What is a Special Enrollment Period?
A SEP is a time outside of the Annual Enrollment Period (AEP) during which eligible Medicare beneficiaries can make changes to their Medicare plans. These changes could include switching from Original Medicare to a Medicare Advantage plan, changing Medicare Advantage plans as well as adding or changing a Prescription Drug plan.
SEPs are available for specific situations, such as:
- Losing other heath coverage
- Moving to a new service area
- Qualifying for Medicaid
- Returning to the U.S. after living abroad
These SEPs are essential because they allow individuals to avoid penalties or delays in receiving coverage when their circumstances change.
Key changes to SEPs in Medicare for 2025:
Starting in 2025, CMS eliminated the quarterly SEP that allowed dual eligible and Low-Income Subsidy (LIS) beneficiaries to make Medicare Advantage plan changes on a quarterly basis (quarters 1-3).
The quarterly SEP was changed to:
- A monthly SEP allowing all dual eligible beneficiaries that qualify for LIS to leave their Medicare Advantage Prescription Drug (MAPD) plan for Original Medicare and join a standalone Prescription Drug Plan (PDP) or switch to a different PDP.
- A monthly integrated SEP allowing ONLY full-benefit dual eligible beneficiaries to switch between integrated Dual Special Needs Plans (D-SNPs) with aligned Medicaid plans.
- The Integrated SEP (INT-SEP) can be used one time per month with an effective date the first of the following month for full dual beneficiaries.
- Eligible plans include:
- FIDE SNP: Fully Integrated Dual Eligible Special Needs Plan
- HIDE SNP: Highly Integrated Dual Eligible Special Needs Plan
- AIP: D-SNP Applicable Integrated Plan
- Eligible plans include:
- The Integrated SEP (INT-SEP) can be used one time per month with an effective date the first of the following month for full dual beneficiaries.
Dual eligible beneficiaries have the option to change plans throughout the year. These changes aim to provide beneficiaries with more consistent opportunities to align their Medicare coverage with their current health needs and personal situations. However, it is crucial to understand the specific limitations of the monthly SEP to avoid any unintended disruption in coverage.
Disaster/Emergency SEP
The Medicare SEP for Disaster/Emergency, also known as the FEMA Disaster SEP, allows beneficiaries affected by a federally declared disaster or emergency to make changes to their MAPD or PDP outside the standard enrollment periods. This SEP provides flexibility for individuals who may have experienced disruptions in healthcare services or faced challenges in managing their coverage due to natural disasters, pandemics, or other emergency situations. The SEP typically lasts for a limited time, starting from the declaration of the disaster and extending for a specific period. During this time, beneficiaries can enroll in, switch, or drop their Medicare plans.
In conclusion, the changes to SEPs for 2025, reflect a broader effort to provide beneficiaries with more flexibility and access to essential healthcare coverage. Its important for beneficiaries to stay informed about new rules and take advantage of opportunities they offer, so they can continue to receive the care and support they need.
If you need help deciphering SEPs, call Hovis & Associates at (888) 613-6196.