Special Enrollment Periods for Medicare Advantage Plans and Medicare Prescription Drug Plans
by Susan R. Tolbert, Licensed Health Agent
Most Medicare beneficiaries are aware of the Fall Annual Enrollment Period that occurs from October 15 – December 7 each year. During this time period, Medicare health and prescription drug coverage can be added, dropped, or changed for the upcoming plan year. This gives Medicare beneficiaries the opportunity to evaluate their plans and specifically compare them to potential new plans on the market in the area they reside and subsequently make changes as desired or needed.
In addition to the Fall Annual Enrollment period and the Medicare Advantage Open Enrollment period, there are Special Enrollment Periods in which beneficiaries could qualify to make a plan change. It is good to be aware of the Special Enrollment Periods as they could apply to you now or in the future. Please feel free to reach out to Newbrooke Insurance if you are anticipating any of the situations listed below as each qualifier may have different times periods for processing the changes. The Special Enrollment Periods listed below are not inclusive of all the qualifiers for a Special Enrollment Period but does include the main ones.
- You want to enroll in a five-star Medicare Advantage or Part D plan
Once each year Medicare beneficiaries can move to a five-star Medicare Advantage or Part D plan. If you are currently not in a five-star plan and
find a five-star plan is available in the county you reside, you can move to this plan outside of the Medicare Annual Enrollment Period.
(Note: If you are not aware of Medicare star ratings, please see this topic the Medicare Question & Answer section.)
- You gain, lose, or have a change in Medicaid or Extra Help eligibility status.
State and Federal assistance programs often change their criteria for eligibility. Income for Medicare beneficiaries may also change and could
place individuals in or out of assistance programs which will trigger a Special Enrollment period and the opportunity to make a plan change.
- You experience contract violations or enrollment errors.
If you find that your Medicare Advantage or Part D plan has violated any provision of the contract or made an enrollment error you may be
entitled to a Special Enrollment Period.
- You move – make a permanent home address change.
Once you know that you will be moving outside of the current county that you reside in, please contact your broker who can help navigate
the logistics and options available to you as you will qualify for a Special Enrollment Period that will come with different options based on
the location of your new residence.
- You are in a nursing home or become admitted to a nursing home.
Permanent residence in a nursing home qualifies Medicare beneficiaries to enroll or dis-enroll from Medicare Advantage or
Part D plans once a month.
- Your Medicare Advantage Plan terminates a significant amount of its network providers.
If your Medicare Advantage plan stops contracting with many of its providers in its network during the course of the calendar year,
and the Centers for Medicare & Medicaid Services determines these terminations are substantial, you will have a one-time Special
Enrollment Period to choose a different Medicare Advantage plan.
- You are in a consistently low performing plan.
If your Medicare Advantage or Medicare Prescription Drug plan receives less than three stars for three years in a row you can qualify
for a Special Enrollment Period to move to a different plan.
- Your plan no longer offers coverage.
If your plan drops or loses its contract with the Center for Medicare & Medicaid Services, you will have a Special Enrollment period
to select another plan.
- You experience exceptional circumstances.
Medicare will allow beneficiaries to change plans when they are affected by exceptional circumstances such as natural disasters
including earthquakes, hurricanes/storms, etc.