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What Circumstances Make You Eligible for Medicare’s Special Enrollment?

June 1, 2017

Life doesn’t always go as we expect.

Circumstances out of our control can change at a moment’s notice or we experience natural changes that are a result of the ebb and flow of life.

You may question what a move or a loss of other insurance coverage means for your Medicare Advantage and your prescription coverage.

The good news is that Medicare allows for some Special Enrollment Periods or SEPs.

There are rules that govern the types of changes you can make and when you can make them are different for each individual SEP.

Learn more about the 5 things you should know about Medicare by downloading this free ebook!

Let’s delve into the different special circumstances that can affect your Medicare coverage.

You make a move

A change of address isn’t generally a quick decision, which means you’ll most likely have time to understand what needs to be done to adjust your coverage before you make the move.

  • Your options. In this case, you can switch to a new Medicare Advantage or Medicare Prescription Drug Plan. You also have the option to go back to Original Medicare coverage. 
  • The timing. When the switch will happen depends on when you tell your carrier about the move. If you alert them of the move before the move happens, your window to switch plans is from the month before the month you move until two months after. For example, if you tell your carrier in June that you’re moving in July, the period to make changes begins in June and lasts until September. If you tell your carrier you’ve moved after the move happens, your chance to switch begins that month and continues for two more months.

Current coverage is lost

There are several scenarios in which your coverage could be lost, such as the loss of a job you were covered through, losing drug coverage that’s as good as Medicare drug coverage, or you voluntarily leave the plan.

Whatever the reason is that you lost coverage, you still have some choices.

  • The options. You can join a Medicare Advantage Plan or a Medicare Prescription Drug Plan.
  • The timing. Though the parameters can vary depending on the exact circumstances, the general rule is that your window to make a change is open for two full months after the month in which you lost coverage.

Opportunity for other coverage

You may have a chance to enroll in other coverage through your employer, you may be enrolled in a PACE plan, or you could have the opportunity for coverage through an organization such as the VA.

  • The options. Your only option is to drop your Medicare Advantage Plan with drug coverage or your Medicare Prescription Drug Plan and enroll in the other plan.
  • The timing. If your new coverage is through your employer, you’d make the switch whenever the new plan’s eligibility begins. If the switch isn’t because of a new employer option, you can drop your current coverage at any time.

Medicare’s contract with your plan changes

It’s possible that Medicare could terminate their contract with your specific plan.

  • The options. You will need to make a switch to a different Medicare Advantage Plan or Medicare Prescription Drug Plan.
  • The timing. It will depend on the reason for your plan’s contract change with Medicare. 
  • If the contract was changed due to a sanction by Medicare, your change will be handled on a case-by-case basis.If the contract is terminated by Medicare, your window to change starts two months before and one month after the contract ends. 
  • If Medicare chooses not to renew your plan’s contract, your period in which to change begins on December 8th and ends the last day of February.   

Trying to figure out the details of a change in coverage can be tricky. Consider enlisting an expert insurance advisor to help you.

Have you ever had to navigate a change in your Medicare coverage?

5 Things to know about medicare when you turn 65

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