP was made available nationwide to beneficiaries of all states, tribes, territories, and the District of Columbia and ran from March 1, 2020, through June 30, 2020. To be eligible for this SEP for MA and Part D plans, a beneficiary must have been unable to make a change to their coverage during a valid election period as a result of the COVID pandemic. There has been no extension of that Covid-19 SEP despite the pandemic continuing. However, there is and always has been a SEP for on a case by case basis for “Other Exceptional Circumstances.” CMS will consider granting an enrollment or disenrollment opportunity for other exceptional circumstances.
There is a wide variety of SEPs available to deal with the many unique circumstances that could impact your ability to enroll in or change your Medicare coverage. While those we discussed here cover many of those bases, it is not all-inclusive, and there may still be other situations when you could qualify for a SEP. If you are in the Central New York area and are unsure if you are eligible for a SEP, contact Maura O’Toole at the FitzGibbons Agency, and she can help you determine what if any SEP you may be eligible for.
Have further Questions? Just Ask Fitz!
Maura O’Toole
Huntington Agency
6 Southgate Road
Baldwinsville, NY 13027
(315) 312-0803
