Medicare Part D Special Enrollment Periods

In certain situations, people with Medicare may be eligible for a special enrollment period (SEP)—outside of the annual enrollment period (Nov. 15-Dec. 31)—to join a plan or switch to a different plan that provides Medicare prescription drug coverage.

The chart below describes the different situations in which individuals may be eligible for SEPs.

Ongoing SEPs
Situation Who is eligible?

Change in residence

Individuals who are no longer eligible to be enrolled in a PDP due to a change in residence or those who have new Part D plan options available to them as a result of a move.

Dual-eligibles

Individuals who receive any type of assistance from the Medicaid program or who lose their Medicaid eligibility. This SEP is ongoing for dual eligibles and provides a one-time election for individuals who lose their dual eligibility.

Contract violations

Individuals in a PDP that violates its contract. This is a one-time SEP for individuals to select a new PDP.
Non-renewals or terminations Individuals affected by PDP non-renewals or plan terminations.
Involuntary loss of creditable coverage Individuals who involuntarily lose creditable coverage, including a reduction in the level of coverage so that it is no longer creditable. This is a one-time SEP for individuals to select a new PDP.
Not adequately informed about creditable prescription drug coverage Individuals who were not adequately informed of the creditable status of drug coverage provided by an entity required to give such notice or who were not adequately informed of a loss of creditable coverage. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment.
Enroll in or maintain other creditable coverage Individuals may disenroll from a Part D plan (including PDPs and MA-PDs) to enroll in or maintain other creditable drug coverage (such as TRICARE or VA coverage).
Error by a Federal employee Individuals whose enrollment or non-enrollment in Part D is erroneous due to an action, inaction or error by a federal employee. This one-time SEP is granted on a case-by-case basis and permits one enrollment or disenrollment.
Employer Group Health Plan Individuals enrolling in employer group/union‑ sponsored Part D plans, individuals disenrolling from a Part D plan to take employer/union-sponsored coverage of any kind, or individuals disenrolling from employer/union-sponsored coverage (including COBRA coverage) to enroll in a Part D plan.
CMS sanction Individuals who want to disenroll from a PDP as a result of a CMS sanction of the Part D sponsor. This SEP is granted on a case-by-case basis.
Cost plan Enrollees of HMOs or CMPs that are not renewing their cost contracts (if the individual is also enrolled in a Part D benefit through that cost plan).
PACE Individuals enrolling in PACE. This is a one-time SEP for the individual to disenroll from a PDP.
Institutionalized individuals Individuals who move into, reside in, or move out of an institution such as a SNF, long-term care hospital, etc.
Medicare entitlement determination is made retroactively Individuals whose Medicare entitlement determination is made retroactively and who should have been provided the opportunity to enroll in a PDP during their IEP.
Individuals who enroll in Part B during the Part B General Enrollment Period (GEP) Individuals who are not entitled to premium-free Part A and who enroll in Part B during the General Enrollment Period for Part B (January – March).
New LIS Eligibles Individuals who are not currently enrolled in a Part D plan and who newly qualify for LIS because they have SSI or applied for LIS at SSA or State.
SPAP Individuals who belong to a qualified SPAP may make one enrollment choice at any time through the end of each calendar year (i.e. once per year).
Full-benefit dual eligibles with retroactive uncovered months Full-benefit dual eligibles who voluntarily enroll in a Part D plan in the month(s) before the individual would otherwise have been auto-enrolled.
MA coordinating SEPs There are a number of SEPs that were established to coordinate with MA election period (e.g., SEP65, OEPI, OEPNEW, etc).

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Resources

  • » Part D Special Enrollment Period chart
    In certain situations, people with Medicare may be eligible for a special enrollment period (SEP)—outside of the annual enrollment period (November 15—December 31)—to join a plan or switch to a different plan that provides Medicare prescription drug coverage.
Last Updated: 5/25/2010
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