Common Qualifying Situations for SEPs
Here are some of the most frequent scenarios that open a Special Enrollment Period:
1. You move to a new residence
If your new address places you outside your current plan’s service area, you automatically qualify for a SEP. The same applies if you move within the same area but gain access to new plan options that weren’t available at your old address.
2. You lose other insurance coverage
A loss of coverage often triggers a SEP. Examples include:
- Losing Medicaid eligibility
- Losing employer or union-sponsored health coverage
- Losing coverage that Medicare considers “creditable” (i.e., as good as Medicare’s standard drug coverage)
3. You gain access to new coverage
You may qualify for a SEP if you:
- Join employer or union coverage
- Enroll in coverage that is considered equivalent to Medicare’s drug coverage (e.g., TRICARE or VA benefits)
- Enroll in a PACE plan (Program of All-Inclusive Care for the Elderly)
4. Your plan changes its contract with Medicare
If your Medicare Advantage or Part D plan loses its contract with Medicare, is discontinued, or is sanctioned, you are given time to find a new plan.
5. You are affected by a natural disaster or emergency
Medicare allows SEPs for beneficiaries who live in—or have recently moved from—FEMA-designated disaster areas, such as regions impacted by hurricanes, wildfires, floods, or major storms.
There are two important notes here:
- The SEP is not automatic; you must request the Exceptional Circumstances SEP.
- You must attest that you lived in—or depended on someone who lived in—a disaster-stricken area.
6. You experience exceptional circumstances
Medicare may grant a SEP for a variety of unusual situations, such as:
- Being incarcerated and later released
- Being provided incorrect or misleading information by an employer or health plan
- Losing Medicaid coverage
- Other significant issues outside your control
If your circumstances fit into one of these categories—or even if you’re unsure—it’s worth exploring your eligibility for a SEP. Medicare provides a detailed Q&A and additional guidance on qualifying events, and you can also speak with Medicare directly or consult a local State Health Insurance Assistance Program (SHIP) for personalized help.
