A Medicare Special Enrollment Period (SEP) allows you to make changes to your Medicare coverage if you experience an event that significantly changes your circumstances or impacts your access to coverage, such as moving to another state or losing Medicaid eligibility.
Unlike other standard Medicare enrollment periods, SEP enrollments are not tied to specific dates. Instead, your ability to make plan changes is based on when your qualifying life event occurs. Different SEPs have different rules about what changes you can make, when you can make them, and how long you have to make changes. Learn about which SEPs may apply to your circumstances and what you can do during that window.
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The Importance of Adjusting Your Medicare Plan to Fit Your Life’s Changes
Changes are a part of life, and some changes could make you eligible for an SEP to make coverage adjustments outside of a set enrollment period. For example, you may move or lose employer-sponsored coverage upon retirement, or your current plan may change its contract with Medicare.
These changes can impact your healthcare coverage. For example, moving may mean you are no longer in your plan’s network area, or losing employer-sponsored health insurance upon retirement would make it necessary for you to enroll in Medicare coverage as soon as possible to avoid a lapse in coverage. As your circumstances change, it is important to reflect on how your Medicare plan can best support you.
What Qualifying Life Events Trigger a Special Enrollment Period for Medicare?
Qualifying life events that may trigger a Special Enrollment Period include health coverage, residence, and eligibility changes. An SEP Medicare option may be triggered if you become eligible for both Medicare and Medicaid, if you qualify for Extra Help in paying for Medicare prescription drug coverage, or if you are enrolled in an SNP but the plan no longer covers your condition. However, the most common reasons a beneficiary may become eligible for an SEP include health coverage changes, residence changes, and health condition changes.
Here’s a look at each event type in more detail.
Health Coverage Changes
Losing Employer-sponsored Health Insurance
If you lose coverage from an employer because you leave or lose your job or retire, you may be eligible for a two-month SEP that allows you to join a Medicare Advantage plan or a Medicare Part D plan. However, it should be noted that this SEP does not apply to COBRA coverage or retiree health plans. This means the SEP begins the month after your current coverage ends, even if you elect to get COBRA or a retiree plan from your employer.
Your Current Insurer Goes Out of Business
If your current insurer goes out of business — for example, Medicare may terminate the insurer’s contract, leaving them no choice but to close — you may be eligible for an SEP that lets you switch from your current Medicare Advantage plan or a Medicare Part D plan to another plan.
This SEP starts two months before your current contract ends and one month after the contract has been terminated.
You Lose Spouse-covered Insurance
If you lose spouse-covered insurance because your spouse leaves their job or you get a divorce, you may be eligible for an SEP to join a Medicare Advantage plan with drug coverage or join a Medicare Part D plan.
This SEP lasts for two full months after you lose your current coverage.
You Lose Medicaid Eligibility
Medicaid redetermination could affect the eligibility for thousands of Medicare beneficiaries enrolled in dual-eligible Medicare plans. Medicaid redetermination sees the end of restrictions put into place during the COVID-19 pandemic, allowing states to begin re-evaluating the enrollment status of Medicaid recipients as of April 2023.
If you are no longer eligible for Medicaid, you may be eligible for an SEP that allows you to join, switch, or drop a Medicare Advantage plan or a Medicare Part D plan.
Your SEP lasts three months from the date you are notified or the date you are no longer eligible, whichever is later.
Residence Changes
Moving Outside Your Current Plan’s Service Area
If you move outside your current plan’s service area, you may be eligible for an SEP that lets you switch to a new Medicare Advantage plan or a Medicare Part D plan.
If you tell your provider about the move before you leave, your SEP starts the month before you leave and continues for two months after your move. If you tell your provider after you move, your SEP begins the month you relocate plus two more months.
Moving to a New Area with More Options
You may also be eligible for an SEP if you move to a new location within your plan’s coverage area, but you now have access to other plans with different options. The actions you can take and the timelines for the move are the same as moving outside your plan’s current service area.
Moving In or Out of Certain Medical Institutions
If you move into or out of a skilled nursing facility or long-term care hospital, you may be eligible for an SEP that remains in place as long as you live in the institution and for two months after you leave.
Under this SEP, you can join a Medicare Advantage plan, switch your current plan, return to Original Medicare, or drop your drug coverage.
Other Eligible Changes
Experiencing Natural Disaster or Emergency
You may be eligible for a Medicare SEP if you experience a natural disaster or emergency. These disasters include floods, earthquakes, or hurricanes, while emergencies include unexpected hospitalizations or temporary cognitive disabilities.
In the case of a disaster, you must live in the area eligible to apply for Federal Emergency Management Agency (FEMA) assistance due to the incident. You have 60 days to complete your plan enrollment after the official FEMA incident period ends.
Becoming Eligible for Medicare Due to Medical Condition
Sometimes, you may be eligible for an SEP due to a medical condition. For example, if you have a chronic or disabling illness and a Medicare Special Needs Plan (SNP) provides illness-specific coverage, you can join this SNP. There is no timeframe for this move — you can join at any time, but once enrolled, you can no longer make changes using this SEP.
What Can You Do During a Medicare SEP?
Your exact SEP type determines what specific actions you can take, but generally you can expect to be able to:
- Switch to a new Medicare Advantage plan or prescription drug plan. Most SEPs allow you to switch Medicare Advantage plans or enroll in a stand-alone Part D drug plan.
- Drop your Medicare Advantage plan and return to Original Medicare. SEPs may allow you to return to Original Medicare if you lose your Medicaid eligibility.
- Join a Medicare Advantage plan or Medicare Part D plan. If you lose employer-sponsored health care, you may be able to join a new Medicare Advantage plan or Part D plan.
- Switch from an SNP to a different Medicare Advantage plan or Part D plan. If your SNP no longer covers your condition, you may be able to switch to a different Medicare Advantage plan or Part D plan.
Note that for the most part, you cannot enroll in Original Medicare for the first time during an SEP unless you already are enrolled in a Medicare Advantage plan and choose to drop it to return to Original Medicare.
How to Enroll During Your Medicare Special Enrollment Period
If you believe you qualify for an SEP, start by visiting HealthCare.gov or calling the Marketplace Call Center at 1-800-318-2596. Representatives can verify if you qualify for an SEP. It’s worth noting that some states run their own healthcare marketplaces. In this case, contact the state directly to get information about their Special Enrollment Medicare options.
Once you confirm that you are eligible to enroll, you can pick a new plan or switch depending on what your SEP allows. You may be asked to provide documents that confirm your eligibility for an SEP, such as mail addressed to you at a new residence or confirmation from your doctor that you suffer from a chronic condition.
Once you have picked a plan, provided the requested documents, and made your first premium payment, your coverage can start.
What You Need to Know About the Unwinding Special Enrollment Period
The Unwinding SEP is related to Medicaid redetermination. It is a temporary Special Enrollment Period to help individuals and families that are losing Medicaid or Children’s Health Insurance Program (CHIP) coverage due to the removal of the continuous enrollment condition. Under the Families First Coronavirus Response Act (FFCRA), the continuous enrollment condition prevented the churn of Medicaid recipients who experienced temporary changes in income or other life circumstances, making them ineligible for Medicaid.
When this condition is removed, however, millions of Americans may no longer be eligible for Medicaid as states carry out redetermination assessments.
Between March 31, 2023, and July 31, 2024, any Marketplace-eligible consumers who submit a new application or update an existing application with Healthcare.gov may be eligible for the Unwinding SEP, which gives 60 days after the application is submitted to select a new plan. Under the Unwinding SEP, proof of a qualifying life event is not required.
Benefits of Enrolling During Your Medicare SEP Instead of Waiting
Choosing to enroll during your SEP offers benefits such as:
- No gap in coverage: By enrolling during your SEP, you avoid the problem of coverage gaps. If you wait, you could be without health insurance for several weeks or months.
- No waiting for the next enrollment period: If you choose not to enroll during your SEP, you’ll have to wait until the next enrollment period.
- Avoid late enrollment penalties: Enrolling during your SEP can help you avoid late enrollment penalties that may be assessed if you no longer have creditable coverage.
When to Enroll If You Miss Your Medicare SEP
If you skip or otherwise miss your Medicare SEP, you still have three other enrollment periods to make changes to your Medicare plan:
- Annual Enrollment Period: This runs from Oct. 15 to Dec. 7 each year. During this period, you can switch from Original Medicare to Medicare Advantage or make changes to your existing Medicare Advantage plan, as well as join or switch stand-alone Part D plans.
- General Enrollment Period: This runs from Jan. 1 to March 31 each year. Enrollment for Medicare Part A and Part B is available during this period to anyone who missed their Initial Enrollment Period.
- Medicare Advantage Open Enrollment Period: This runs from Jan. 1 to March 31 and also applies during the first three months you enroll in Medicare. During this period, you can switch to another Medicare Advantage plan with or without drug coverage, join a Medicare drug plan, or drop your Medicare Advantage plan and return to Original Medicare.
Putting It All Together
Special Enrollment Periods offer a way to join, switch, or drop healthcare coverage outside of Medicare’s main enrollment periods. SEPs accommodate major life events such as retirement and relocation, as these events can disrupt existing health coverage and necessitate a transition or a change in your Medicare coverage. Depending on the circumstances, you may have one to three months to choose and find a plan that fits your needs.