THE LINK BETWEEN YOU AND MEDICARE

This material has been created or produced by CLAIM with financial assistance, in whole or part, through a grant from the Administration for Community Living. Funding is administered through the Missouri Department of Commerce and Insurance and service is provided by Primaris Foundation, a

non-profit organization.

Medicare Special Enrollment Periods

Presentation Objectives

Be able to identify the different Special Enrollment Periods (SEP’s) and who they are applicable to.

Know the time frame of each Special Enrollment Period.

Understand the requirements and provisions of each Special Enrollment Period.

Medicare Advantage (MA) Open Enrollment Period (MA OEP)

3-Month period each year during which you can:

• Switch MA Plans (MA-PD to MA, or MA to MA-PD)

• Drop MA Plan and return to Original Medicare- If you do, you can enroll in a Part D plan- You won’t have a Guaranteed Issue Right for a Medigap policy

You must already be in an MA Plan on January 1 to use this enrollment period.Doesn’t apply to Medicare Savings Accounts (MSAs) or Cost Plans.

StartsJan 1

ContinuesFeb

EndsMar 31

Coverage BeginsFirst of month after you enroll

Medicare Special Enrollments

8-Month period when you can enroll inüPart AüPart BIf you enroll during SEP, you can enroll in üMA (must have Part A and Part B)üPart D (Part A and/or Part B)You have 6 months from the Part B effective date to buy a Medigap policy

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8Month of Retirement

Medicare Special Enrollment PeriodsYou have creditable drug coverage or lose creditable coverage through no fault of your own

You have Medicaid and Medicare, LIS, or MSP

Your plan leaves the Medicare Program or reduces its service area

You enter, live at, or leave a long-term care facility (like a nursing home)

You gain, lose, or have a change in your Extra Help, Medicaid, or MSP status

You are eligible for a Special Needs Plan (SNP) or lose eligibility for your SNP

You join, leave, or lose employer or union coverage

You move out of the service area (permanently change your home address)

Medicare Special Enrollment Periods

You want to disenroll from your first

Medicare Advantage Plan

You want to enroll in/disenroll from PACE

(Program of All-Inclusive Care for the

Elderly)

You have had Medicare eligibility issues

You are passively enrolled into a Part D plan or Dual-eligible

SNP (D-SNP)

You experience contract violations or enrollment

errors

Your plan no longer offers coverage

You disenroll from your Medicare Advantage

Plan during the Medicare Advantage

Open Enrollment Period

You qualify for a new Part B Initial Enrollment

Period when you turn 65

You have been in a consistently low-

performing Medicare Advantage or Part D

plan

You experience an “exceptional

circumstance”

You are enrolled in a State Pharmaceutical Assistance Program

(SPAP)

SEP Provisions

You have an SEP if:You have creditable drug coverage or lose creditable coverage through no fault of your own

If you want to disenroll from Medicare drug coverage to maintain or enroll in credible coverage such as VA, Tri-care, or a State Pharmaceutical Program that offers credible coverage you have an SEP. It can be used to disenroll from an MAP or a part D to enroll into another type of creditable coverage

Your SEP lasts & coverage begins:

The SEP begins the month you are told your coverage will end and lasts for 2 months after you lose your coverage or2 months after you receive notice, whichever is later.

Your Coverage begins the first day of the month after you submit a completed application or up to 2 months after your SEP ends, if you request it.

The SEP lasts 2 months ending after the month your employer or union coverage ends.

Coverage will begin the first day after your plan receives your disenrollment request.

SEP ProvisionsYour SEP lasts 2 months ending after the month I which your employer or union coverage ends. Once you move to or reside in a qualified institution or move out of, you have 2 months to enroll or disenroll from an MAP or part D plan or switch plans.

While in an SNP plan, you can enroll and disenroll for institutionalized people at any time. *NOT before becoming institutionalized or qualifying for an SNP for institutionalized.

You join, leave, or lose employer or union coverage (current or retiree), including COBRA.

You enter, live at, or leave a long-term care facility (like a nursing home) or

You are eligible for a Special Needs Plan (SNP) or lose eligibility for your SNP

SEP Provisions

You have an SEP once per year. If you are automatically enrolled in a part D plan by your SPAP, you will not have this SEP) *You may not drop part D Coverage using this SEP.*You have an SEP for two months after you’re notified of the loss or lose the SPAP (whichever comes later)

YOU ARE ENROLLED IN A STATE PHARMACEUTICAL

ASSISTANCE PROGRAM (SPAP)

YOU LOSE SPAP ELIGIBILITY

SEP ProvisionsRanging from SEP for 3 months after you are notified to once per quarter for the first 3 quarters of the year, depending on which program you have. You can disenroll any time during the 12 mos your MAP first started and return to Original Medicare. Your Initial Enrollment Period of 7 mos.

YOU GAIN, LOSE, OR HAVE A CHANGE IN YOUR EXTRA HELP, MEDICAID, OR MSP

STATUS.

YOU WANT TO DISENROLL FROM YOUR FIRST MAP.

YOU QUALIFY FOR A NEW PART B INITIAL

ENROLLMENT PERIOD WHEN YOU TURN 65.

SEP ProvisionsTrial period is within the first 12 months of having the policy.You can do this any time and the SEP lasts up to two months after the effective date of your disenrollment from the PACE program.If you notify your plan in advance, you have an SEP to switch as early as the month before your move up to two months.

Medigap “trial period” – is dropped to enroll in a MAP for the first time.

Enroll/Disenroll from PACE (program of all-inclusive care for elderly) to join a MAP or part D.

You move (permanently change your home address) out of the plan’s service are or to an area where more plans are available by new coverage.

SEP Provisions

You have had Medicare eligibility issues

You have received retroactive enrollment into

Medicare

You do not have premium-free part A and you enroll

in part B during the general enrollment period.

You lost part B, but still have part A and are

involuntarily disenrolled from your MAP.

You lose eligibility to continue getting coverage

through your SNP.

You’re enrolled in a chronic care SNP, ut your provider fails to confirm

that you have the chronic condition required for

eligibility by the end of the first month of enrollment.

SEP ProvisionsCMS auto-enrolls you in a part D plan after identifying your Extra Help status or a new D-SNP after your previous D-SNP ends.Your MAP or part D plan violated a material provision of your contract.

A federal employee made a mistake in your enrollment/disenrollment in a Medicare part D plan.CMS sanctions a MAP or part D plan and you disenroll because of that.CMS determines your previous drug coverage did not adequately inform you of a loss of creditable coverage or your drug coverage was not creditable.

You are passively enrolled into a Part D plan or Dual-eligible SNP

(D-SNP)

You experience contract violations (such as misleading

marketing) or enrollment errors.

SEP ProvisionsYour MAP or part D plan no longer offers Medicare coverage.

Your MAP or part D plan doesn’t renew its service.

Mid-year, your MAP or part D closes or changes its contract with CMS so you will be forced to disenroll.

CMS terminates your MAP or part D’s contract because of misconduct or other problems.

CMS decides to immediately terminate its contract with your MAP or part D plan.

SEP Provisions

You qualify for New part D Initial enrollment period when you turn 65.You have been in a consistently low-performing MAP or part D plan.Your MAP stops contracting with many of its providers.

You qualify for new part D initial enrollment period to join a stand-alone part D drug plan because you are a person on SSDI who is turning 65.

You have been in a plan that has received an overall Medicare star rating of less than three stars for three consecutive years.

Your MAP stops contracting with many providers in its network during the course of the calendar year and CMS determines these terminations are substantial.

Exceptional Circumstance SEPs

Every year these are granted to Medicare beneficiaries. This is not a new SEP.

The guidance for this SEP is no different than other years: call 1-800-MEDICARE and explain that they have an issue with their plan choice.

There is no deadline for this SEP – they are available throughout the year.

Because this is an Exceptional Circumstances SEP, only CMS is allowed to approve the SEP.

Beneficiaries only have to call in to 1-800-MEDICARE and explain their circumstances. It isn’t our expectation that they will have documentation or screenshots. The call center representatives will assist with the rest of the process.

Examples of Exceptional CircumstancesIf you enrolled in

a Medicare Advantage Plan or Part D plan by mistake or after receiving misleading information, you may be able to disenroll and change plans.

Typically, you have the right to change plans if you:

Joined unintentionally: You may have enrolled believing you were joining

a Medigap plan to supplement Original Medicare. Or, you meant to sign up for a stand-alone Part D plan and accidentally

joined Medicare Advantage

Joined based on incorrect or misleading information: You may have

been misled for example if a plan representative told you that your

doctors are in the plan’s network but they are not, or you were promised

benefits that the plan does not really cover.

Through no fault of your own, ended up or were kept in a plan you do not

want: If you tried to switch plans during an enrollment period but were

kept in your old plan. You can also make a change if you were enrolled in a plan because of an administrative or

computer error.

Examples of Exceptional Circumstances

Your disenrollment steps process depends on whether or not you have used services.

If you used any service since joining the plan (for example, saw a doctor or filled a prescription) and received a denial of coverage, you should request retroactive disenrollment, meaning disenrollment back to the date you enrolled in the plan. Depending on your situation, you may then wish to select Original Medicare (with or without a Part D plan) or a different Medicare Advantage Plan. If you are granted retroactive disenrollment, be sure to ask your providers to re-file claims with your new plan.

If you have not used any services since joining the plan, you may want to request a Special Enrollment Period (SEP) to disenroll from your plan. This option may be processed faster than retroactive disenrollment. If your request is granted, you will be disenrolled from your plan at the end of the month in which you made the request. To prevent gaps in coverage, sign up for new coverage immediately after you are disenrolled from the plan you did not want.

Questions?

Kori Ross, Region 6 Liaison and Trainer kross@primaris.org

1-800-390-3330 CLAIMwww.missouriclaim.orgwww.medicare.gov