If you lose Medicaid coverage, and you’re eligible for Medicare, you may qualify for a Medicare special enrollment period (SEP).
An SEP is a limited window outside of the traditional Medicare enrollment periods during which eligible individuals can change their coverage.
Medicaid and Medicare are both government health programs overseen by a branch of the Department of Health and Human Services (HHS) called the Centers for Medicare & Medicaid Services (CMS).
One primary difference between the two programs is their eligibility requirements. Most individuals who qualify for Medicaid do so by having limited income and resources. But to be eligible for Medicare, you must be age 65 years or older, or have a qualifying health condition or disability.
It’s possible to be dually eligible.
If an individual is enrolled in both programs or eligible for Medicare while enrolled in Medicaid, they may qualify for a special enrollment period (SEP) if they lose their Medicaid coverage.
In this article, we discuss how this eligibility works.
Typically, you can enroll in Medicare during set enrollment periods throughout the year, and each enrollment period allows certain types of changes to your coverage.
For example, the Medicare open enrollment period (OEP) is an annual period from October 15 to December 7, where individuals can drop, switch, or add various types of Medicare coverage.
However, if you experience a life event that affects your insurance coverage outside of one of these set enrollment periods, you may still be able to modify your coverage. For these situations, Medicare offers special enrollment periods, or SEPs.
Special enrollment periods help people avoid late enrollment penalties, which are fees that Medicare-eligible individuals must pay for going without Medicare coverage.
Factors such as moving outside your plan’s coverage area and having a chance to gain alternative coverage can all trigger an SEP.
Loss of Medicaid coverage is another situation that can trigger an SEP.
If you’re losing Medicaid coverage and you’re eligible for Medicare, there are two potential situations where an SEP would apply.
- You had Medicaid coverage when you first became eligible for Medicare, but you did not sign up for Medicare during your initial enrollment period (IEP).
- You had both Medicaid and Medicare coverage at the time you lost your Medicaid coverage.
In the first scenario — where you missed your IEP — you may qualify for a 6-month SEP that starts after your Medicaid coverage ends.
In the second scenario — where you had existing Medicare coverage — you may qualify for an SEP that lasts 3 months from the later of these two dates: when you lost eligibility or when you were notified of the loss of eligibility.
During this SEP, you may take the following actions:
- join a Medicare Advantage plan or a Part D prescription drug plan
- switch to a different Medicare Advantage plan or Part D prescription drug plan
- drop your Medicare Advantage plan and return to Original Medicare
- drop your Part D prescription drug plan
If you missed either of these two SEPs, you will need to wait for the general enrollment period (GEP) to enroll in Medicare or modify your coverage. The GEP is from January 1 to March 31 each year.
If you’re enrolling in Original Medicare for the first time during your SEP, you can do so by filling out form CMS-10797 and mailing or faxing it to your local Social Security office.
You may also speak with a Social Security representative at 800-772-1213 (TTY: 800-325-0778).
If you’ve lost Medicaid coverage and wish to modify your existing Medicare coverage during your SEP, you have a few options for how to do so.
You can review your coverage options on the Medicare website and speak with a Medicare representative by phone at 800-633-4227 (TTY: 877-486-2048). Operators are available 24 hours a day, 7 days a week.
You may also speak with someone in person by visiting your local Social Security office.
For unbiased guidance on Medicare and eligibility for an SEP, consider contacting your local State Health Insurance Assistance Program (SHIP).
If you’re dually eligible for Medicaid and Medicare, and you lose your Medicaid coverage, you’re entitled to a Medicare special enrollment period (SEP).
The length of the SEP and the actions available differ based on whether you’re signed up for Medicare.
If you missed your Medicare initial enrollment period (IEP), you’ll qualify for a 6-month SEP during which you can sign up for Original Medicare.
If you’re already enrolled in Medicare, you’ll qualify for a 3-month SEP during which you can make a variety of changes to your coverage, including adding or dropping Medicare Advantage and Part D plans.