Medicare Special Enrollment Period: Do You Qualify?

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A Medicare Advantage Special Enrollment Period (SEP) allows you to make changes to your Medicare Advantage plan or buy a new Medicare Advantage plan. Normally, you can only change or purchase these plans during the Initial Enrollment Period (IEP) or the General Enrollment Period (GEP) from January 1-March 31 each year.

However, people who experience certain life events are able to switch plans or buy new ones outside of these IEP and GEP periods. Here is our guide to finding out if you might qualify for a Medicare Advantage plan through an SEP:

Who qualifies for Medicare Advantage?

Anyone who qualifies for Original Medicare can qualify for a Medicare Advantage plan. For most people this means you must be 65 or older and a U.S. citizen. Medicare Advantage plans are private insurance policies bought instead of Medicare Parts A and B—aka Original Medicare. To qualify for a specific Medicare Advantage plan it must be offered in the area you live, because these plans are regional. 

What are the three ways to sign up for Medicare Advantage?

The three ways to sign up for or switch Medicare Advantage plans are:

1. During Initial Enrollment Period (IEP): The IEP is a seven-month window that begins three months before your 65th birthday and ends three months after your 65th birthday. During this time, you can buy any Medicare Advantage plan available in your area. 
   

2. During General Enrollment Period (GEP): The GEP occurs each year from January 1-March 31. During this period, if you have already bought into a Medicare Advantage plan, you can switch to a new one or change coverage. You can also sign up for Original Medicare for the first time during this period, but you may be subject to late enrollment penalties. If you do sign up for Original Medicare for the first time during GEP, you become eligible for a Medicare Advantage plan.
   

3. During a Special Enrollment Period (SEP): The SEP is triggered by specific circumstances and allows you to buy or switch a Medicare Advantage plan outside of the usual enrollment widows. See below for more detail on what types of life events can trigger an SEP.

What circumstances could qualify me for SEP?

The SEP is generally triggered by life events that cause a loss of previous health care coverage. SEP-triggering events include: if a spouse who provided coverage divorces or passes away, having a baby or adopting a child, if coverage is lost through an employer, if one moves out of a previous health plan’s service area, if one no longer qualifies for a government assistance program that was providing health care, or if one’s previous health plan doesn’t meet government regulations or goes bankrupt.

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COVID-19 has been considered a special circumstance and people that missed sign-up due to complications in dealing with the pandemic can in most cases get a SEP. In 2021, there is a general enrollment SEP from Feb 15-May 15, 2021.

What is the Medicare 5-Star Special Enrollment Period?

Medicare Advantage plans are each given a star rating 1-5  by Medicare, based on factors such as quality of the plan and performance of the plan. A 1-star rating is considered to have lower quality or performance, while a 5-star rating is considered higher quality or performance. This information is determined by surveys of patients and providers, independent analysis of the facilities, and availability of different types of services.

If you have a Medicare Advantage plan rated lower than 5 stars and a Medicare Advantage plan with a 5-star rating exists in your area, you can switch to it between December 8 of one year and November 30 of the following year. This window is known as the 5-star Special Enrollment Period.

If you had drug coverage through your previous Medicare Advantage plan, you may lose that coverage if you don’t check that the new plan covers the same prescription drugs.

How do I know if I qualify for an SEP?

The best way to check if you qualify for an SEP is to look up your state’s list of SEP life event criteria and see if it matches your experience. If you are unsure if you qualify, you can always talk to an insurance agent who can help you review the best options for switching in your circumstances.