There could be a time when the traditional Medicare enrollment periods simply do not fit your situation. Through no fault of your own, you could face gaps in care because you could not sign up for Medicare when you needed it. That’s why Medicare created these Special Enrollment Periods. Like the rare white peacock, we’re all special in our own way.

Special Enrollment Periods for Original Medicare

When it comes to signing up for Medicare the first time, there is really only one Special Enrollment Period you need to know about. It happens when you turn 65 but want to stay on your employer’s health plan. As long as your employers hires the equivalent of at least 20 full-time employees, you can wait to sign up for Medicare until you leave your job or leave your health plan, whichever comes first. Then, you have eight months to sign up.

For years, that was the only leeway you had to sign up for Original Medicare. You may have more options soon now that Congress passed The BENES Act. The law will allow a Special Enrollment Period for people who miss their Initial Enrollment Period or General Enrollment Period for a qualifying reason. These reasons may include:

• Getting misinformation from an employer or employer health plan that caused you to delay Medicare enrollment
• Incarceration at the time of initial Medicare enrollment
• Loss of Medicaid coverage that requires you to go on Medicare
• A natural disaster or a public health emergency (like COVID)
• Other situations on a case-by-case

These Special Enrollment Periods are only proposals at this time. I will keep you posted when they become official.

Special Enrollment Periods for Medicare Advantage and Part D

Private insurance companies run Medicare Advantage and Part D plans. That increases the odds they could change, get cancelled, or fail to live up to their contractual requirements with the government. You could even have a life circumstance that changes what kind of Medicare plan you are eligible for. With this in mind, the following circumstances may qualify you for a Special Enrollment Period (SEP) that allows to change your Medicare Advantage or Part D plan to another Medicare Advantage or Part D plan. Unless specifically stated, these SEPs last two months.

Changing Plans When You Move In or Out of These Locations 

• Back to the United States from a foreign country
• Jail/prison
• Outside of your plan’s network
• A nursing home, long-term care hospital, or other medical institution*
• Within your plan’s network but to an area address that has more plan options

*If you currently reside in or move into one of these facilities, you can change your Medicare Advantage plan at any time or even change back to Original Medicare.

Changing Plans When You Gain or Lose Other Health Coverage or Subsidies

• A health plan with creditable drug coverage (i.e., drug coverage as good as a basic Part D plan)*
• Medicaid coverage**
• Employer, union, or COBRA coverage*
• Extra Help Part D Low-Income Subsidy**
• Program of All-Inclusive Care for the Elderly (PACE)*
• State Pharmaceutical Assistance Program (SPAP)***
• TRICARE or VA benefits with creditable coverage

*You can cancel your Medicare plan as soon as you enroll in a new plan.

*When you are eligible for Medicaid or Extra Help, you can change Medicare plans once during each of the following three periods: January-March, April-June, or July-September. To change plans from October-December, you would defer to Medicare Open Enrollment. If you lose Medicaid coverage, you have three months to choose a new plan or you can opt for Original Medicare instead.

*Part D plans can be changed once a year when you are on a SPAP.

Changing Plans When There Is an Issue With Your Current Plan

• Medicare places a sanction on your plan that affects you.*
• Medicare terminates its contract your plan’s contract.
• You were not notified that your current drug coverage was not creditable.
• Your current health plan changes and your drug coverage is no longer creditable.
• Your plan is not renewed by Medicare.**

*Medicare looks at sanctions on a case-by-case basis. You can change plans two months before and up to one month after Medicare terminates your plan’s contract.

**If your plan isn’t renewed for the coming year, you can change plans between December 8 and February 28/29.

 

Eligibility | TRICARE. (2022). Tricare.mil. https://www.tricare.mil/Plans/Eligibility

Eligibility Requirements for Programs of All-Inclusive Care for the Elderly (PACE®) | National PACE Association. (2022). Npaonline.org. https://www.npaonline.org/pace-you/eligibility-requirements-programs-all-inclusive-care-elderly-pace%C2%AE

Extra Help with Medicare Prescription Drug Plan Costs. (2022). SSA.gov. https://www.ssa.gov/benefits/medicare/prescriptionhelp.html

Find a Pharmaceutical Assistance Program for the drugs you take. (2022). Medicare.gov. https://www.medicare.gov/plan-compare/#/pharmaceutical-assistance-program

House Passes H.R. 2477, The “BENES Act of 2020.” (2020). SSA.gov. https://www.ssa.gov/legislation/legis_bulletin_121420.html

Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and other Revisions to Medicare Enrollment and Eligibility Rules (CMS-4199-P). (2022). CMS.gov. https://www.cms.gov/newsroom/fact-sheets/implementing-certain-provisions-consolidated-appropriations-act-2021-and-other-revisions-medicare-1