Appendix A: Medicare Part D - Special Enrollment Periods (SEPs)

Dual-Eligible Individuals or Individuals Who Lose Their Dual-Eligibility

Individuals who have Medicare A and B and are receiving Medical Assistance are eligible for a Part D plan.

There is an SEP for individuals who are entitled to Medicare Part A and/or Part B and receive any type of assistance from the Title XIX (MA) program. This also includes individuals often referred to as “partial duals” who receive cost sharing assistance under MA (e.g. QMB, SLMB, etc). This SEP begins the month the individual becomes dually-eligible and exists as long as she/he receives MA benefits. This SEP allows an individual to enroll in, or disenroll from, a Part D plan. The effective date of the individual’s enrollment in their new plan is the first day of the month following receipt of an enrollment request. However, the effective date for auto-enrollments may be retroactive.

In addition, PDP eligible individuals no longer eligible for benefits under Title XIX benefits will have an SEP beginning with the month they lose eligibility plus two additional months to make an enrollment choice in another PDP, and MA-PD, or to disenroll entirely from Part D

LIS re-determination beneficiaries

Individuals who lose their low income subsidy eligibility for 2012 as a result of the LIS redetermination process. This SEP runs from January through March 2012 and allows for one enrollment election.

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.

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 Cost Maintenance Plans (CMPs) that are not renewing their cost contracts (if the individual is also enrolled in a Part D benefit through that cost plan).

PACE – Program of All Inclusive Care for the Elderly

In Pennsylvania, this is known as the Life Program.

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 an 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 SSI at their local SSA office.

State Pharmacy Assistance Program (SPAP) – Includes PACE Program, Chronic Renal Disease Program and Special Pharmaceutical Benefits Program

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).

All LIS

These individuals now have ongoing SEP just like persons who are dual eligible and can change their Part D at any time.

Individuals enrolled in a Medicare Advantage Plan based on incorrect or misleading information.

This is a one time SEP that allows these individuals to disenroll from the Medicare Advantage Plan and enroll in another Medicare Advantage Plan or a PDP.