Do I qualify for a Special Enrollment Period if I have a problem with my private insurance plan?

Jay JohnsonDear Marci0 Comments

sep
Dear Marci,

While I am not anticipating any problems with my private insurance plan, I would like to be prepared for the worst. If difficulties arise, am I allowed to change plans at any time?

Ronald (Bowman, ND)

Dear Ronald,

The short answer to your question is that it depends on the specific difficulties that you are facing with the plan. Under certain circumstances, you may be eligible for a Special Enrollment Period (SEP) to change your Medicare Advantage Plan and/or Part D prescription drug plan outside of the usual enrollment or disenrollment periods. If you get an SEP, your new coverage will usually start the first of the month after your sign up for or disenroll from your plan.

An SEP allows you to change your Medicare Advantage Plan or your stand-alone Part D plan that works with Original Medicare. Here are three common difficulties you might encounter with your plan to warrant an SEP:

  1. Your plan violated its contract with Medicare. If you believe your plan did not follow Medicare’s rules, you may have the right to an SEP, which begins once Medicare determines if the violation occurred and extends for 90 days from the time you disenroll from your current plan. Examples of rule violations include not giving you information about your benefits in a timely manner, not providing benefits to you in a timely manner, the benefits your plan provided not meeting Medicare’s quality standards, or your plan giving you misleading marketing information to get you to enroll, such as promising a zero dollar premium for a plan that does have a premium. Call 1-800-MEDICARE and explain your situation. Be prepared to show how your plan broke Medicare’s rules, e.g., the name of the plan agent who told you wrong information about the plan.
  2. Your plan ends coverage. If there is a plan termination (your plan decides to no longer offer Medicare coverage), you will have an SEP to enroll in a new plan starting two months before the plan ends through one month after the month that the plan ends. Your plan must give you 60 days notice before the date that the plan ends coverage. You can ask that your new plan coverage start the month after you get notice or up to two months after your old coverage ends. If your plan decides to end Medicare coverage at the end of the year, you will have an SEP to enroll in a new plan from December 8 of the current year until the last day of February of the next year. Your plan must notify you by October 1 that it will not offer coverage the following year. Note that this SEP is in addition to the Fall Open Enrollment Period, which runs October 15 through December 7 of each year. During Fall Open Enrollment, you can make any changes to your Medicare coverage. If Medicare ends your plan because the plan violates its contract, you will get an SEP to enroll in a new plan starting one month before the plan ends through one month after it ends. This can happen at any time during the year.
  3. Your plan is under review by Medicare. If your plan is under sanction (Medicare has found a problem with your plan), such as if the plan does not meet Medicare requirements for handling appeals, you can use an SEP to choose a new plan if the sanction directly affects you. The start and length of your SEP is decided on a case-by-case basis. Learn more by reading the Medicare announcement that describes the sanction, or by calling 1-800-MEDICARE.

Ronald, click here to access a chart on Special Enrollment Periods that will help you determine whether or not you qualify for an SEP under these and other circumstances.

– Marci  

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