Can You Change Medicare Plans Outside Open Enrollment? Special Enrollment Periods Explained

The Normal Windows, and Why SEPs Exist

Most people make plan changes during the Annual Enrollment Period, which runs October 15 through December 7 each year, with new coverage starting January 1. If you are in a Medicare Advantage plan, there is also a Medicare Advantage Open Enrollment Period from January 1 through March 31, which lets you make one change, such as switching to another Advantage plan or returning to Original Medicare. Our post on the Annual Enrollment Period dates and rules covers those windows in depth.

Special Enrollment Periods fill the gaps. The reasoning is that some events change what a plan can offer you or what you are eligible for, and it would be unfair to make you wait up to a year to respond. An SEP is a rule that says, in effect, “this event gives you a window to choose again.”

Three general principles hold for nearly all of them:

• You need a qualifying event. According to CMS guidance, a plan may ask you to attest that you are eligible for an enrollment period, but it may not require evidence, and it has to deny the enrollment if you are not eligible.
• The window has a start and an end. Miss it, and you generally wait for the next regular period.
• Most SEPs apply to Medicare Advantage and Part D plans. They do not usually open a window to buy a Medigap policy, which has its own, separate rules.

The details below come from the enrollment guidance CMS publishes for plans and from Medicare.gov. Timing can differ based on your situation, so treat this as a map rather than a substitute for checking your own dates.

If You Moved

A move is the most common reason people use an SEP. According to CMS guidance, you qualify if you permanently move outside your plan’s service area, if you move back to the United States after living abroad, if you were released from incarceration, or if a permanent move gives you new Medicare Advantage or Part D options you did not have before.

The timing depends on when you tell your plan. If you notify the plan before the move, the window begins the month before you move. Otherwise it begins on the date of the move. In either case, it runs for two months after the month it begins, or two months after the month of the move, whichever is later. Medicare.gov describes it as the chance to switch continuing for two full months after you move. Telling your plan about the move early is what lets the window start a month ahead.

If Your Plan Ends or Leaves Your Area

When a plan stops operating in your area, the length of your window depends on who ended it. CMS describes three cases:

The table below lists the most common events and their windows, based on CMS guidance.

Event	Typical window
Permanent move out of your service area	Starts the month before the move if you notify your plan early, otherwise on the move date; ends two months after the move month
Plan non-renews on January 1	December 8 through the last day of February
Plan or sponsor ends the contract	Two months before through one month after termination
CMS ends the contract	One month before through two months after termination
Employer or union coverage ends	Through two months after the month it ends
Involuntary loss of creditable drug coverage	Notice date through two months after the loss or notice, whichever is later

• If the plan non-renews its contract or reduces its service area effective January 1, the SEP runs from December 8 through the last day of February.
• If the plan or its sponsor terminates the contract, or it is terminated by mutual consent, the SEP begins two months before the termination date and ends one month after the month of termination.
• If CMS itself terminates the contract, the SEP begins one month before the termination date and ends two months after.

For those who don’t choose a new plan, a Medicare Advantage enrollee generally falls back to Original Medicare when the plan ends, and a stand-alone Part D enrollee is disenrolled, leaving them without drug coverage. We take a closer look at that scenario in a separate post about what happens when an insurer leaves your area. For people moving back to Original Medicare because their Advantage plan is leaving Medicare or no longer covers their area, Medigap has its own guaranteed-issue timing, which Medicare.gov describes as starting 60 days before the Advantage coverage ends and running no more than 63 days after it ends.

If You Lose Other Coverage

Employer, union, and retiree coverage can affect your timeline. According to CMS guidance, there is an SEP tied to enrolling in or leaving employer or union sponsored coverage, which ends two months after the month that coverage ends. Medicare.gov describes the window after losing employer or union coverage as two full months.

Drug coverage has its own version. If you involuntarily lose creditable prescription drug coverage, or it is reduced so that it is no longer creditable, the SEP begins when you are notified and ends two calendar months after the loss or the notice, whichever is later. “Creditable” means the coverage is expected to pay, on average, at least as much as standard Medicare drug coverage. This matters because a gap of 63 days or more without creditable drug coverage can trigger a lifetime late-enrollment penalty, so acting inside the window protects you. Our guide to Medicare while working past 65 covers the employer-coverage side.

If You Qualify for Medicaid or Extra Help

People with Medicaid or the Part D Low-Income Subsidy (Extra Help) have more flexibility than most. CMS describes one SEP that lets dual-eligible and other low-income subsidy enrollees enroll once per month into a stand-alone prescription drug plan. It does not allow moving into or between Medicare Advantage plans that include drug coverage, so it is narrower than people sometimes assume.

A second SEP applies when you gain, lose, or have a change in Medicaid or low-income subsidy status. Medicare.gov describes this as a window that lasts three full months from the date you are no longer eligible or the date you are notified, whichever is later, and CMS describes it as a one-time change for your Part D drug coverage. A third, narrower one lets people with full Medicaid benefits join or switch to certain integrated dual-eligible special needs plans once per calendar month. Because rules around dual eligibility have changed in recent years, it is wise to confirm the current details for your situation. Our posts on Medicare Savings Programs, Extra Help, and dual-eligible special needs plans explain those programs.

If You Move Into or Out of an Institution

If you move into, live in, or move out of an institution such as a skilled nursing facility or long-term care facility, you can enroll in or disenroll from a Part D plan. The window begins when you move in or out, continues while you reside in the institution, and ends two calendar months after the month you move out. Medicare.gov’s page on enrollment periods describes similar timing for living in or leaving nursing homes and rehabilitation facilities. For Medicare Advantage, CMS also has a separate open enrollment period for institutionalized people, which lets them join, leave or change an Advantage plan on a similar timeline.

Other Situations That Can Open a Window

CMS guidance lists many more specialized SEPs. A few that come up in real life:

• A significant change in your plan’s provider network, when CMS determines the change is significant and you are affected. It begins the month you are notified of eligibility and ends two calendar months after.
• A government-declared disaster or emergency, if you live in an affected area (or rely on someone there for help with health care decisions) and did not use another election period because of it. Under CMS guidance the window generally runs until two full calendar months after the end of the declared emergency or disaster.
• A plan that CMS identifies as a consistent poor performer, or that is placed in receivership.
• The five-star plan SEP, which lets you enroll in a plan with an overall rating of five stars once during the period from December 8 through November 30 of the following year, if one is available where you live. Our post on what Star Ratings measure and don’t is worth reading before you rely on a rating.
• Becoming lawfully present in the United States, or an error by a federal employee that affected your enrollment.
• An exceptional circumstance, which requires CMS approval.

Some of these require CMS to approve the situation before the SEP exists, so you generally will not qualify just because a particular circumstance sounds like it fits. Also note that a plan merger or consolidation is not a plan ending for SEP purposes, so people whose plan was simply folded into another one are generally moved over without getting this SEP. If you think one applies, ask the plan or call 1-800-MEDICARE.

What Doesn’t Qualify

Because SEPs are narrow, it helps to say what usually doesn’t open one:

• Your premium went up or you do not like the benefits.
• A drug was dropped from the formulary, or moved to a higher cost tier, in the middle of the year.
• You joined a plan and later realized a doctor wasn’t in its network.
• You want to switch to a plan that has a better rating, unless it is a five-star plan and you meet that SEP’s rules.
• You want to move from a Medigap policy to Medicare Advantage, or the other way around, outside a regular enrollment period or one of the trial-period rules.

If you joined a Medicare Advantage plan around your 65th birthday, or dropped a Medigap policy to join a Medicare Advantage plan for the first time, you may have a 12-month trial period. CMS lists these as their own special enrollment periods, which let you leave for Original Medicare during the first year, and the Medigap side of the trial right is a separate set of rules. Our post on Medicare Advantage trial rights explains how it works. And if you simply want to leave Advantage for Original Medicare, our guide on switching back to Original Medicare explains the options and the Medigap catch.

How to Use an SEP Without Missing It

A few habits make these windows easier to use:

• Write down the date the event happened and the date you were notified. Many SEP clocks start from one of them.
• Contact the new plan, or call 1-800-MEDICARE, and tell them the reason you are enrolling. Expect to be asked to confirm that you qualify, which is usually an attestation rather than paperwork.
• Ask for the effective date. In many cases it is the first of the month after the plan receives your request, although some SEPs allow a later effective date.
• Check your drug list and your doctors for the new plan before you enroll. Our network-checking guide shows how.
• Keep confirmation of your request until your coverage starts.

Because most SEPs are measured in months, a delay of a few weeks can matter. If the event is a move or the end of a plan, you can often begin acting before it happens, which keeps a gap in coverage from opening up.

A Step-by-Step Way to Use a Special Enrollment Period

The rules look complicated on paper, but the process of using one follows a fairly consistent path. Here is the sequence, with notes on where people slip.

• Identify the event. Write down what happened and the exact date. A move has a move date. A plan ending has an end date on the notice. A loss of employer coverage has a date the coverage stopped. Most SEP clocks start from one of these dates, or from the date you were notified.
• Match the event to a window. Use the table above, the CMS guidance, or a call to 1-800-MEDICARE or a State Health Insurance Assistance Program (SHIP) counselor to confirm which period applies and when it ends.
• Decide what you are changing to. Options usually include another Medicare Advantage plan, a stand-alone Part D plan, or Original Medicare. Remember that some SEPs only allow certain moves. The Extra Help SEP, for example, allows a monthly change into a stand-alone drug plan but not into or between Medicare Advantage plans with drug coverage.
• Check the new plan before you enroll. Look up your doctors, hospital, pharmacy and every medication. Our plan comparison checklist works at any time of year.
• Submit the enrollment request inside the window. You can apply through the plan, through Medicare.gov, or by phone. Say that you are using a Special Enrollment Period and name the reason.
• Confirm the effective date. Several SEPs let you pick an effective date up to a few months out. The CMS guidance describes this for moves and employer coverage, with the date never earlier than the plan receiving your request.
• Keep the confirmation, and watch for your new member materials and card before the effective date. Do not cancel an old arrangement, if you still have one, until you know the new one is in place.

How It Plays Out for Each Kind of Coverage

SEPs mostly govern Medicare Advantage and Part D, so what they mean depends on what you have today.

If you have Original Medicare with a Medigap policy and no drug plan changes, an SEP generally isn’t needed to keep your coverage. It becomes relevant for your drug plan, and it can matter if you decide to move into Medicare Advantage. Remember that moving from Medigap into Advantage is easy at the right time, but moving back later may involve health questions for a new Medigap policy outside of guaranteed-issue situations. Our posts on switching back to Original Medicare and trial rights explain that catch.

If you have a Medicare Advantage plan with drug coverage, most SEPs let you move to another Advantage plan or to Original Medicare. If you choose Original Medicare you will usually need a stand-alone drug plan, and CMS guidance describes coordinating drug-plan windows that go with the Advantage SEPs. Going without creditable drug coverage for 63 days or more can lead to a late-enrollment penalty, so line the two up.

If you have a stand-alone Part D plan, the SEPs that matter most are a move, a plan ending, loss of creditable coverage, and the low-income ones. The windows are tight, and being without drug coverage is the main risk.

If you have employer or retiree coverage, the SEPs for joining or leaving that coverage can be useful, but they interact with Part B timing rules, such as the eight-month Part B special enrollment period after employment or group coverage based on current employment ends. Our guide to Medicare while working past 65 covers that side.

Scenarios

None of these is a real person, and the details are simplified.

Picture a retiree whose Advantage plan sent a notice that it will not be offered next year. She has two chances. She can choose during the fall Annual Enrollment Period, with coverage beginning January 1, or she can wait for the special window that runs from December 8 through the end of February. If she waits and picks in January, coverage starts February 1, and the first month would be Original Medicare unless she acts earlier.

Picture a man who retired and lost job-based drug coverage that was creditable. His window runs through two months after the month coverage ends, or the notice date, whichever is later. If he lets 63 days pass without any creditable drug coverage, he risks a penalty, so for him the calendar matters more than the choice of plan.

Picture a couple who are moving to another state in the spring. If they tell their plan before the move, the window starts the month before. They can compare plans in the new area while still covered on the old one, and pick an effective date no earlier than the date they move and the plan receives the request.

Picture a person who joined a plan after a salesperson gave misleading information. This is not one of the routine SEPs, but CMS describes case-by-case exceptional circumstances for situations such as being enrolled based on misleading or incorrect information from a plan representative or SHIP counselor, or being enrolled without knowledge or consent. These require CMS review, so the practical step is to call 1-800-MEDICARE promptly and describe what happened.

Costly Mistakes to Avoid

• Waiting until the last week. Most windows are measured in months, and effective dates usually fall on the first of a month, so a late request can leave a gap.
• Assuming the plan will fix the gap for you. A Medicare Advantage plan that ends defaults you to Original Medicare. A stand-alone drug plan that ends disenrolls you. Neither will find you a new plan.
• Using a one-time SEP too early. The network-change SEP and the five-star plan SEP can each be used only once in the relevant period, so don’t spend them on a plan you have not checked.
• Dropping a plan before the new one is confirmed. Wait for confirmation of the new enrollment.
• Forgetting the drug plan. Many people who change medical coverage forget that prescriptions need their own coverage.
• Believing a plan change fixes a Medigap problem. An SEP does not give you a right to buy a Medigap policy without health questions. Those rights come from different rules.

What to Do If a Request Is Denied or Something Goes Wrong

If a plan tells you that you aren’t eligible for a Special Enrollment Period, ask what reason it is giving, and ask whether another enrollment period might apply, such as the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period. Call 1-800-MEDICARE and ask about your options. A SHIP counselor can help you work through it at no cost.

If you missed a window because of circumstances beyond your control, such as a serious medical emergency that covered the entire period, CMS guidance says it can consider an exceptional circumstance SEP. Document what happened, including dates, and ask 1-800-MEDICARE how to request it.

Our post on the Annual Enrollment Period and our overview of Medicare Advantage plans are good next reads if you want to compare what you would be moving into.

Frequently Asked Questions

Can I switch Medicare Advantage plans anytime?

No. You can generally switch during the Annual Enrollment Period, during the Medicare Advantage Open Enrollment Period from January 1 through March 31 if you are already in an Advantage plan, or when a Special Enrollment Period applies.

How long does a Special Enrollment Period last?

It depends on the reason. Many last two months, some start a month before an event, and a few run longer, so check the specific rule for your situation.

Does a Special Enrollment Period let me buy a Medigap policy?

Not on its own. Medigap has separate rules, including a six-month open enrollment period when you first have Part B and guaranteed-issue rights in specific situations.

Does losing my employer coverage give me a Special Enrollment Period?

Generally yes. CMS describes a window that ends two months after the month the employer or union coverage ends, and Part B has its own separate eight-month window after employment ends.

Can I change plans because my doctor left the network?

Only if CMS has determined the network change is significant and it affects you. Otherwise you may have to wait for the next regular enrollment window.