By Sara Duris
Q. What’s the difference between Initial Enrollment or a Special Enrollment in Medicare?
A. When you turn 65, you are eligible to enroll in Medicare. This is your Initial Enrollment period, spanning seven months — the three months before you turn 65, your birthday month, and the three months after your birthday. This is also the time when you can choose to add a Medicare Supplemental or Medigap plan. If an individual chooses to enroll in Medicare Part C, otherwise known as a Medicare Advantage plan, that person has a “trial period” of up to 12 months in which they can choose to enroll in original Medicare parts A and B with a Part D drug plan. At this time, they would also get a “guaranteed issue right” to purchase a Medigap supplemental plan. Under federal law, this right lasts for 63 days after disenrollment from the Medicare Advantage plan.
Once you have either Medicare parts A and B with a Part D drug plan, or Medicare part C, an Advantage plan, you can generally only change plans during Open Enrollment, which lasts from October 15 to December 7, each year. Medicare Advantage plan clients have an additional Open Enrollment for three months, from January 1 until March 31, to change back to original Medicare or switch to a different Advantage plan.
Special Enrollment Periods (SEP) allow individuals to change their Medicare coverage outside of Open Enrollment, when certain specific conditions are met. These are specific enrollment periods that apply to individuals eligible for delayed enrollment in Medicare Parts A, B, C, and D. SEPs are only available if you’re affected by a qualifying life event, such as losing your existing health coverage, moving to another state, or entering or leaving a nursing facility, to name just a few. Medicare SEPs give you a chance to enroll in a plan without penalty.
There are specific requirements to each kind of SEP, such as whether you have delayed enrolling in Part A or Part B, or are changing to a Medicare Advantage Plan or enrolling in a drug plan for the first time. Each SEP also has its own timeframe, too, which can range from two to eight months depending on the scenario.
If you have questions about qualifying for a SEP, contact 1-800-MEDICARE (1-800-633-4227) to talk to a customer service representative. You can also visit the Medicare website (www.medicare.gov) and start a live chat. Additionally, our local State Health Insurance Assistance Program (SHIP) can provide unbiased, no-cost information. Call 269-408-4354 for assistance.
Q. An insurance agent sold me on a different Medicare Advantage plan and told me all my doctors were in their network, but I recently found out that my cardiologist doesn’t accept the new plan. Can I still change back to my old plan?
A. If you enrolled in the wrong Medicare Advantage or Part D plan by mistake or after receiving misleading information, you might be able to disenroll from the plan and enroll in a new plan that is a better fit for your needs.
According to information from the National Council on Aging (NCOA) there are a few scenarios where you have a right to change plans:
- You enrolled in a plan unintentionally.
- You enrolled in a plan based on incorrect or misleading information.
- You accidentally enrolled in the same plan or stayed in a plan you didn’t want.
If you think you fall into one of the above scenarios, the first step is to call 1-800-MEDICARE or start a live chat on Medicare.gov. Be sure to explain in detail how you ended up joining the wrong plan.
Generally, you have two options for disenrollment from a Medicare plan you do not want:
If you received any health care services since joining the plan and coverage was denied, you can request a retroactive disenrollment. This means you will be disenrolled from the plan going back to the date you enrolled in it. In this case, your providers will need to re-submit your claims to your new Medicare plan.
If you have not received any health care services since joining the plan, you can ask for a Special Enrollment Period (SEP — see previous question.) Once you’re approved, this will allow you to disenroll from your Medicare plan at the end of the month in which you requested disenrollment. You should enroll in a new plan immediately to avoid any costly coverage gaps.
Sara Duris is the Professional Referral Specialist on the Information & Access Team at Region IV Area Agency on Aging. The Generations column appears each weekend in The Herald-Palladium.