CMS knows that many Medicare beneficiaries will experience certain life events or changes in finances or health that may mean they need to find different coverage to better fit their new circumstances. As these events may fall outside Medicare’s standard annual enrollment periods, CMS accommodates this need to change coverage through Special Enrollment Periods (SEPs) and Special Needs Plans (SNPs). As a Medicare agent, you should understand what options are available in your area and which of your clients may qualify for them.

Special Enrollment Periods

SEPs allow for changes to Medicare coverage under certain specific circumstances. You can find a complete list of SEPs and the timelines for each at

Some of the more commonly-used SEPs are for:

Change of address for individuals who move:

  • Outside their plans coverage area or to an area with more plan choices.
  • Back to the U.S. after living outside the country.
  • Into or out of an institution such as a nursing home.

Gaining or losing eligibility for a special program, such as:

  • Medicaid
  • A Chronic Condition Special Needs Plan
  • Extra Help
  • A State Pharmacy Assistance Program

Loss of or change to current coverage:

  • Loss of coverage through an employer or union (including COBRA).
  • A change to current coverage that means the coverage is no longer considered credible.

The opportunity to enroll in specific types of other coverage:

  • Coverage offered by union or employer.
  • Drug coverage, such as TRICARE or VA.

Exceptional circumstances:

  • FEMA declared emergencies and natural disasters.
  • An emergency situation that impacts the individual’s capability to meet an enrollment deadline. Individuals in this situation can request an SEP by calling the Social Security Administration, which reviews requests and grants an SEP if the individual meets certain criteria.

Special Needs Plans

SNPs are special Medicare Advantage plans that fall into three categories: Dual-Eligible, Chronic Conditions, and Institutionalized. Each fits the specific needs and circumstances of the special group it serves.

An individual becoming eligible for a SNP triggers a special enrollment period. An individual enrolled in a SNP losing eligibility also triggers an SEP – to allow the person to find a new plan. As SNPs are offered by private insurers, benefits vary. Not all SNPs are available in all areas.

  • Dual-Eligible (D-SNP) – These plans are for low-income individuals who qualify for both Medicare and Medicaid. Each state administers its own Medicaid program and determines the eligibility requirements. D-SNPs help people with the highest needs cover their out-of-pocket medical expenses. These plans coordinate coverage between Medicare and Medicaid under a single plan, making it easier for the beneficiary to navigate the healthcare system.
  • Chronic Conditions (C-SNP) – These plans are for individuals with one or more chronic health conditions. C-SNPs may offer a provider network that includes hospitals and doctors who specialize in the chronic condition, lower out-of-pocket costs for treatment and medications, and access to a care coordinator, who helps enrollees manage the many aspects of their medical care. To qualify, a physician must provide documentation of the diagnosis, usually within 30 days of enrolling in the plan. Enrollees may need to periodically verify that they still meet the requirements of the plan.
  • Institutionalized – These plans are for individuals moving into an institutionalized long-term care setting (such as a nursing home or rehab hospital) for at least 90 days.

Your Clients Count on You

A lot can happen during the year. However, many of your clients will be unaware of SEPs and SNPs that could benefit them if their circumstances changed. It is crucial for you to stay in touch with your clients on a regular basis and encourage them to make you aware of any changes. When you build close relationships, your clients will be comfortable discussing their health and financial situations with you. This will mean you can ensure they have the right coverage.

The experienced team at PTT Financial is here to support you. Contact us today.