Definition · Pharmacy, Medicare enrollment, and access

Special Enrollment Period (SEP)

A Special Enrollment Period (SEP) is a window outside the regular Medicare enrollment periods. It lets a beneficiary join, switch, or drop a Medicare Advantage or Part D plan after a qualifying event. Common triggers include moving out of a plan's service area, losing employer or other coverage, and a plan earning a 5-star rating.

What a Special Enrollment Period is

Medicare's main windows are the Annual Enrollment Period in the fall and the Medicare Advantage Open Enrollment Period early in the year. SEPs cover what happens in between. When certain life events happen, a beneficiary gets a limited window to change Medicare Advantage or Part D coverage. The allowed change and the deadline depend on which SEP applies.

Moving is a common trigger. If someone moves out of their plan's service area, the window starts when they move, or the month before if they tell the plan first, and lasts 2 full months after the move. Losing employer or union coverage opens a window that lasts 2 full months after the month that coverage ends. The 5-star SEP lets someone switch into a 5-star plan once between December 8 and November 30.

People with Medicaid or Extra Help have their own SEP rules, separate from the general ones, and those rules have changed in recent years. Some SEPs require proof of the event, such as a move date or a letter ending other coverage. Agents need to confirm which SEP applies, and document it, before helping someone enroll.

Questions

Special Enrollment Periods, answered

What qualifies you for a Medicare Special Enrollment Period?

Common qualifying events include moving out of your plan's service area and losing employer or union coverage. Others include losing creditable drug coverage and moving into or out of a nursing home. Each event has its own window and its own allowed changes, so check the specific rule.

What is the 5-star Special Enrollment Period?

Some Medicare Advantage plans, Part D plans, and Medicare Cost Plans earn a 5-star quality rating. If one serves your area, the 5-star SEP lets you switch into it. You can use it only once between December 8 and November 30 of the following year.

Do people with Medicaid or Extra Help get a Special Enrollment Period?

Yes. People with both Medicare and Medicaid, and people who get Extra Help with drug costs, have their own SEP rules. Those rules differ from the general SEPs and have changed in recent years, so confirm the current rule on Medicare.gov before acting.

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What a Special Enrollment Period is

Special Enrollment Periods, answered

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