Table of Contents:

  1. Updating Medicare Coverage
  2. Which Events Trigger a Special Enrollment Period?
  3. Who Decides If I Qualify? 

Updating Medicare Coverage

The Annual Enrollment Period (AEP), which occurs from October 15th to December 7th, and the Medicare Advantage Open Enrollment Period (occurring between January 1st and March 31st) are the only opportunities most Medicare beneficiaries have to review and change their coverage each year. Beneficiaries have other changes to sign up for or modify coverage under two circumstances.

The first exception is your Initial Enrollment Period. It only occurs during the 7 months surrounding your 65th birthday. Specifically, it begins three months before your 65th birthday on the first of the month and ends three months after your 65th birthday on the last day of the month. This period is not a fixed set of dates each year like the AEP or MAOEP. For instance, if your birthday is in May, your IEP will begin on the first of February and it will last until the final day of August.

The second situation is known as a Special Enrollment Period (SEP). SEPs occur when Medicare beneficiaries have certain life events. Depending on the life event, you will either be eligible to qualify for an SEP 60 days before the event occurs or 60 days after the occurrence of the event.

Which Events Trigger a Special Enrollment Period?

There are three general categories of life event that will qualify you for an SEP. They are: a change of residence, a loss of health insurance, or a change in household.

Change of Residence

You likely qualify for an SEP if you move to a home that is in a new ZIP code or county (even if the new location is within your current plan’s coverage area), move back to the U.S. from abroad, move out of a temporary or transitional home, or move to follow seasonal work. According to Healthcare.gov, you will need to provide evidence that you had qualifying coverage for at least one of the 60 days preceding your move. You will not be considered for an SEP if you change residence (even temporarily) specifically for medical treatment.

Loss of Health Insurance

If you are disqualified from your current form of healthcare or if the provider who offers your Medicare Advantage plan loses their certificate to sell this plan, you are likely eligible for an SEP. Also, If, within the past 60 days, you lost employer-provided health coverage, privately-procured health coverage (coverage you bought yourself on the Marketplace), coverage through a family member, or eligibility for Medicaid or premium-free Medicare Part A, you may qualify for an SEP.

Change in Household

You may qualify for an SEP due to certain changes in your household, which include marriage and birth or adoption of a child. In the case of death, divorce, legal separation, or spousal abuse/abandonment of any member of your household, you will also be considered for an SEP (though qualification is determined on a case-by-case basis). In all of these cases, an SEP will begin after the change in household occurs, should you qualify.

Other Qualifying Scenarios

While the three categories listed above account for nearly all qualifying SEPs, there are a few circumstances outside of these categories where you may qualify. These include: becoming a U.S. citizen, leaving or changing coverage you received from the U.S. military, being released from jail, or in cases where an employer offers to reimburse you (or anyone in your household) for coverage through an HRA or QSEHRA. It may also be possible to qualify for an SEP if you are displaced by a natural disaster or catastrophic event.

Who Decides if I Qualify?

The Health Insurance Marketplace has an eligibility screener that will determine whether you qualify for a Medicare SEP. If you are denied eligibility, but disagree with the decision, you can appeal within 90 days of receipt of the notice of eligibility from the Health Insurance Marketplace.

Information adapted from the Centers for Medicare & Medicaid Services and HealthCare.gov