Special Enrollment Period (SEP): Details You Need to Know

Special Enrollment Period (SEP): Details You Need to Know

There are cases where you can enroll in Medicare outside of the regular enrollment period when certain conditions are met. It is called the Medicare SEP (Special Enrollment Period).

If you are qualified for the Medicare Special Enrollment Period, you can enroll in Medicare outside your General Enrollment Period (GEP) and IEP (Initial Enrollment Period).

It is also termed as Special Election Periods for Medicare Advantage and Medicare prescription drug plans.

What is a Special Enrollment Period?

The Special Enrollment Period (SEP) is a period outside the general enrollment period. Fall Open Enrollment Period that begins with specific circumstances allows you to enroll in Medicare Part D, Part B, or a private health plan (Part C).

You can change your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, such as if you relocate or lose other coverage. The Special Enrollment Period (SEP) provides the opportunities to make changes. However, the rules about when you can make changes and what types of changes you can make are different for each SEP.

SEPs can also allow you to change or disenroll Part D and private health plans. In Part B, SEP exempts you from paying a premium penalty. Your Part B SEP begins the month after your group or spouse’s employment or individual health plan coverage ends (whichever is earlier). 

In Part D and private health plans, you qualify for SEPs in several situations. For instance, if you lose coverage from any notable drug plan or you move out from your plan’s service area.

SEP (Special Enrollment Period) for Original Medicare

The Medicare SEP (Special Enrollment Period) allows you to change plans or sign up for Original Medicare outside the standard Medicare enrollment period.

Here’s the time duration you get to enroll during SEP;

Special Enrollment Period (in the case of Qualifying Life Events): 2 months

Special Enrollment Period (in the case of Working Past 65): 8 months

If you don’t have Medicare: People who qualify for delayed Medicare because they have reliable coverage — usually from an employer — get an 8-month Special Enrollment Period for enrolling in Medicare Parts A, B, C, and D. 

If you have Medicare: For people who already have Medicare and are experiencing a qualifying life event, there is a particular two-month period to change a Medicare Advantage or Part D plan.

Special Election (Enrollment) Period for Medicare Advantage and Prescription Drug Plans

The Special Election Period (SEP), also known as the Special Enrollment Period, for Medicare Advantage and Prescription Drug Plans is slightly different from the Original Medicare SEP.

The Medicare Advantage/Prescription Drug Special Enrollment Period applies to people who have lost their coverage for any qualified reasons. For example, You might become eligible if your plan stopped accepting Medicare, or you moved out of your area or moved out of the plan’s service area.

Another situation where you may be eligible for a Medicare Advantage/Prescription drug SEP is if your area is hit with a disaster. For this Special Enrollment Period, there are various restrictions you should be aware of. 

  • You had not yet changed your coverage at the time of the significant crisis or disaster declaration.
  • The FEMA (Federal Emergency Management Agency) has declared a significant emergency or disaster in your county.
  • The valid SEP for your situation has not expired.
  • You lived in the county when FEMA declared a major emergency or disaster.
  • You had a valid election period running out when FEMA declared a major emergency or disaster.

How Do Special Enrollment Periods Work?

If you think you may be eligible for SEP, it is essential to contact Medicare immediately to confirm your eligibility and find out what deadlines apply.

Generally, if you register or make changes during SEP, you will not have to pay late enrollment fees or penalties – but there are some exceptions.

Suppose you have health insurance through your employer and work for an employer with fewer than 20 employees. In that case, it is vital to register for Medicare Part A and Part B when you first qualify, or you may have to pay the penalty subject to late enrollment.

In another case, if you do not register for Medicare Part D (prescription drug coverage) when you are eligible and do not have reliable prescription drug coverage from another plan, a SEP may allow you to register for coverage. However, fines may still apply.

If you’re not sure how Medicare works with your employer-provided health insurance, check with Medicare or our insurance agents to make sure you’re signed up at the right time. Late enrollment penalties can continue for the entire time you have Medicare coverage.

What if I think I qualify for a Special Enrollment Period? 

Visit HealthCare.gov/screener and answer a few questions to determine if you qualify for a Special Enrollment Period to enroll or change the plan. You’ll also know if you’re eligible for coverage through Medicaid or the Children’s Health Insurance Program (CHIP) when you apply.

You can also consult to Marketplace Call Center by calling at 1-800-318-2596 to check the eligibility or register by phone (TTY users can call 1-855-889-4325). The representative will check whether you are eligible.

IMPORTANT: Different states may have different Special Enrollment Periods because of the different Marketplaces. Therefore, it is suggested to visit HealthCare.gov first to verify your state’s Marketplace.

What if the Marketplace Needs Documents to Confirm My Special Enrollment Period?

Once you have submitted your application for new marketplace enrollment, you may be asked to send documents confirming events that qualify you for the Special Enrollment Period. You will find this request on your eligibility results screen, and you can download or get it in the mail.

It is suggested to choose a plan first, where Simpler Horizons’ experienced insurance agents can help you. Then, you have to upload your documents online or post copies (don’t send originals) to begin your coverage. Once you have selected a plan, you have 30 days to send the acceptable documents.

Your coverage start date depends on when you choose a plan. 

However, you cannot use your coverage until your documents confirm your eligibility for a Special Enrollment Period, then make your first premium payment.

If your eligibility results do not ask you to provide documents, you are not required to do so. Instead, choose a plan and enroll. For more information, visit HealthCare.gov/coverage-outside-open-enrollment/confirmspecial-enrollment-period.

For choosing a suitable plan, you can always rely on experienced insurance agents who understand your medical needs and guide you towards the right option. 

If you are eligible for SEP but haven’t yet decided what plan to replace with, give us a call, and our agents specialized in Medicare will help you.

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