Special Enrollment Period
aka. SEP
What is a Medicare Special Enrollment Period?
A Special Enrollment Period (SEP) can used in many different ways when it comes to coordinating Medicare Enrollment with Social Security as well as Medicare insurance plan enrollment, plan eligibility, and moving among Medicare insurance plans. Medicare SEP allow Medicare eligible beneficiaries to enroll under specific circumstances that do not fit within the “typical” enrollment period windows. For example, using Part B SEP for Medicare coordination with Social Security or Medicare SEP used for guaranteed-issue into Medicare Supplement Plans. Each SEP is very specific to how it can be applied.
How are Medicare Special Enrollment Periods used?
Again, each Medicare Special Enrollment Period SEP is specific to how it can be used. SEP is not a “one size fits all” general enrollment window. To be clear, these are intended to be used outside the common enrollment periods, such as coordinating Medicare with Social Security (IEP) and Medicare insurance plan enrollment (IEP). Your particular situation will dictate whether or not you’re eligible for a Medicare Special Election Period SEP. In many cases, you will be notified by Medicare or the insurance plan of your SEP eligibility by mail.
To differentiate, the common enrollment periods that surround someone turning 65 is IEP (Initial Enrollment Period) or changing Part D prescription plans in the fall with AEP (Annual Enrollment Period).
It’s important to clearly differentiate the type of a SEP that you’re eligible to use and how it can be applied to your enrollment situation. Here are the two most common SEP uses:
Special Election Period - Part B SEP with Social Security
This Part B SEP is used to coordinate your Medicare with Social Security if you do not already have Medicare (ie. need to start Medicare after leaving an employer plan over the age of 65 and outside the typical window to enroll at 65 using IEP). This particular scenario is covered under Initial Enrollment & Timelines under Medicare Enrollment Planning, however, I’ll cover this below in a hypothetical example to clarify how it can be used.
Medicare Special Election Period - SEP plan enrollment & eligibility.
Medicare insurance plan SEPs are different than the Part B SEP for Medicare enrollment used with Social Security. These Medicare plan SEPs are typically used by someone that is already on Medicare and has extenuating circumstances that fall outside the standard enrollment windows, such as moving or losing coverage due to plan cancellation in their area.
It’s nearly impossible to list every scenario or list every possible SEP election for all Medicare insurance plans. However, in this section, I’ll be reviewing Medicare Enrollment with Social Security using a Part B SEP. Further down, I’ll review common Medicare insurance plan SEP scenarios, so you can see the difference.
For a list of all the Medicare Special Enrollment Periods, review the list at Medicare.gov. If you feel we can help you clarify your Medicare SEP eligibility, please call us and let us know more about your situation. We will do our best to review your circumstances to see how we can help guide you through your SEP options and apply for insurance coverage.
Coordinating Social Security Medicare Part B SEP.
Special Election Period - Part B SEP Enrollment
The following example is the most common Social Security Part B SEP I help clients with when they are over the age of 65 and looking for guidance before they leave their employer group plan and transitioning to Medicare.
In addition to using this Social Security Part B SEP, you will also likely use two other Medicare plan SEP elections to properly start your Medicare insurance products for guaranteed issue and to avoid Part B and Part D penalties. There are different timelines for Medicare Supplement Plans enrollment and Medicare Prescription Drug Plan enrollment. If you want specific enrollment timelines for these insurance plans, go to Medicare Insurance Plan Enrollment Periods, here.
Call my office directly to review the steps to get any Medicare Special Election Periods organized. I want you to be confident with your transition from your employer group plan– knowing you’ll be covered without a lapse in coverage.
Are you working past 65, delaying your Social Security, and enrolling in Medicare at a later date?
This can be the most complicated election for coordinating your Medicare effective dates with Part B SEP, yet it is one of the most common since many people work past 65. I’ll walk you through each step to thoroughly review exactly what you need to get Medicare started on time, without penalties, and without any hassles.
In this Medicare enrollment scenario we will assume you are working past the age of 65, delaying your Social Security retirement benefit, and also covered through your employer sponsored plan with more than 20 employees, or you are older than 65 and covered through a spouse’s employer sponsored plan more than 20 employees.
Note: Im very specific with the employer plan being more than 20 employees because if you or your spouse’s employer plan is more than 20 employees, then the employer group plan remains primary to Medicare the month you turn 65, and continues to be after the age of 65 while you’re still working. This means that even though you are over the age of 65, you are able to delay your enrollment into Part B of Medicare since it is not needed as primary coverage (employer plan remains primary).
In this enrollment situation, enrollment into Part B can be delayed until you fully transition to Medicare once you retire from the employer group plan. “Part A Only” may have been activated at 65 if you enrolled online for “Part A Only” and/or delayed Part B, but technically, whether or not you enrolled in “Part A Only” with more than 20 employees in your group plan, “Part A Only” is in essence “sitting on the sidelines” until you elect to start Part B with your Part B Special Enrollment Period. Both Part A and B become primary the 1st of the month you elect Medicare to start and your group plan ends at the last day of the month you retired.
If your employer group plans is less than 20 employees, Medicare will become primary and the group plan would then act as the supplemental coverage to Medicare. If under 20 employees on the employer plan, you should use the standard IEP 3 months before your 65th birthday month and proactively enroll in Part B even though you are still working. If you are unsure, check with your benefits administrator for more details on this subject.
I recommend you try to negotiate for the employer to pay your Part B premium as well as the group plan coverage which would be acting as your supplemental in this scenario. Many times the company may offer to pay for the Part B premium, the Medicare Supplement Plan, and/or your Medicare Part D Plan while working. It is much cheaper for your employer if you to go off their group plan after 65, so they are typically willing to reimburse the Medicare Part B premium and Medicare insurance products for you each month as opposed to keeping you on the group plan after 65 (depends on the employer). It’s best to check with your benefits administrator to confirm your group plan status.
If you have more questions, call my office so I can go through this with you. It can be tricky, but I’m very familiar with timing these Special Election Period scenarios for clients. Let us know how we can help.
Back to the initial SEP scenario above. If you’re over 65, working, delaying your Social Security retirement benefit, and wishing to enroll at some future date for Medicare to begin the day you leave your or your spouse’s employer group plan.
Let’s assume, you’re 68 years old and wishing to retire in the month of September for a seamless transition to Medicare for October, 1 2023. In this scenario, your birthday is irrelevant when it comes to enrolling in Medicare with Social Security. Since you are outside the Initial Enrollment Period (IEP) (the 7 months surrounding your 65th birthday), you’ll need a different election tool to activate your Medicare properly. You’ll be using whats called, a Special Election Period or SEP.
Since you have currently been covered on an employer group plan prior to the month leading to your 65th birthday, you’ve had what is called “creditable coverage”. This creditable coverage is going to allow you to enroll into Medicare on the 1st of the month on any month (within 8 months of current coverage) in the future if you remain covered under that employer group plan while employed with the company. For this example, we are using 10/01/2023 as a retirement date, so I can illustrate specific examples for you.
In this specific scenario you would need to print forms from CMS or print from the Forms & Documents under Resources on this site. These forms are CMS form L564 and form 40B. 40B is a form that you’ll use to “say” that you want to elect to start your Medicare Part B on “X” date. In this example, we are targeting 10/01/2023 for the start date. Print and fill out form 40B indicating your intended Part B start date of 10/01/2023.
Now, to form L564. This form is what activates the use of form 40B. L564 is a form that your employer administrator will fill out showing you’ve had creditable coverage under their group plan from date “X” to date “Y” — signed by the benefits administrator in your company. You can get this form signed up to 8 months prior to your intended Medicare start date- 10/01/2023. 2-4 months prior to your start date is sufficient in my opinion.
To continue with the hypothetical, you filled out the 40B in June/July and had your employer sign off on your creditable coverage on L564 and returned the form to you. You can submit both forms to the Social Security office in person for your 10/01/2023 start date. If you’re working with me on this, I’ll be happy to guide you and fax the documents to the local Social Security office with your consent to get a hard copy receipt of enrollment with a date stamp.
Use these forms below and activate your Medicare Part B with a Special Enrollment Period.
Continuing on with the same hypothetical, your Medicare is set for 10/01/2023. You’ll receive a quarterly Part B billing statement for the Part B premium because you have no Social Security benefit to withdraw the Part B premium from. Remember, Part A is “premium free” since you paid into the system for more than 10 years. If “Part A Only” was activated online at 65, it is still technically “sitting on the sidelines”until Part B goes into effect. Once L564 and 40B go through for Part B, you Original Medicare will be activated on 10/01/2023, once the employer group plan ends coverage the last day of September.
On 10/01/2023 Medicare is now primary. I recommend that you get quotes, pricing, and enroll yourself in the plan of your choice during the same time you’re getting your Medicare started. This way they all begin on the 1st of the month you want coverage to begin and not the following month. You will have exactly the same guaranteed issue rights as someone that applied to Medicare during their IEP at 65. You’ll simply use your Part B SEP for the Medicare Supplement Plan guaranteed-issue, and Medicare SEP for the Part D plan within 63 days of the last date covered by the employer plan.
You are not subject to late enrollment penalties for Part B or Part D because of the creditable coverage you had through the employer group plan or your spouse’s employer plan. L564 took care of the proof for the Part B penalty, but you may need to show proof of creditable coverage to the FIRST enrollment into a Part D plan whether it be a standalone Part D or Part D included in a Medicare Advantage plan.
After your initial Part D enrollment, you should not need to resubmit proof. If you enroll in Medicare insurance products with my office, we will help you get this organized and submit it with your application before they even ask- avoiding any confusion as to whether or not you had creditable coverage. Best to give them the proof ahead of time than deal with it at a later time.
Once you elect to start your Social Security retirement benefit at a later time (ie. 68-70 in this example), the Part B premium will then be withdrawn automatically each month prior to the monthly draft (Monthly SS Benefit amount minus the Part B premium = monthly Social Security benefit draft into your checking account) The standard Part B premium for 2023 is $164.90 (more if subject to IRMAA).
This is one example- please call if you want me to run through your specific enrollment scenario so we can pin point the exact month(s) you need to complete each step to get insurance products started on your desired Medicare start date.
Mentor One Insight
Mike is 68 (outside his IEP at 65), he is still working and delaying his Social Security. He is covered through a large employer plan (over 20 employees) so he can delay his Medicare Part B and use his group plan as his primary coverage while he works past the age of 65. He has creditable coverage through his employer plan for Part B and Part D. He can retire any month he wants and can elect to have Medicare begin without penalty on the 1st of the month he chooses. He wants to start July 1 – 07/01/2023. He is retiring June 5th -06/05/2023 and therefore, has coverage through 06/30/2023 with his employer plan (check with your benefits to be sure you’re covered through the end of the month- take advantage of this if you can).
In March/April (3-4 months prior to his desired start date of July 1 – 07/01/2023), Mike printed off the forms 40B and L564 and reviewed the timing of his Medicare with John over the phone to pin point his exact dates. Since he settled on July 1 for his Medicare start date based on leaving his employer at 68 years old on June 5th. He filled out form 40B that indicated a 07/01/2023 Medicare Part B SEP start date (Part A will become primary on 07/01/2023 as well). Mike now contacts his employer benefits division to get a representative to sign off on his creditable coverage with form L564 to allow him to activate his form 40B. He submits both forms to Social Security in the month of March or early April (depending on when his employer gets the L564 back to him). Doing this a few months ahead is best.
Mike gets confirmation of Part B effective 07/01/2023. Part A may have an earlier date and it will always show the earlier date if elected “Part A Only”. However, Part A will become primary on 07/01/2023 because the primary insurer (employer) drops coverage 06/30/2023. Both Part A and Part B are coordinated and effective 07/01/2023 using the Part B Special Election Period
He is now set for his Medicare start date of 07/01/2023 without penalty for his Medicare coverage at 68 years old. Mike meets with John to review Medicare insurance plans, pricing, and enrolls in the plan of his choice at the same time the 40B and L564 are being processed. It’s best to have your insurance plan(s) chosen before the 1st so we can apply and get signatures for the coverage to all be starting on the 1st of the month you selected Medicare to start.
Additional creditable coverage proof is sent to the Part D plan of his choice– the Part D penalty is now not applicable to him. He is now fully covered without a lapse in his coverage. His group plan ends June 30th and his Medicare as well as his Medicare insurance product(s) all start July 1 without a lapse in coverage. It’s common for clients to enroll in the insurance products as soon as the SEP for Part B is approved. This ensures that the Medicare insurance products begin on the same day Medicare becomes primary.
Medicare Plan Special Election Periods.
Special Election Period - Medicare plans, eligibility, and moving/cancelled plans.
I moved to a new address that isn’t in my plan service area.
I moved to new address that’s still in my plans service area, but I have new plan options in my new location.
I moved back to the United States after living outside the country
I just moved into, currently live in, or just moved out of an institution (like skilled nursing facility or long-term care hospital).
I’m no longer eligible for Medicaid (Medi-Cal in CA)
I left coverage from my employer or union (including COBRA coverage)
I involuntarily lose other drug coverage that’s as good as Medicare drug coverage (credible drug coverage), or my other coverage changed and is no longer credible.
Medicare ends (terminates) my plan’s contract.
My Medicare Advantage plan, Medicare Prescription drug plan, or Medicare Cost’s plan contract with Medicare isn’t renewed.
I’m eligible for both Medicare and Medicaid (or Medi-Cal in CA).
I qualify for Extra Help paying for Medicare prescription drug coverage.
I dropped a Medigap policy the first time I joined a Medicare Advantage plan.
I wasn’t properly told that I was losing private drug coverage that was as good as Medicare drug coverage (credible coverage).
