By: Susan Stewart, Licensed Insurance Agent
Every year, seniors must choose the Medicare Part D drug plan that best fits their healthcare needs and budget during what’s called the Annual Enrollment Period, or AEP. This window, which runs from October 15th to December 7th, lets seniors make as many changes to their plans as they want. However, it’s much more difficult to make changes throughout the rest of the year.
To make a change to your Medicare Part D drug plan or Medicare Advantage plan outside the AEP, you need to be eligible for what’s called a Special Enrollment Period (SEP), which gives you an exception if you meet certain conditions. (Note, these rules don’t apply if you’re new to Medicare under a variety of circumstances.)
Do you need to update your Medicare Part D drug plan or Medicare Advantage plan outside the AEP? The most common Special Enrollment Periods Medicare will approve to change your current Medicare Advantage Plan or Prescription Drug Plan are:
- You’ve moved out of your service area in the last 60 days or are planning to move in the next 60 days.
- You’re eligible for a Chronic Special Needs Plan (CSNP). Diabetes, Chronic Heart Failure, and Cardiovascular Disorders are the most common CSNPs. Some areas have plans for beneficiaries with lung disorders or End Stage Renal Disease.
- You’ve experienced a change in your Medicaid and/or Extra Help level. Medicaid is state-run to assist those who are financially eligible. Extra Help is a federal government program to assist in the cost of prescriptions for those who are financially eligible.
- You’ve recently been in or are currently in a skilled nursing facility.
- Certain states offer a monthly option to change if you have full Medicaid.
- A natural disaster in your county prevented you from changing your plan during the last AEP.
However, there are many misconceptions around SEPs. Here are a few examples of conditions that won’t qualify you to get one:
- Your doctor or medical facility is ending their contract with the carrier. That can happen at any time, leaving a beneficiary with the need to find a new doctor or use different facilities, which you may not want to do.
- Wishing you’d stayed on your previous plan for any reason, including that you didn’t understand the plan or that you were taking up a new plan.
- Preferring your neighbor’s plan.
- Being unhappy with claim payments or issues with authorization.
While there are a few more reasons that you could be eligible for an SEP, most of them are for rare or unusual circumstances, such as a recent release from prison. A call to the federal office of Medicare can permit certain changes, but they are even less common than recent prison release. There are highly unusual conditions that can only be applied by Medicare. Licensed agents have no access to them. I’ve never had one of those cross my desk as an agent.
To confirm your eligibility for an SEP, your best move is to speak with a licensed insurance agent. Still, if you’ve already been told several times there is no SEP for your situation, it’s best to wait until the new plans are released for viewing/discussion on October 1st, right before each year’s AEP.
