Do You Qualify for a Special Enrollment Period?

If so, you may be able to change your coverage. This is because Medicare’s Special Enrollment Periods – called “SEPs “ – allow you to leave your Medicare Advantage Plan or your Part D Prescription Drug Plan and enroll in a different plan, even if it is not during Medicare’s annual open enrollment period from Oct 15 – Dec 7 each year. Below, a few of these SEPs are discussed.


Point 1: Know how to determine if you qualify for an SEP because your plan broke Medicare’s rules.

If you believe your plan did not follow Medicare rules, you may have the right to change plans. Here are some examples of rule violations:

  • Your plan did not send you a notice telling you it wasn’t going to cover one of your drugs in 2017
  • Your plan did not provide benefits in a timely manner
  • Your plan did not provide benefits that meet Medicare’s quality standards
  • Your plan gave you misleading or inaccurate information that enticed you to enroll
  • Your plan did not give you information about benefits in a timely manner


If Medicare determines that your plan broke rules, you will qualify for an SEP. The SEP starts once Medicare decides that your plan broke rules. If you enroll in a new plan right away, coverage starts on the first day of the next month. Otherwise, you have 90 additional days to choose a new plan once you disenroll from your current plan. Your new coverage generally starts the first day of the month following the month that the plan receives your enrollment application. In the meantime, Original Medicare covers you.


To see if you qualify for SEP, you can call 1-800-MEDICARE and explain your situation. Your local Health Insurance Counseling & Advocacy Program (HICAP) or your California Senior Medicare Patrol program – called SMP — can also assist you in understanding Medicare’s enrollment periods and the rules that plans must follow. To qualify for this SEP, you must be able to demonstrate how the plan broke Medicare’s rules, so you should keep plan notices. It is also useful to track the names of plan representatives you talk with and the dates you talked with them.


Point 2: Know your right to an SEP if a federal employee makes a mistake with your drug plan enrollment.

You may also have an SEP if a federal employee made a mistake when enrolling or disenrolling you from a drug plan. One example would be if you called 1-800-MEDICARE to enroll in a new Part D plan for 2017 and you now find that you were never enrolled. This SEP starts the month that Medicare approves it and lasts for two more months. To use this SEP, you must be able to show that a federal employee made a mistake. It is useful to have the name of the federal employee who helped you, such as the name of the 1-800-MEDICARE customer service representative you spoke with, the date and time of the call, and the outcome. Call 1-800-MEDICARE to learn if you qualify for this SEP. You can also contact your local HICAP at 1-800-434-0222 for more information about this SEP.


Point 3: Know if you have an SEP because of a plan termination or sanction.

You may have an SEP if your plan ends, which is called a termination. What if your plan decides to end coverage in the midst of a coverage year? You will have an SEP to enroll in a new plan starting two months before the plan ends and up to one month after the month that plan ends. What if your plan announces it will not provide Medicare coverage in the coming year? You will have until the end of February of the coming year to select a new plan. What if Medicare ends your plan because the plan violated its contract with them? You will get an SEP to enroll in a new plan starting one month before the plan ends and up to one month after it ends. This can happen at any time during the year, so pay attention to all notices you receive from your plan and from Medicare.


You may have an SEP if your plan is penalized by Medicare, which is called a sanction. This means that Medicare has found a problem with your plan. One example would be if the plan does not meet Medicare requirements for handling appeals. There are many other potential reasons. The start date and length of this SEP is decided on a case-by-case basis. If this applies to you, you will receive an announcement from Medicare. Read the Medicare announcement for more information, call 1-800-MEDICARE, or contact your local HICAP.


Take Action:

If you have a problem with your Medicare Advantage or Part D prescription coverage, consider whether you are eligible for an SEP.

  1. Contact 1-800-MEDICARE to explain your situation.
  2. Gather required information, including notices from your plan and information from government employees.
  3. Contact your Health Insurance Counseling & Advocacy Program (HICAP) if you have questions about if you qualify for an SEP, or if you want help accessing an SEP.
  4. Contact your Senior Medicare Patrol (SMP) at 1-855-613-7080 if you have questions about Medicare’s plan marketing rules.


This edited Medicare Minute summary is authored by Medicare Rights Center and the SHIP National Technical Assistance Center.