Imagine this — a flustered prospect calls you on January 7. In a voice laced with frustration, he explains one of his friends referred him to you. He’s not happy with his current prescription drug coverage and wants to change plans.
It’s your first time talking to this potential client, and your conversation could be the stepping stone to making a multitude of sales. Will you: (a) tell him you’d like to help but the Annual Enrollment Period (AEP) ended last month or (b) see what you can do?
Listen to this article:
As AEP comes to a close, it’s important to remember Special Election Periods (SEPs) and the invaluable opportunities to help others and grow your business that accompany them.
There are many factors that can qualify your client for an SEP to change his health and drug coverage. Let’s take a closer look at a few of the triggers which qualify your client for a Medicare Part D SEP and how these SEPs work.
Receiving Extra Help
Extra Help (also known as the Part D Low-Income Subsidy or LIS) is a Medicare program that helps qualifying individuals with low incomes and limited resources pay their Part D costs. 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, he has an SEP to enroll in, drop, or switch Medicare Advantage (MA) or Part D plans that starts the month he’s able to join Medicaid or an MSP. This SEP allows him to switch his health or drug plans once a month.
If your client applies for Extra Help and is granted it, he has an SEP to join, drop, or switch prescription drug plans (PDPs) or Medicare Advantage Prescription Drug (MAPD) plans. Further, this client can choose to switch his drug coverage once a month with a dual/LIS SEP, provided he continues to receive Extra Help.
If your client loses his Extra Help eligibility, he has a one-time SEP to drop or switch his MA or Part D plan.
Enrolling in a Qualified SPAP
Your client may be eligible for a State Pharmaceutical Assistance Program (SPAP) which offers prescription drug assistance to seniors with low incomes.
If your client qualifies for an SPAP, he has one SEP per year he 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 he was not automatically enrolled in a Part D plan by his SPAP.
Losing SPAP eligibility also gives your client an SEP to join or switch to a different Part D or MAPD plan, even if he did not previously have Part D coverage. This SEP begins the month your client was notified of his loss of SPAP eligibility or loses his SPAP eligibility, whichever happens first, and ends two months after whichever happens second.
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 qualifies for this program, he has an SEP to drop his MA or Part D plan to join PACE at any time. If he disenrolls from PACE, he has an SEP to enroll in an MA or Part D plan that ends two months after his disenrollment is effective.
Non-Medicare Drug Coverage
Sometimes, your client may be able to obtain coverage from a non-Medicare source. If so, he could have an SEP to change his health or drug plan.
Eligibility and desire to join or maintain creditable drug coverage through the VA, TRICARE, or an SPAP provides your client an SEP to drop his MAPD or PDP and stay or enroll in one of those programs.
Additionally, your client has an SEP if he wants to join or drop his employer/union-sponsored health and/or drug coverage, whether or not it’s considered creditable.
If your client drops his employee/retiree coverage, he has an SEP to join or switch MA or Part D plans. This SEP lasts until two months after the month his former coverage ends. Conversely, if your client wishes to enroll in his employee/retiree coverage, he has an SEP to drop his MA or Part D plan and join his employee/retiree plan upon becoming eligible for it.
Turning 65 While Already on Medicare
If your client is already on Medicare because of a disability and is turning 65, he qualifies for an SEP to change his health and/or drug coverage and a new Part D Initial Enrollment Period (IEP). Both of these start three months before the month he turns 65 and last three months after his birth month.
With this SEP, your client can drop his MA or MAPD plan to switch to Original Medicare or an MA plan without prescription drug coverage. He can then use the IEP to join a PDP.
Desiring 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, he has an SEP to join that plan from December 8 of the year the rating was released through November 30 of the following year. He can only use this SEP once per year.
Being Enrolled in an Under-Performing Plan
On a similar note, 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, he has an SEP to switch to a plan rated 3 out of 5 stars or higher. This SEP begins when your client receives notice of the situation from CMS in the fall and continues through the upcoming year. Your client must call 1-800-MEDICARE directly to use it.
Medicare Part B Related Events
Does your client have to pay a premium for his Medicare Part A coverage? Did or will he 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 his MA plan? If so, he has a two-month SEP, which starts when he learned he lost his Part B coverage, to enroll in a Part D plan.
Going Through Other Qualifying Events
On top of all the triggers previously mentioned, there are still more ways your client could qualify for an SEP to change his prescription drug coverage. To name a few other ones, he could qualify if he’s eligible for a Special Needs Plan, disenrolls from his first MA plan, or drops his MA plan during the Medicare Advantage Open Enrollment Period. What’s more, if your client experiences an “exceptional circumstance” that he believes should allow him an SEP, he has the right to ask CMS for one!
In short, 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 make money during lock-in, but can also help you expand your client base and build your reputation as a knowledgeable, trustworthy consultant.
Editor’s Note: A modified version of this post was previously published in the November 2016 issue of California Broker Magazine. This post was originally published in December 2017. It has been updated to reflect more current information.
Not affiliated with or endorsed by Medicare or any government agency.
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