Medicare Advantange Special Election Period (SEP)

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January 12, 2015

What is a Special Election Period (SEP)?

Special enrollment periods constitute periods outside of the usual IEP for Part D or AEP when an individual may elect a plan or change his or her current plan selection. As detailed below, there are various types of SEPs, including SEPs for dual eligibles, those whose current plan terminates, individuals changing residence and for beneficiaries meeting “exceptional conditions”.

Depending on the nature of the particular special election period, an individual may take a variety of actions, including:

  • Discontinuing enrollment in a Medicare Advantage (MA) plan and enrolling in Original Medicare with a new Part D plan
  • Joining a Part D plan for the first time
  • Switching from one Part D plan to another Part D plan

Certain SEPs may be limited to an enrollment or disenrollment request. If the individual disenrolls from (or is disenrolled from) the PDP, the individual may subsequently enroll in a new Part D plan within the SEP time period. Once the individual’s enrollment in a new Part D plan becomes effective, the SEP ends even if the time frame for the SEP is still in effect. In other words, the SEP ends when the individual’s enrollment in a new Part D plan becomes effective or when the SEP time frame ends, whichever comes first, unless specified otherwise for an SEP.

The following are examples of questions that might be used to determine eligibility for an SEP:

Type of SEP Examples of Questions
Change of Residence Have you recently moved? If so, when? Where did you move from?
Employer/Union Group Health Plan D you currently have (or are leaving) coverage offered by an employer or union?
Have you recently lost such coverage?
Disenroll from Part D to enroll in Creditable Coverage Are you a member of TriCare?
Do you want to obtain VA benefits?
Dual Eligbile Do you currently have Medicaid coverage?
Does the state pay for your Medicaid premiums?
Did you recently receive a yellow letter from Medicare (for full duals)?
Have you recently lost coverage under Medicaid?
Other Low Income Subsidy Do you receive extra help?
Have you recently received a green letter from Medicare?
Did you receive a letter from Medicare letting you know that you automatically qualify for extra help?
Did you receive SSI cash benefits without Medicaid?
How much do you pay for your prescriptions?
Institutionalized Are you moving into or are you a current resident of an institution such as a nursing facility or long-term care hospital?
Are you moving out of such a facility?
PACE For enrollment – are you currently enrolled in a special plan called “PACE”? (Not available in all states.)
Additional SEPs include:

  • Contract violation
  • Non-renewals or terminations
  • Individuals who disenroll in connection with a CMS sanction
  • Individuals enrolled in Cost Plans that are not renewing their contracts
  • Individuals who dropped a Medigap policy when they enrolled for the first time in an MA Plan and who are still in a “Trial Period”
  • Those with End Stage Renal Disease (ESRD) whose entitlement determination was made retroactively
  • Individuals whose Medicare entitlement determination was made retroactively
  • MA SEPs to coordinate with Part D enrollment periods
  • Individuals who lose special needs status
  • Beneficiaries who belong to a qualified SPAP or who lose SPAP elibility (SPAPs are not available in all states)
  • Beneficiaries that are non-dual eligible with LIS and those who lose LIS status
  • Enrollment into a Chrnoic Special Needs Plan (CSNP) and for individuals found ineligible for a Chronic Care SNP
  • Enrollment in an MA Plan, PDP or Cost Plan with a plan performance rating of five stars
  • Beneficiaries turning 65
  • Medicare Advantage Disenrollment Period (MADP)

Ranking of Election Periods

  • ICEP/IEP-D
  • SEP
  • AEP/MADP
  • OEPI

Note: For a complete description of all Special Enrollment Periods, please review the Medicare Managed Care Manual, Chapter 2 – Medicare Advantage Enrollment and Disenrollment.

As always, we thank you for your support and cooperation. For questions or comments, please email us at Compliance@YourMedicare.com or you may call the toll-free number listed below.

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