Texas Medicare Special Enrollment Periods
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Texas Medicare Special Enrollment Periods
At times an individual may enroll in Medicare outside of the regular Medicare enrollment periods due to extenuating circumstances. These are known as the Medicare Special Enrollment Periods (SEP). If you qualify for a Medicare Special Enrollment Period, you may enroll in Medicare outside of your Initial Enrollment Period (IEP) and the General Enrollment Period (GEP).
If you are 65 or older and are covered under a group health plan, your’s or your spouse’s current employment, you have a Special Enrollment Period during which you can sign up for Medicare Part B. This means that you may delay your decision to enroll in Medicare Part B without having to wait for the General Enrollment Period and without having to pay the 10% premium penalty for a late enrollment.
Most people get Medicare Part A without paying a premium if they’ve worked at least 40 quarters (10 years) and paid their Medicare taxes. However, if you don’t have enough work history to get premium-free Medicare Part A and delay Medicare enrollment when you turn 65 because you have employer-sponsored coverage, you can also use your Special Enrollment Period to sign up for Part A. Otherwise, a late-enrollment penalty may apply for Medicare Part A if you don’t enroll when you’re first eligible and need to pay a premium.
Under such circumstances, you may:
- Enroll in Medicare Part A and/or Part B any time while you’re covered under the group health plan based on your current employment.
- Enroll in Medicare Part A and/or Part B during the eight-month period that begins with the month your group health coverage ends or the month your employment ends, whichever comes first. Medicare Special Enrollment Period rules do not apply if employment or employer-provided group health plan coverage ends during your Initial Enrollment Period.
If you do not enroll in Medicare by the end of the eight-month period, you will end up having to wait until the next General Enrollment Period, which begins January 1 of the next year. You also may have to pay a higher premium for Medicare Part B. If you don’t qualify for premium-free Medicare Part A, you may also owe a late-enrollment penalty for Part A as well.
People who receive Social Security disability benefits and are covered under a group health plan, from either their own or a family member’s current employment, also have a Medicare Special Enrollment Period. For more information on situations that may qualify you for a Special Enrollment Period, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week; TTY users can call 1-877-486-2048.
Special Enrollment Periods for Medicare Advantage Plans and Medicare Part D Drug Plans
You are limited in when and how often you can join, change or leave a Medicare Advantage Plan (also known as a Medicare private health plan) or prescription drug plan (Part D).
You can enroll in a Medicare Advantage or Part D plan during the initial period when you first qualify for Medicare.
You can switch from your Medicare Advantage Plan to another MA Plan, or to Original Medicare with or without a Part D plan, during the Medicare Advantage Open Enrollment Period (MA OEP). The MA OEP occurs each year from January 1 through March 31. You can only use this period if you have a Medicare Advantage Plan.
You can change your health coverage and add, drop, or change your drug coverage during Fall Open Enrollment. Fall Open Enrollment occurs each year from October 15 through December 7.
Outside of the above three periods, you can only change your health and/or drug coverage if you qualify for a Special Enrollment Period (SEP).
Special circumstances (Special Enrollment Periods)
You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP.
Medicare Advantage “Trial Period”
People who enroll in a Medicare Advantage plan when they are first eligible for Medicare Part Aat age 65 get a “trial period” (up to 12 months) to tryout Medicare Advantage. This SEP allows them to disenroll from their first Medicare Advantage plan and go to Original Medicare. At this time, they also get a “guaranteed issue right” to purchase a Medigap supplemental plan. Under federal law, this right lasts for 63 days after dis-enrollment from the MA plan. (They also get a Special Enrollment Period to join a Part D plan.)
You lose your current coverage
This SEP occurs if you lose your Medicaid, employer, union, COBRA coverage. Also, if you lose other creditable prescription drug coverage. Lastly, this SEP can be used if you leave a Medicare Cost plan or you drop your coverage in a Program of All-inclusive Care for the Elderly (PACE) plan. Each of these has a different time period that they can be used.
You have a chance to get other coverage
This SEP is used when you have a chance to enroll in other coverage offered by your employer or union. Also if you have or are enrolling in other drug coverage as good as Medicare prescription drug coverage (like TRICARE or VA coverage). Lastly, if you enroll in a Program of All-inclusive Care for the Elderly (PACE) plan.
Your plan changes its contract with Medicare
This SEP can be used when Medicare takes an official action (called a “sanction”) because of a problem with the plan that affects me. It also can be used if Medicare ends (terminates) your plan’s contract. Another reason to use this SEP is if your Medicare Advantage Plan, Medicare Prescription Drug Plan, or Medicare Cost Plan’s contract with Medicare isn’t renewed.
You have a severe or disabling condition
If you have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with my condition you can join a Medicare Chronic Care Special Needs Plan (SNP). You can join anytime, but once you join, your chance to make changes using this SEP ends.
You no longer have a condition that qualifies as a special need
If you are enrolled in a Special Needs Plan (SNP) and no longer have a condition that qualifies as a special need that the plan serves, you can switch from a Special Needs Plan (SNP) to a Medicare Advantage Plan or Medicare Prescription Drug Plan.
People with Limited Income
There are three commonly used Special Enrollment Periods for Medicare Advantage enrollees who have limited income and resources.
Medicare Advantage Dual
This SEP for duals can be used by anyone with Medicare who has any kind of Medicaid —whether it’s full Medicaid or enrollment in one of the MedicareSavings Programs. This SEP allows people who are dually entitled to Medicare and Medicaid to enroll, disenroll, or switch to another Medicare Advantage plan once per quarter during the first three quarters of the year, with the new election becoming effective on the first day of the next month. The SEP is considered “used” based on the date of the enrollment request. For example, if a plan receives an application during the month of March, the application is effective date is April 1 but the SEP is “used” for the 1stquarter, not the 2ndquarter. During the 4thquarter, duals wishing to change plans must take advantage of the Annual Enrollment Period (Oct. 15 –Dec. 7), with their changes becoming effective January 1 of the following year. Remember: Duals are not allowed to join Medicare Savings Account plans (MSAs).
The SEP for duals starts when someone becomes dually entitled to any Medicaid-administered program. The SEP ends two months after the person loses their Medicaid entitlement. Enrollment in the new plan is effective the first day of the month following enrollment, except for elections made during the AEP.
Medicare Advantage Low-Income Subsidy (LIS)/Extra Help
This SEP is for people who applied for and were found eligible by the Social Security Administration for the Part D low-income subsidy (LIS)/Extra Help. This SEP allows people who are dually entitled to Medicare and Medicaid to enroll, disenroll, or switch to another MA plan once per quarter during the first three quarters of the year, with the new election becoming effective on the first day of the next month. The SEP is considered “used” based on the date of the enrollment request. For example, if a plan receives an application during the month of March, the application is effective date is April 1 but the SEP is “used” for the 1st quarter, not the 2nd quarter during the 4th quarter, duals wishing to change plans must take advantage of the Annual Enrollment Period (Oct. 15 –Dec. 7), with their changes becoming effective January 1 of the following year. The Part D plan can be an MA-PD (Medicare Advantage plan with prescription drug coverage) or a stand-alone PDP (Prescription Drug Plan). The LIS/Extra Help SEP starts the month someone is found eligible for Extra Help. It ends two months after the person loses their Extra Help status. Enrollment in the new plan is effective the first day of the month following enrollment, except for elections made during the AEP.
Medicare Advantage State Pharmaceutical Assistance Program (SPAP)
This SEP may be used in the states with State Pharmaceutical Assistance Programs (SPAPs). SPAP participants can use this SEP to join or switch to another Part D plan (a PDP or an MA-PD). This SEP was intended to give new SPAP participants an opportunity to join or switch to another Part D plan when their SPAP enrollment takes effect. This SEP may be used once per the calendar year, with the new plan taking effect on the first day of the month following enrollment.
Medicare Advantage SEP to Coordinate with Part D
There are two commonly used Special Enrollment Periods that allow a person to disenroll from a Medicare Advantage plan and enroll in a Part D prescription drug plan.
Medicare Advantage 65
This SEP allows people who join a Medicare Advantage plan (excluding a Medical Savings Account) at age 65during their Medicare Initial Enrollment Period (IEP) to disenroll from that MA plan and go to Original Medicare. If they joined a Medicare Advantage plan with prescription drug coverage (an MA-PD), they may exercise this SEP by enrolling in a stand-alone Prescription Drug Plan (PDP).
Note: Those who use this SEP should also consider supplementing Medicare, either by applying for the Qualified Medicare Beneficiary Program (QMB) if they are eligible or by purchasing a Medigap policy. They have a right guaranteed by federal law to purchase any Medigap policy since this SEP has the effect of extending their Medigap Open Enrollment Period.
This SEP may be used at any time within the first calendar year (12 months) after joining a Medicare Advantage plan at age 65. Original Medicare and the PDP enrollment (if applicable) take effect on the first day of the month following the month in which the SEP was used.
Medicare Advantage SEP to Coordinate with Subsequent Part D Initial Enrollment Period (IEP)
People who are under 65 and have Medicare because of disability get an additional Part D Initial Enrollment Period (IEP) when they turn 65. This SEP allows them to coordinate with the additional Part D IEP. They can use this SEP to disenroll from an MA-only or an MA-PD and return to Original Medicare or enroll in an MA-only plan, regardless if they use the Part D IEP to enroll in a PDP. The SEP begins and ends concurrently with the additional Part D IEP.
Medicare Advantage SEPs to Remedy Erroneous Enrollments
There are two Special Enrollment Periods that may help some of your clients deal with erroneous Medicare Advantage enrollment. One of these SEPs covers incomplete and unintended enrollments; the other covers enrollments caused by the action, inaction, or error of a federal employee. These SEPs can be used by your clients to disenroll from a plan they never wanted to be in but were enrolled through the abuse or fraud of MA plan marketers. It is used to undo a dis-enrollment action that kept your clients from enrolling in a plan (so that an enrollment period election can be used to join a plan), and even to secure retroactive enrollment into another plan. Usually, this would mean re-enrollment into the plan your client was in before the unintended or erroneous enrollment.
Medicare Advantage Enrollment Not Legally Valid
This SEP may be used when a Medicare Advantage plan enrollment was not complete. An enrollment might not be complete, for example, if it was not signed by the beneficiary. One of the most notable examples of an incomplete and consequently invalid enrollment is one your client did not intend to make.
For example, if your client thought she was buying a Medigap policy or enrolling in a Medicaid managed care plan with a similar name, she never had the intent to join the Medicare Advantage plan. She should be able to use this SEP.
Generally, this SEP involves a dis-enrollment from the plan into which the person was mistakenly enrolled and re-enrollment back into the prior Part D plan. In order to prevent a gap in Part D coverage, the re-enrollment might be made retroactive by the Centers for Medicare & Medicaid Services (CMS)to place your client back in the situation she never intended to switch out of.
This SEP usually involves SMS using its discretion to decide whether an enrollment is incomplete. The timing of the dis-enrollment and re-enrollment will be determined by CMS. In general, once somebody establishes that the enrollment was not complete, including decisions that enrollments were not intended, CMS will time dis-enrollment and re-enrollment back to the prior plan so that the individual experiences no gap in Part D coverage.
Medicare Advantage Federal Error
Nobody is perfect —federal employee error can cause a Part D plan enrollment that should not have happened. Federal errors might also prevent an intended enrollment into aPart D plan.CMS decides on a case-by-case basis whether to approve this SEP, which permits enrollment into or dis-enrollment from a Medicare Advantage plan with prescription drug coverage (MA-PD). This SEP begins in the month CMS tells a beneficiary the SEP has been granted and ends two months later. Enrollment in the new plan is effective the first day of the month following enrollment.
Easing enrollment into Medicare Advantage plans:
Medicare allows pre-approved health insurance plan sponsors to automatically move individuals enrolled in one of their plans into that sponsor’s MA plan once the individual becomes eligible for Medicare. This process is called “seamless conversion.” This default enrollment is only for Medicaid managed care enrollees who are newly eligible for Medicare and who are enrolled into a Dual Eligible Special Needs Plan (D-SNP)or a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) administered by an MA organization (under the same parent organization that operates the Medicaid managed care plan). Plans are required to inform the individual at least 60 days prior to the conversion, and persons who do not wish to enroll in the MA plan must actively opt-out of the seamless conversion.
Additionally, CMS in consultation with Medicaid may passively enroll full-benefit duals enrolled in a non-renewing integrated D-SNP into comparable D-SNP. Individuals enrolled through passive enrollment, have a three-month SEP to disenroll from their assigned plan and enroll in a different plan.
Medicare Advantage SEPs Based on Residence
There are two commonly used Special Enrollment Periods for people enrolled in Medicare Advantage related to where they live or relocate to.
Medicare Advantage Relocation
This SEP is for Medicare beneficiaries who, as a result of a permanent move, are no longer eligible to belong to their Medicare Advantage plan, or even if they are still eligible to remain in the plan, they will have new MA or PartD plan options available to them as a result of the move. (Generally, new plan options become available only upon moves to another state.)
Generally, plan members are responsible for notifying the current plan about a permanent move. Upon such notification, the SEP begins the month before the move and continues until two months after the move. Upon selecting a new plan, the beneficiary can choose an effective date of up to three months after the month the enrollment was submitted.
Medicare Advantage SEP for Individuals Affected by a FEMA-Declared Weather-related Emergency or Major Disaster
This SEP allows individuals affected by a weather-related emergency or major disaster who were entitled to but unable to complete a valid election to enroll, disenroll, or switch Medicare Advantage plans. This SEP is also available to individuals who do not live in the affected areas but rely on help making healthcare decisions for friends or family members who live in the affected areas.
The SEP is available from the start of the incident period (i.e., when the emergency was declared) and for four full calendar months thereafter.
Medicare Advantage SEP for Institutionalized Individuals
The Medicare Advantage Open Enrollment Period (or OEPI) that allows nursing home residents and others residing in residential long-term care facilities to enroll or switch Medicare Advantage plans are similar to the Part D SEPfor institutionalized beneficiaries.
The OEPI allows beneficiaries with Medicare Parts A and B who move into, reside in, or are discharged from certain long-term care facilities to join or disenroll from a Medicare Advantage plan. People eligible for the OEPI may join a Medicare Advantage plan, switch to a different Medicare Advantage plan or disenroll from Medicare Advantage and go to Original Medicare. They are not allowed to change their Part D status using the OEPI. If they previously had Part D, they must join an MA-PD or a PDP. If they did not previously have Part D, they are not allowed to join an MA-PD nor a PDP.
Specifically, this SEP can be used by people in nursing homes, psychiatric hospitals, rehabilitation hospitals, long-term care hospitals, and swing beds. The OEPI also is applicable to individuals who are admitted to a skilled nursing facility in which they can join a Special Needs Plan (SNP) for institutionalized individuals. The SEP may be used to enroll or disenroll from an applicable institutional SNP.
This SEP begins in the month of admission and continues for up to two months following discharge. Unlike the PDP SEP for institutionalized persons, the OEPI may be used repeatedly to switch plans as frequently as monthly (although this would not be are commended practice).
References: You can find a complete explanation of all Medicare AdvantageSEPs in the Center for Medicare & Medicaid Services (CMS) Medicare Managed Care Manual, Chapter 2–Medicare Advantage Enrollment and Disenrollment, Section 30.4, Special Election Period (SEP), and Medicare.gov.