Updated: May 18, 2022
In this article we will help you understand all the rules to help you change Medicare Advantage Plans to get the plan you need to help you pay for health and prescriptions after AEP (annual enrollment period). These rules are call "Special Enrollment Periods".
We all know that every year from Oct 15th to Dec 7, you can enroll into a Medicare Advantage and part D prescription drug coverage anytime without out any limitations, because its the AEP(Annual enrollment period). After that people generally think that they have to keep the same plan all year, even if they are unsatisfied. However, this isn't true on some occasions.
In fact right after AEP, you have OEP starting Jan 1st to March 31st (the Open enrollment period) where you can make one change just incase you don't like your Medicare advantage plan you chose in AEP.
Why you may need a Special Enrollment period?
Let say you got Original Medicare( Part A and B) and never signed up for part D, because you didn't need Prescriptions when you were first eligible. However, now you need it.
You didn't change plans during AEP, and found that coverages in your current plan has changed.
You accidentally enrolled into another plan just getting basic information, and didn't know you were completing an application.
You didn't know a new Medicare Advantage plan replaces the current one you have and is NOT an addition to your current coverages.
You saw some commercials for plans in your area that offered $0 plans and you have a Medicare supplement (Medicare gap) plan.
There are several reasons someone would need to switch, but these are the most common. Since each of these plans are federally regulated you want to know how to get your application approved by the centers of Medicare.
So lets jump right into it, and find you a special enrollment period to help you get the heath and prescription coverage you need.
Special Enrollment Periods(SEP):
Moved Residence- Did you make a permanent move? The rule states you have two months after your move or 2 months after you notify the insurance company of your move. Zip code or county has to change.
Employee/Union Coverage- Did you lose creditable coverage due to you loosing your job or retiring? You have 3 months to find a new plan
Prescription coverage- Did you loose prescription drug coverage?(Failure to pay your prescription plan bill doesn't count). You have 2 months from your termination notice to enroll into another Medicare advantage or part D prescription drug plan.
Medicare Supplement - Did you try dropping your Medicare supplement and part d plan to switch to a Medicare advantage plan? You have 12 months to switch back if this was your first time getting a Medicare advantage plan. This is called a Trial Period. Note: this SEP only enrolls you into a part D prescription drug plan. In your trial period you can also go back to Medicare supplement plan without underwriting.
Medicaid or Extra help (LIS) status- There is one SEP for when you gain/lose/have a change in status of Medicaid and extra help assistance. You have 3 months to change
plans 1 time. If you have never tried to get Extra help apply here. It actually helps reduce your cost for medication co-pays and health/prescription drug plan premium monthly payments courteous of social security.
6. Medicaid/Extra Help (LIS) Dual Eligible - If you have had Medicaid or extra help (LIS) for sometime and had no changes in your status you can change 1 time every quarter. Q1: Jan-Mar, Q2: Apr- Jun, and Q3: Jul- Sept. NOTE: You can not use this Oct-Dec since AEP is at this time.
7. Institutionalized- Did you move in/out of a skilled nursing facility? (Sometimes when we are hospitalized for catastrophic injuries or illnesses we need a skilled nursing facility to help up get back to 100%) These can also be Intermediate care facility for mentally disabled individuals, Psychiatric unit or hospital, rehabilitation center, or long term care/swing bed hospital. You have 3 months to select another plan.
8. Centers of Medicare Enrollment - Where you automatically placed into a health/prescription drug plan by the centers of Medicare? You have 3 months after your effective date into the plan to change to a plan you want.
9. Five Star plans- Companies like Aetna, Cigna, and Humana's Careplus have 5 star plans. These plans are based on member satisfaction on quality and performance.
10. Chronic Conditions- Do you have diabetes, congestive heart failure, or any other chronic condition? Some Insurance companies have plans for certain chronic conditions that you could enroll into. Note: you will need to provide proof from a certified physician, and if you're cured from chronic condition you have 2 months to enroll to a new plan.
11. Lost Part B- Did you lose your Medicare advantage plan, because you failed to make your part B coverage monthly payment? This year that part premium for 2021 is $148.50 if your income is less than $88,000. Most individuals get this automatically drafted out of their social security. In this event you have 2 months to enroll into another prescription drug plan.
12. Government Declared Disaster- This SEP is strictly for individuals who were affected by an emergency declared disaster by the Federal, State, or local government. You can only use this SEP if your disaster happened in the same time frame of another election period. For example: Let's say you just have original Medicare or a Medicare supplement plan and wanted to enroll into a Medicare advantage plan you see advertised on TV in April. If a flood happens that's considered a federal disaster on October 20, causing you not to be able to enroll into a plan in AEP you can use this SEP to get into a new Medicare advantage plan.
13. Accessible formats- Did your insurance company fail to provide your plan materials in an format that you requested to understand the information better? These formats could be Braille for blind people, Large print, or audio files.
14. SPAP (State Pharmaceutical Assistance program)- This SEP is for individuals who have qualified for additional help from their state with prescription coverage. Find out if your area has a program for you.
15. PACE (Program of All Inclusive Care)- This SEP is for members of PACE where the elderly need someone to come in and sit with them and help with their care. You have 2 months after your enrollment into PACE to change plans.
16. Non- Renewal of Contract- Was your Health/Prescription Contract not renewed by the insurance company? This SEPs begins Dec 8- last day of February.
There are other Special enrollment periods such as if you got released from prison, became eligible for US citizenship, that an insurance agent could assist with. There are others that are only available for the Centers of Medicare to do for you. Such as if you if you had a major change in provider network of doctors in your area, if you were given information that was false when signing up, and other instances that is approved on case- by -case bases.
So, definitely don't feel like you are on your own if you were told you are unable to switch after AEP(annual enrollment period). If you answered "yes" to any of the questions, and you need better coverage for health or prescriptions find a plan that suits all your needs.
Make sure to discuss all of your needs from doctors you are currently or plan to see, checking prescriptions, asking about other needs such as vision and dental.