All Medicare patients are eligible to change their Medicare Advantage or Medicare Prescription Drug Plan during Open Enrollment (October 15th - December 7th). There's also an additional Medicare Advantage Open Enrollment Period each year (starting in 2019) from January 1st through March 31st during which patients enrolled in Medicare Advantage plans have the option to enroll in a new plan.
But, what if they want to switch their plan outside of these aforementioned Open Enrollment periods? Most patients won't be eligible to, which is why helping your patients during Open Enrollment is imperative. However, there are special circumstances ("Special Enrollment Periods") in which patients are eligible to switch their plan outside of Open Enrollment.
Their living situation has changed:
- They moved to a new address that isn't in their current plan's service area or the new location has additional plan options.
- They moved back to the U.S. after living outside the country.
- They just moved into, currently live in, or just moved out of an institution (i.e. long-term care facility*). If they are moving into or already live in a long-term care facility, patients are eligible to enroll, switch, or dis-enroll every month while in the facility, as well as up to two months after leaving the facility. *A long-term care (LTC) facility provides care for residents who require some form of medical care. These include a skilled nursing facility (SNF), a nursing facility (NF), an intermediate care facility for individuals with intellectual disabilities (ICF/IID), a psychiatric hospital, a long-term care hospital, and a swing-bed hospital.
They lose their current coverage:
- They are no longer eligible for Medicaid.
- They left or dropped creditable coverage from an employer, union, Medicare Cost Plan, or Program of All-Inclusive Care for the Elderly (PACE) plan.
- They are informed their current drug coverage through an employer or union has changed and is no longer considered creditable.
- They involuntarily lose other creditable drug coverage.
Their plan changes its contract with Medicare:
- Their plan is sanctioned by Medicare because of a problem with the plan.
- Medicare terminates their plan's contract or their contract isn't renewed.
Other special situations:
- They are eligible for both Medicaid and Medicare ("Dual Eligible").
- They qualify for Extra Help paying for Medicare prescription drug coverage.
- They enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility.
- They have a severe or disabling condition, and there's a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with their condition.
- They are enrolled in a SNP (Special Needs Plan) and no longer has the chronic condition that qualifies as a special need that the plan serves.
5-Star Special Enrollment Period
- There is a 5-star Medicare Prescription Drug Plan, Medicare Advantage Plan, or Medicare Cost Plan available in their service area, and their current plan does not have 5-star rating from CMS. If so, they have a one-time opportunity to enroll in a 5-star plan in their service area between December 8 - November 30th of each year.
Learn more about best practices for doing dual eligible plan comparisons!