Medicare Advantange 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:

• 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.