Imagine this — a flustered client calls you on January 7. They’re not happy with their current prescription drug coverage and want to change plans. Will you: (a) tell them you’d like to help but the Annual Enrollment Period (AEP) ended last month or (b) see what you can do?
As AEP comes to a close, it’s important to remember Special Enrollment Periods (SEPs) and the invaluable opportunities to help others and grow your business that accompany them.
There are many factors that can qualify your clients for a Medicare Part D SEP to change their health and drug coverage. Let’s take a closer look at the triggers for an SEP for Medicare and how these SEPs work.
Where Your Client Lives Has Changed
Your client may move for a variety of reasons, including changes in their health. Here are the SEPs your client could utilize if they recently moved or plan to soon.
Moved to a New Address or Service Area
If your client recently moved to a new address that isn’t in their current plan’s service area or if they moved to a new address that’s still in the service area but there are new plan options available, then they may have an SEP to enroll in a new prescription drug plan (PDP) or Medicare Advantage (MA) plan.
This SEP lasts three months. If they tell their Part D provider before they move, then the SEP begins the month before the month they move and continues for two full months after the move. If they tell the carrier after they move, then the SEP begins the month they tell the plan and continues for two additional full months.
Moved Back into the Country
If your client recently moved back to the U.S. after living abroad, then they have two full months after the month they move back to find new coverage.
Living in or Moved out of an Institution
If your client lives in an institution, like a nursing home or rehabilitation hospital, then they have an ongoing SEP to join, switch, or drop Medicare drug coverage. If they move out of an institution, then they have two full months after the month they moved to change coverage.
Released from Incarceration
If your client was recently released from prison and was paying for Medicare Part A and Part B while incarcerated, then they have two full calendar months after being released to find drug coverage. If they weren’t paying for Parts A and B, then they must sign up for Medicare Part A and/or B before enrolling in a drug plan.
Your Client Lost Current Coverage
Clients can lose coverage voluntarily or involuntarily for different reasons. Here are some ways a beneficiary could lose their current coverage and the SEP opportunities for finding a new plan.
No Longer Qualifies for Cost-Savings Programs
Changes in your client’s financial status mean they may qualify for a Medicare Part D SEP.
Medicaid
If your client lost their Medicaid eligibility, they have an SEP to drop or switch Medicare drug plans. The SEP lasts for three full months either from the date they were no longer eligible or the date they were notified of no longer being eligible, whichever is later.
Extra Help
Extra Help (also known as the Part D Low-Income Subsidy or LIS) is a Medicare program that helps eligible individuals with low incomes and limited resources pay their Part D costs. If your client loses Extra Help eligibility, they have a one-time SEP to drop or switch their MA or Part D plan for three months from either the date they’re no longer eligible or the date that they received notice that they were no longer eligible, whichever is later.
SPAP for Medicare Assistance
Your client may be utilizing a State Pharmaceutical Assistance Program (SPAP), which offers prescription drug assistance to Medicare beneficiaries with low incomes.
Losing SPAP eligibility gives your client an SEP to join or switch to a different Part D or Medicare Advantage Prescription Drug (MAPD) plan, even if they did not previously have Part D coverage. This SEP begins the month your client was notified they lost SPAP eligibility or the month they lose their SPAP eligibility, whichever happens first, and ends two months after whichever happens second.
Left Employer or Union Coverage
Individuals may work past 65 and keep creditable drug coverage (or not creditable if they don’t mind late enrollment penalties) through their employer or union. If your client drops their employee/retiree coverage (including COBRA), they have an SEP to join or switch MA or Part D plans. This SEP lasts until two months after the month their former coverage ends.
Involuntarily Lost Creditable Drug Coverage
Sometimes plan changes can mean that your client loses other drug coverage that once qualified as creditable. If this is the case, then they have an SEP for two full months after the month they lost creditable coverage or for two full months after they receive notification that their current coverage is no longer creditable, whichever is later.
Left a Medicare Cost Plan
If your client has drug coverage through a Medicare Cost Plan and they leave the plan, then they have an SEP to enroll in a new PDP or MA plan. They can join up to two full months after the month they drop their Cost Plan.
Left Medicare’s PACE Program
The Program of All-Inclusive Care for the Elderly (PACE) is a government program that helps get qualifying members coordinated care in their homes and communities. It offers coverage for doctor/hospital visits and prescription drugs, among other services.
If your client drops their coverage from PACE (voluntarily or involuntarily through changes in eligibility), then they have two full months after the month they drop their PACE plan to join a new MAPD or PDP.
Your Client Can Get Other Coverage
Your client may still be eligible for an SEP even if they don’t lose their current coverage. Here are different scenarios when they may be able to change drug plans.
Becomes Entitled to Non-Medicare Drug Coverage
Sometimes, your client may be able to obtain coverage from a non-Medicare source. If so, they could have an SEP to change health or drug plans.
If your client becomes eligible and wants to join or maintain creditable drug coverage that’s as good as Medicare drug coverage (like TRICARE or VA coverage), your client has an SEP to drop their MAPD or PDP and enroll in one of those programs at any time during the year.
Additionally, your client has an SEP if they want to join employer/union-sponsored health and/or drug coverage, whether or not it’s considered creditable. If your client wishes to enroll in employee/retiree coverage, they have an SEP to drop an MA or Part D plan and join the employee/retiree plan upon becoming eligible for it and the employer/union allows enrollment.
Qualifies for Cost-Savings Programs
Similarly to if your client loses eligibility, they may have an SEP if they start qualifying for financial assistance through these programs.
Extra Help
Your client can receive Extra Help in either of two ways: through application or automatic enrollment based on being eligible for Medicaid, a Medicare Savings Program (MSP), or Supplemental Security Income.
In the case that your client has automatic enrollment, they have an SEP to enroll in, drop, or switch Medicare Advantage (MA) or Part D plans that starts the month they’re able to join Medicaid or an MSP. This SEP allows your client to switch health or prescription drug plans once a month.
If your client applies for Extra Help and is granted it, they have an SEP to join, drop, or switch PDPs or MAPD plans once per month. This dual/LIS SEP allows full-benefit dually eligible individuals (QMB+, SLMB+, FBDE), partial-benefit dually eligible individuals (QMB, SLMB, QI, QDWI), and Extra Help-only eligible individuals to make a once-per-month election into Original Medicare and a stand-alone PDP. It also allows a once-per-month election to switch between standalone PDPs. This replaces what used to be a quarterly dual/LIS SEP.
SPAP
If your client is enrolled in an SPAP, they have one SEP per year they can use at any time to enroll in an MA or Part D plan for the first time or to switch MA or Part D plans, as long as they were not automatically enrolled in a Part D plan by their SPAP.
Becomes Eligible for Medicare’s PACE Program
If your client qualifies for Medicare’s PACE program, they have an SEP to drop an MA or Part D plan to join a PACE plan at any time.
Wants to Enroll in a 5-Star Plan
Every fall, CMS rates plans for the upcoming year based on their overall performance. If AEP has passed but your client would like to join an MA or Part D plan rated 5 out of 5 stars for next year, they have an SEP to join that plan from December 8 of the year the rating was released through November 30 of the following year. They can only use this SEP once per year.
Being Enrolled in an Under-Performing Plan
If your client has been enrolled in an MA or Part D plan that has received a star rating of less than 3 out of 5 stars for three consecutive years, they have an SEP to switch to a plan rated 3 out of 5 stars or higher. Your client can enroll in a better-performing plan at any time after their current coverage earns the under-performing designation.
Turns 65 While Already on Medicare
If your client is already on Medicare because of a disability and is turning 65, they qualify for an SEP to change their health and/or drug coverage and a new Initial Enrollment Period for Part D. Both of these start three months before the month they turn 65 and last three months after their birth month.
With this SEP, your client can drop their MA or MAPD plan to switch to Original Medicare or an MA plan without prescription drug coverage. They can then use the IEP to join a PDP.
The Plan Changed Its Contract with Medicare
Sometimes, carrier changes outside of your client’s control can result in an SEP.
Medicare Passes a Sanction
If there’s a problem with a plan, Medicare might take official action and put a sanction on the carrier to fix the issue. If this happens, your client can enroll in a new MAPD plan or PDP. The SEP begins when Medicare imposes the sanction and lasts until the sanction ends or until your client switches plans, whichever happens first.
The Carrier Terminates the Contract Midyear
Things can happen, including a carrier ending its contract with Medicare in the middle of the contract year. If this happens, your client can switch to a new MA plan or PDP beginning two months before the contract is terminated and ending one full month after the contract ends. If your client doesn’t enroll in a new plan, they’ll automatically be enrolled into Original Medicare.
The Contract Isn’t Renewed
If an MAPD plan, PDP, or Medicare Cost Plan contract was set to renew at the beginning of the year but ended up not renewing, then your client will have a chance to enroll in a new plan after AEP. This SEP lasts from December 8 to the last day of February of the following year.
Other Special Situations
As you can see, there are many SEP options that might be available to your client. Here are a few more special circumstances.
The State Took Over the Plan
If a carrier has financial issues, the state may take over the plan for a time. If this happens, your client can enroll in a new MAPD plan or PDP from the month the state action takes effect until the state action is no longer in effect or until your client switches plans, whichever is first.
C-SNP Eligibility Changes
If your client is enrolled in a Chronic Care Special Needs Plan (C-SNP) but no longer has the condition that qualified them for it, then they can join a PDP up to three months after the effective date of their involuntary disenrollment from the C-SNP.
Medicare Part B Related Events
Does your client have to pay a premium for their Medicare Part A coverage? Did or will they enroll in Part B during the Medicare General Enrollment Period, which runs from January 1 through March 31? If the answers to those questions are “yes,” your client has an SEP to enroll in a Part D plan between April 1 and June 30.
Did your client have Parts A and B but lose Part B coverage and their MA plan? If so, they have a two-month SEP, which starts when they learned they lost their Part B coverage, to enroll in a Part D plan.
Going Through Another Qualifying Life Event
On top of all the triggers previously mentioned, there are still more ways your client could qualify for an SEP to change their prescription drug coverage. To name a few other ones, they could qualify if they:
- Live in an area with a declared disaster or emergency
- Disenroll from their first MA plan using their MA trial right or drops their MA plan during the Medicare Advantage Open Enrollment Period
- Join a plan or chose not to join a plan because of an error made by a federal employee
- Join a plan based on misleading or incorrect info from a plan representative or State Health Insurance Assistance Program
What’s more, if your client experiences an “exceptional circumstance” that they believe should allow them an SEP, they have the right to ask CMS for one by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
When you receive calls from prospects or clients wanting to change their coverage post-AEP, don’t turn them away. Remember to ask questions and determine if they’re eligible for an SEP. These little windows of opportunity not only offer you the chance to earn commission during lock-in but can also help you expand your client base and build your reputation as a knowledgeable, trustworthy professional.
To learn more about when you can enroll clients in Part D, check out CMS’ fact sheet, Understanding Medicare Advantage & Medicare Drug Plan Enrollment Periods, and utilize this interactive page as a sort of checklist.
Fortunately, there’s no SEP needed for agents to join an FMO like Ritter! Register today and gain access to our contracts, sales support, technology, event invites, and more!
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