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Changing Medicare Coverage Outside Open Enrollment Possible Under Special Circumstances

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Changing Medicare coverage is a tricky business. Officially, the rules say that, once open enrollment is over, that’s it – you’ve made your choice for the coming year. Sure, there’s a do-over period for the Medicare Advantage folks during the first quarter each year, but otherwise it’s settled. You’re effectively locked in to the plan you’ve picked.

Or are you? As it always turns out with anything Medicare-related, things are never quite that simple. As you dig a little deeper into the rules governing Medicare, you’ll find that, in fact, there is a rather long list of reasons why you just might be able to switch plans completely outside of open enrollment. To guide our discussion, we’re relying on this report from KFF (formerly the Kaiser Family Foundation) which we found in the “frequently asked questions” section on their website.

We’re also going to take a look at the definitive info straight from the Medicare website – all in an effort to provide you with “news you can use” about changing your Medicare coverage. All we can do here is cover a few highlights, so you’ll need to do some homework for the complete picture as it applies in your situation.

Changing Medicare Coverage: the “Special Enrollment Period”

The KFF article starts right in by asking and then answering the frequently asked question, “Can I change my Medicare coverage outside of the open enrollment period?”

“You can,” the article responds, “but generally only under special circumstances that qualify you for a Special Enrollment Period (SEP). These circumstances include (but are not limited to) moving to a new location that is outside of your current plan’s service area or where additional plan options are available, moving back into the U.S. after living abroad, moving into or out of a facility, termination of Medicaid eligibility, or if Medicare terminates your current Medicare Advantage plan.”

For a more complete recitation of all the events that can qualify you for a Special Enrollment Period, the KFF article contains a link to the Medicare website and a webpage called “Special circumstances (Special Enrollment Periods).” We decided to head over there for a closer look.

Plenty of Allowances for Changing Medicare Coverage

When we clicked on the link, it took us to a site with the heading Special Enrollment Periods. “You can make changes to your Medicare Advantage and Medicare drug coverage when certain events happen in your life, like if you move or you lose other coverage,” the official site says. “These chances to make changes are called Special Enrollment Periods (SEP). The types of changes you can make and the timing depend on your life event.”

After that simple statement, things get complicated. The Medicare site lists several broad categories of life change, including:

*If you change where you live;

*If you lose your current coverage;

*If you have a chance to get other coverage (such as employer coverage);

*If your plan changes the terms of your Medicare contract mid-year;

*Other special situations (the site lists more than a dozen of these).

A Few Common Reasons Why Changing Coverage is Allowed

We lack the space here on the Blog to begin to cover all the SEP contingencies, but here are a few scenarios we think might be more common. Note that this list is not exhaustive – make sure you get good professional advice from a Medicare broker or other expert about your situation.

Change of Address: If you move out of your plan’s service area, you’ll be allowed to enroll in a new plan even if it’s not during open enrollment. Similarly, if you’ve been living outside the U.S., you’ll have two months following your return during which you can re-enroll. Residents moving into or out of skilled nursing facilities have similar flexibility.

Loss of Coverage: Several changes (many of them beyond your control) can affect your coverage outside the open enrollment period. For example, if you have recently lost eligibility for Medicaid, you have several Medicare enrollment options any time during the year. Similarly, if you have other drug coverage besides Medicare that changes its terms to reduce your coverage, you can likely sign up either for a new Medicare Advantage plan or for Part D drug coverage.

Loss of Medicare Contract: You may find that the plan you’re on loses its contract with Medicare. This can happen because the plan hits a financial crisis and gets taken over by state officials. At times Medicare issues a sanction against some insurance plans, or even terminates a plan’s contract, in which case you have enrollment options for new coverage.

As noted above, there’s another long list of particular circumstances in which the prohibition against changing plans outside of open enrollment is waived. Check out the website, and then plan to sit down with a Medicare advisor who can guide you.

More Factors That Can Affect Freedom to Change Coverage

The KFF article adds a few more tidbits of information that may apply to you or to someone you know. Bottom line is, under certain circumstances, qualifying beneficiaries may have the flexibility to change plans multiple times per year.

“Some beneficiaries can change coverage on a quarterly basis,” KFF explains. “This includes enrollees who receive assistance from Medicaid and enrollees who receive Extra Help paying their Medicare drug plan premiums and cost sharing, who can switch Part D plans or Medicare Advantage plans once per calendar quarter in the first three quarters of the year, and during the Medicare Open Enrollment period that runs from October 15 through December 7 each year.”

As if that weren’t confusing enough, we were surprised to read this from the KFF FAQ page: “Some beneficiaries can change coverage from month to month. This includes beneficiaries in certain institutions, such as nursing homes, who can switch Medicare Advantage or Part D plans once a month for as long as they are living there.” That seems like a lot of change to us!

So, in answer to the question about changing plans outside of open enrollment, be aware that the answer may very well be “yes” if you fit Medicare’s qualifications. Better make sure you plan ahead and get some good, objective advice. Contact us and we’ll be happy to help.

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(originally reported at

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