Seasonal

Special Enrollment Period (SEP), when you can change plans outside AEP

5 min read

Most plan changes happen in the fall during AEP. But life doesn't always run on a calendar. If your parent recently moved, lost employer coverage, got or lost Medicaid, or qualified for Extra Help (LIS), a Special Enrollment Period (SEP) may apply, and there's no need to wait until October.

What SEP is, in one sentence

A Special Enrollment Period is an exception to the rule. The rule is that a Medicare Advantage plan (Part C) or a Part D prescription drug plan changes once a year, between October 15 and December 7. SEP lets your parent do it at another time, provided a specific qualifying life event has occurred.

The most common situations that trigger SEP

The full federal list is longer, but these are the ones we see most often in our practice:

A move

An address change outside the current plan's service area, for example, moving from Illinois to Florida for the winter or relocating from Chicago to another state, opens an SEP. Usually 2 months from the date your parent notifies the plan about the move.

Loss of employer coverage

If your parent or their spouse retires and loses workplace coverage, a 2-month window opens to join a Medicare Advantage plan or Part D plan.

Getting or losing Medicaid

If your parent has Medicaid or gets Extra Help, they can switch to a different stand-alone drug plan (Part D) once a month, or leave a Medicare Advantage plan and return to Original Medicare with a stand-alone drug plan. The change takes effect on the first day of the next month. This monthly option is not available to someone their plan has identified as at risk, or potentially at risk, of misusing certain prescription drugs under its drug management program. People with full Medicaid benefits can also join an integrated D-SNP, a plan that coordinates their Medicare with their Medicaid plan, once a month, if one is available in their area. Not every D-SNP is integrated. After getting, changing or losing Medicaid, a separate window opens for 3 full months from the change or from the notice about it, whichever is later.

Getting or losing Extra Help (LIS)

Works similarly to Medicaid. A status change opens a window to adjust the drug plan.

Enrollment error or misleading information

If your parent was enrolled in a plan by mistake or based on incorrect information, they can reverse the enrollment and pick a different plan. This requires documentation.

5-star plan

Once a year, between December 8 and November 30, your parent can switch to a plan with the highest CMS rating (5 stars), if one is available in their area.

Newly obtained legal U.S. residency

A newly granted right to Medicare opens its own enrollment window.

That isn't the full list. The complete one is at Medicare.gov. But if you recognize your parent's situation in any of these, it's worth checking, because most of these windows are short: usually 2 months after a move or loss of employer coverage, 3 months after a Medicaid change. The exception is the monthly option for people with Medicaid or Extra Help, described above.

What SEP doesn't cover

SEP applies to Medicare Advantage and Part D plans. It doesn't apply to basic Medicare enrollment (Part A and B). Those follow different rules and have their own enrollment periods. If your parent is just turning 65 or enrolling in Medicare for the first time, we cover that in our enrollment guide.

SEP also isn't a reason to switch plans "just because." If your parent doesn't like their plan, but none of the situations above apply, they most likely need to wait until AEP. The exception is the MA-OEP window (January 1 to March 31), when people already enrolled in Medicare Advantage can make one change or return to Original Medicare.

A single doctor leaving your parent's plan generally does not trigger an SEP on its own. You may qualify, however, if the departure represents a "significant change" to the network, such as a major hospital system dropping the plan. If you qualify, you usually have 60 days from the notification date to switch plans.

What we need to help

If you think SEP may apply, please have on hand:

• your parent's Medicare card and the name of their current plan (if they have one),
• a document confirming the qualifying event, a letter about loss of employer coverage, a Medicaid decision, moving documents,
• a list of prescription drugs and the names of doctors your parent uses.

With that in hand, you can call us or set up a no-obligation meeting. We'll check whether an SEP actually applies and whether the new plan covers what your parent needs.