Maximize Your Medicare Benefits Using Special Enrollment Periods (SEPs)
What is Special Enrollment Period (SEP) in Medicare?
Special Enrollment Period (SEP) in Medicare is a specific timeframe outside of standard enrollment periods that allows eligible beneficiaries to make changes to their Medicare coverage due to qualifying life events.
These events can include moving to a new area where different Medicare plans are available, losing employer or other creditable health coverage, gaining or losing Medicaid eligibility, or experiencing a plan-related change such as contract termination. Unlike standard Medicare enrollment periods, SEP offers flexibility to ensure continuous and appropriate coverage without penalties.
Why is SEP important?
SEP is important because it protects Medicare beneficiaries from coverage disruptions and unexpected healthcare costs due to life changes beyond their control. Without SEP, individuals who experience significant life events—such as relocation, loss of employer-sponsored insurance, or changes in financial status—could be locked into coverage that no longer meets their needs or be left uninsured. SEP also helps beneficiaries avoid late enrollment penalties and allows them to access new or better-suited coverage when circumstances change.
Which Medicare plans can you make changes to during SEP?
During an SEP, current beneficiaries can make changes to Medicare Advantage Plans (Part C), Medicare Prescription Drug Plans (Part D), and Medicare Advantage Prescription Drug Plans (MAPD), which combine Medicare Part C and Part D.
Depending on the specific SEP, individuals may switch from one Medicare Advantage plan to another, return to Original Medicare (Part A & Part B), and enroll in or change a Part D prescription drug plan. New beneficiaries can enroll in Medicare for the first time if they were previously delayed coverage. The exact options available depend on the reason for the SEP.
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Explore Medicare AdvantageWho is eligible for Special Enrollment Period?
Eligibility for an SEP is determined by specific life events that impact Medicare coverage. So, it is important to find out if your life-changing circumstance or event is one of the approved life events by Medicare.
How do I know if I qualify for Special Enrollment Period?
Determining if you qualify for a Special Enrollment Period (SEP) can be complex, as there are over 30 life-changing events that may trigger eligibility, including moving, losing coverage, or changes in Medicaid status.
Speaking with a licensed insurance agent is crucial to understanding your options and ensuring you don’t miss an opportunity to enroll or switch plans. At Hesteon Solutions, our experts guide you through the process, assess your situation, and help you make informed decisions to maximize your Medicare benefits.
Contact us to check your SEP eligibility and secure coverage today!
Which life events are eligible for Special Enrollment Period?
There are more than 30 specific life events that are eligible for SEP. It can be overwhelming to go through the entire list one at a time. Some of them describe the same underlying event and hence, can be simplified.
The list of life events can be broken down into 4 broad categories based on the source of impact:
- Personal Life Changes
- Gaining or Losing Eligibility to Specific Programs
- Plan-related Changes
- Loss of Coverage (does not affect current beneficiaries)
1. SEP Events due to Personal Life Changes
Life events that directly affect you, such as moving, being impacted by a natural disaster, incarceration, or extended volunteer work abroad can affect Medicare eligibility and plan options. If you relocate to an area with different plan availability, experience a FEMA-declared emergency that disrupts enrollment, or are released from incarceration, you qualify for a Special Enrollment Period (SEP) to update or enroll in coverage. These SEPs ensure continued access to healthcare when significant personal circumstances change.
Moving to a New Address
If you move to a new location where your current Medicare Advantage or Part D plan is not available or new plans become available, you qualify for a SEP to switch plans.
Impacted by a Natural Disaster or Emergency
If federal (including FEMA), state, or local government entity has declared a disaster or emergency that prevented you from enrolling, switching, or making changes to your Medicare plan during an enrollment period (Initial Enrollment Period (IEP), General Enrollment Period (GEP), or an eligible Special Enrollment Period), you qualify for this SEP.
LOOKING FOR MEDICARE ENROLLMENT PERIODS?
View Enrollment Periods & DeadlinesVolunteer Work Abroad
If you previously delayed Medicare enrollment due to volunteering outside the U.S. for at least 12 months with a recognized organization, you qualify for an SEP upon return.
Formerly Incarcerated Individuals
If you were recently released from incarceration and are now eligible for Medicare, you can enroll in Medicare Parts A & B, a Medicare Advantage plan, or a Part D plan.
Released from Jail or Other Incarceration
If you were already eligible for Medicare before being incarcerated, you qualify for an SEP upon release to enroll in or switch plans.
The table below outlines the eligibility period, allowed changes, and key limitations for each SEP event related to this category.
View Eligibility, Allowed Changes & Limitations
| Life Event | Eligibility Period | Changes Allowed | Limitations |
|---|---|---|---|
| Moving to a New Address | 1 month before and up to 2 months after moving. | Switch or enroll in Medicare Advantage or Part D. | Move must affect plan availability. |
| Impacted by a Natural Disaster or Emergency | Begins on date of declaration, ends 2 months after end date. | Enroll, drop, or switch plans. | Only applies to affected areas and individuals. |
| Volunteer Work Abroad | Up to 6 months after returning to the U.S. | Enroll in Medicare Part A & B. | Must have volunteered for 12+ months. |
| Formerly Incarcerated Individuals | Starts on release date, ends 12 months later. | Enroll in Medicare Part A & B. | Only applies if newly eligible for Medicare. |
| Released from Jail or Other Incarceration | Up to 2 months after release. | Enroll in or switch Medicare Advantage or Part D. | Applies only if previously eligible for Medicare. |
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2. SEP Events due to Gaining or Losing Eligibility to Specific Programs
Medicare coverage is closely tied to eligibility for programs like Medicaid, Extra Help (LIS), Special Needs Plans (SNPs), State Pharmaceutical Assistance Programs (SPAPs), and PACE coverage. If you gain or lose eligibility for any of these programs, you qualify for an SEP to switch or enroll in a new plan that aligns with your updated status. This ensures that beneficiaries have access to the most cost-effective and appropriate healthcare options.
Medicaid
If you gain or lose Medicaid eligibility, you qualify for an SEP to switch or enroll in a new Medicare Advantage or Part D plan.
Special Needs Plan (SNP) Status
If you become eligible for, or lose eligibility for, a Medicare Special Needs Plan (SNP), you qualify for an SEP to enroll in or switch SNPs.
Extra Help (also known as Low-Income Subsidy, or LIS)
If you gain or lose eligibility for Extra Help with Part D costs for Prescription Drug Plans (PDP), you qualify for an SEP to enroll in or change Part D plans.
LOOKING FOR HELP WITH DRUG COSTS?
Learn about Medicare's Extra HelpState Pharmaceutical Assistance Program (SPAP) Benefits
If you gain or lose eligibility for a State Pharmaceutical Assistance Program (SPAP), you qualify for an SEP to switch Part D plans.
Programs of All-Inclusive Care for the Elderly (PACE)
If you leave or lose eligibility for a Programs of All-Inclusive Care for the Elderly (PACE) plan, you can switch to a Medicare Advantage or Part D plan.
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Discover Local Assistance OptionsRefer to the following table for a breakdown of eligibility, permitted plan changes, and any restrictions that apply.
View Eligibility, Allowed Changes & Limitations
| Life Event | Eligibility Period | Changes Allowed | Limitations |
|---|---|---|---|
| Gaining or Losing Medicaid | Up to 3 months after eligibility change. | Switch to or enroll in Medicare Advantage or Part D. | Loss of Medicaid must be documented. |
| Gaining or Losing SNP Status | Up to 3 months after eligibility change. | Enroll in, switch, or drop SNP. | Must meet or lose SNP qualifications. |
| Gaining or Losing Extra Help | Ongoing while eligible. | Switch Medicare Advantage or Part D at any time. | Changes allowed once per quarter. |
| Gaining or Losing SPAP Benefits | Up to 2 months after change. | Switch to another Part D plan. | Must be in a state with an SPAP. |
| Leaving or Losing PACE Coverage | Up to 2 months after leaving. | Enroll in or switch Medicare Advantage or Part D. | Applies if previously enrolled in a PACE program. |
3. SEP Events due to Plan-Related Changes
Sometimes, Medicare plan changes are beyond a beneficiary’s control. If a Medicare Advantage or Part D plan with a 5-star rating becomes available, a plan is terminated or violates its contract, or if there are government or employer-related enrollment errors, affected individuals qualify for an SEP. Additionally, those who receive retroactive Medicare entitlement can enroll in appropriate coverage to align with their new eligibility date.
5-Star Plan Becomes Available
If a Medicare Advantage or Part D plan with a 5-star rating becomes available, you can switch to it once per year.
Plan Contract Violation, Termination, or Non-Renewal
If your Medicare plan violates contract terms or stops participating in Medicare, you qualify for an SEP to choose a new plan.
Enrollment Errors Due to Government or Plan Mistake
If an error by Medicare, Social Security, or your insurance provider affects your enrollment, you can enroll or switch plans.
CMS or State Assignment
If CMS or your state Medicaid office assigns you to a plan, you qualify for an SEP to select a different one.
Employer or Group Health Plan Misrepresentation
If an employer misleads you about Medicare coverage, you get an SEP to enroll in Medicare Part B.
Retroactive Medicare Entitlement
If you receive retroactive Medicare benefits, you qualify for an SEP to enroll in Medicare Advantage or Part D.
Leaving Medicare Advantage in First 12 Months
If you joined a Medicare Advantage plan for the first time and want to return to Original Medicare within 12 months, you qualify for an SEP.
Leaving a Medicare Cost Plan
If you voluntarily leave or if a Medicare Cost Plan is discontinued in your area, you qualify for an SEP to choose new coverage.
The table summarizes the specific enrollment periods, available options, and important conditions for each SEP event in this section.
View Eligibility, Allowed Changes & Limitations
| Life Event | Eligibility Period | Changes Allowed | Limitations |
|---|---|---|---|
| 5-Star Plan Becomes Available | Once per year | Switch to a 5-star Medicare Advantage or Part D plan | Limited to available 5-star plans |
| Plan Contract Violation, Termination, or Non-Renewal | Up to 2 months after plan ends | Enroll in a new Medicare Advantage or Part D plan | Applies if the plan is discontinued |
| Enrollment Errors Due to Government or Plan Mistake | Determined case by case | Enroll, drop, or switch plans | Subject to Medicare approval |
| CMS or State Assignment | Determined by CMS or state | Enroll in, drop, or switch plans | Applies if CMS or state assigns a plan |
| Employer Misrepresentation | Starts when reported, ends 6 months later | Enroll in Medicare Part B | Requires documented proof |
| Retroactive Medicare Entitlement | Up to 2 months after notification | Enroll in Medicare Advantage or Part D | Applies if Medicare eligibility was delayed |
| Leaving Medicare Advantage in First 12 Months | Up to 12 months from enrollment | Return to Original Medicare and enroll in Medigap | Only available once in a lifetime |
| Leaving a Medicare Cost Plan | Up to 2 months after leaving | Switch to Medicare Advantage, Part D, or Original Medicare | Applies if cost plan ends or is voluntarily left |
4. SEP Events due to Loss of Coverage
Losing employer-sponsored or other creditable health coverage can leave individuals without necessary healthcare benefits. Whether you lose employer or union coverage (including COBRA) or prescription drug coverage, Medicare provides an SEP to help you transition smoothly to Medicare Part A, Part B, a Medicare Advantage plan, or a Part D prescription drug plan. This prevents coverage gaps and potential late enrollment penalties.
Losing Employer or Union Coverage (Including COBRA)
If you lose employer-sponsored health coverage or COBRA coverage, you qualify for an SEP to enroll in Medicare Part A, Part B, or a Medicare Advantage/Part D plan.
Losing Creditable Drug Coverage (Including Employer/Union)
If your prescription drug coverage is no longer considered "creditable" (comparable to Medicare's standard coverage), you qualify for an SEP to enroll in Part D without a penalty.
QUESTIONS ABOUT MEDICARE PART D?
Learn about Prescription Drug PlansThe following table provides an overview of SEP events due to personal life changes, including eligibility periods, allowable changes, and important limitations to consider.
View Eligibility, Allowed Changes & Limitations
| Life Event | Eligibility Period | Changes Allowed | Limitations |
|---|---|---|---|
| Losing Employer or Union Coverage (Including COBRA) | Up to 8 months after coverage loss | Enroll in Medicare Parts A & B, Medicare Advantage, or Part D | Does not apply if voluntarily leaving coverage |
| Losing Creditable Drug Coverage (Including Employer/Union) | Up to 2 months after coverage loss | Enroll in or switch Part D plan | Must have had prior creditable drug coverage |
How Can Hesteon Help Maximize Your SEP Benefits?
At Hesteon Solutions, we specialize in helping Medicare beneficiaries navigate Special Enrollment Periods (SEPs) to ensure they receive the best possible coverage without unnecessary delays or penalties.
Whether you’ve experienced a life event such as moving, losing employer coverage, or gaining Medicaid eligibility, our licensed agents provide expert guidance on how to use SEPs to enroll in, switch, or enhance your Medicare plan. With personalized support and in-depth knowledge of Medicare, Hesteon ensures that you maximize your benefits, avoid coverage gaps, and make informed decisions during your SEP.
Contact us today for a free consultation and let us help you make the most of your Medicare options!
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