Medicare Matters: Helping Your Medicare Clients Through The Use of Special Enrollment Periods

By: Dan Mangus, as featured by the National Association of Health Underwriters

Many circumstances allow clients to make changes in their Medicare prescription drug plan or Medicare Advantage plan. These opportunities are called special election periods. SEPs are outside of IEP, AEP or MA OEP when individuals may choose a plan or change their current plan election.

Here is an excerpt from the CMS Medicare Managed Care Manual that gives samples of questions that an agent could use to determine if a client is eligible for a SEP for a PDP or MA plan.

Type of SEP and examples of questions you ask:

Change in Residence

  • Have you recently moved? If so, when?
  • Where did you move from?

Employer/Union Group Health Plan (EGHP)

  • Do you currently have (or are leaving) coverage offered by an employer or union?
  • Have you recently lost such coverage?

Disenroll from Part D to Enroll in Creditable Coverage

  • Are you a member of TRICARE?
    Do you have or want to obtain VA benefits?

Full Dual-Eligible or Other Low-Income Subsidy

  • Do you currently have Medicaid coverage?
  • Does your state pay for your Medicare premiums?
  • Do you receive SSI cash benefits without Medicaid? Did you receive a letter from Medicare letting you know that you automatically qualify for extra help?
  • How much do you pay for your prescriptions?

Retroactive Notice of Medicare Entitlement

  • Have you recently received a notice telling you that you have been approved for Medicare for a “retroactive” date? If so, when did you receive this notice?


  • For enrollment—Are you currently enrolled in a special plan called “PACE”?

CMS/State Assignment

  • Have you recently received a blue letter (reassignment notice) from Medicare?
  • Did your state/plan send you a letter to let you know it is moving you to a different plan?
  • Did you recently receive a yellow letter (autoenrollment notice) from Medicare?
  • Have you recently received a green letter (facilitated enrollment notice) from Medicare?

Change in Dual/LIS Status

  • Have you recently gained/lost coverage under Medicaid?
  • Did you recently receive a grey letter (loss of deemed status notice) from Medicare?
  • Did you recently receive an orange letter (change in extra help co-payment notice) from Medicare?
  • Did you recently receive a purple letter (deemed status notice) from Medicare?

Helping clients make adjustments in their plans under special circumstances can often significantly improve their coverage and access to care. In today’s competitive environment, it is vital that agents thoroughly examine their clients’ situations and find ways to build a comprehensive plan that best fits their current needs.


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