Life Changes that Might Qualify You for Medicare Special Enrollment

Posted by Pattie Scoma
Estimated Reading Time 2 minutes 42 seconds

Choosing the right Medicare plan for your needs is a critical decision that can impact your access to care and out-of-pocket costs.  While the Annual Enrollment Period in the fall and the Medicare Advantage Open Enrollment Period in the beginning of the year offer key opportunities to make changes, what happens if you realize your plan is not working for you outside of these windows?

Fortunately, Medicare beneficiaries may qualify for a Special Enrollment Period under certain circumstances. Knowing when and how this applies can help you make timely changes and avoid being locked into a plan that does not meet your needs.

What Is a Special Enrollment Period?

A Special Enrollment Period, often called a SEP, is a time outside of standard enrollment periods when you are allowed to make changes to your Medicare coverage. This could include switching Medicare Advantage plans, returning to Original Medicare, or enrolling in a Part D prescription drug plan. SEPs are triggered by specific life events or changes in your circumstances.

When Can You Qualify for a Special Enrollment Period?

There are several situations that may qualify you for a Special Enrollment Period. Here are some of the most common examples:

1. You Move to a New Location

If you move to an area that is outside your current plan’s service area, or you gain access to new plans in your new location, you may be eligible for a SEP to change your coverage.

2. You Lose Other Coverage

If you lose employer coverage, retire, or your other health insurance ends, you could qualify for a SEP to enroll in Medicare or make changes to your current plan.

3. Your Plan Changes or Leaves Medicare

If your current plan is discontinued or Medicare terminates its contract with your plan, you will have the opportunity to select new coverage through a SEP.

4. You Receive Extra Help or Medicaid

If you become eligible for programs that help with Medicare costs such as Medicaid or Extra Help with prescription drugs, or if you lose eligibility for those programs, you may qualify for a SEP.

5. You Enroll in or Leave a Five-Star Medicare Plan

Medicare rates plans using a five-star system. If a five-star plan becomes available in your area, you may have a one-time opportunity each year to switch to that plan even outside of the regular enrollment periods.

6. Other Exceptional Circumstances

Certain situations such as being impacted by a natural disaster, experiencing an error in plan enrollment, or other complex issues can sometimes lead to a SEP as determined by Medicare.

What Should You Do Next?

If you believe you are eligible for a Special Enrollment Period, do not wait. Timing is critical, and each SEP has a limited window in which you can take action. The first step is to identify your qualifying event and gather any necessary documentation. Next, review your Medicare options to determine which plan best fits your current needs.

This process can be confusing, especially if you are unsure which plans are available or how to review them. That is where a knowledgeable licensed insurance agent help can make all the difference.

Get Help at No Cost

Navigating Medicare rules and enrollment periods can be challenging, but you do not have to do it alone. Working with a licensed insurance broker gives you access to professional guidance tailored to your specific situation. Best of all, this service is completely free. A Licensed Insurance broker can help you understand your eligibility for a Special Enrollment Period, review available plans, and make confident decisions.

If you think you may qualify for a Special Enrollment Period or need help reviewing your Medicare coverage, contact us and connect with a licensed insurance agent at your earliest convenience. We are here to help you make the right choice for your health and peace of mind.