Q: I didn't change my insurance coverage earlier this year, but now think I might want to change. My doctor has told me about some new health problems and I have new medications to take. Do I have any options open to me?
A: This question is not just a yes or no question. I will therefore review some terms and options out there, and you can determine if you qualify for any special circumstance.
Enrollment Periods are the time frames during which you are allowed to enroll/change your insurance. For the purposes of this discussion, I am sticking with Medicare Part D because that is what you asked about. If you have a Medicare Advantage Plan with Prescription Drug coverage, then these enrollment periods apply to your situation as well. There are different Special Enrollment Periods (SEPs) for Medicare Part D (Oct. 15 to Dec. 7), and Medicare Part B.
There are at least 16 different qualifying situations that enable you to have a Special Enrollment Period. I will use the next two articles to review the 16 SEPs.
1. You have creditable drug coverage and lose creditable coverage through no fault of your own.
2. You choose to change employer/union coverage (through either current or past employment).
As individuals retire or age into Medicare, their insurance situation can change dramatically. There are a multitude of options open to those with Medicare. The terms are different, the prices are different, the products offered are dramatically different each year.
The purpose of this column is to give those who are eligible for Medicare, or soon to be eligible for Medicare, some understanding of their insurance options and how it could impact their health and finances.
These questions and answers are meant as a guide to help you understand the complex questions you are now thinking about. Each individual's specific situation may create a different solution. You shouldn't necessarily do what your friends, family and neighbors do.
3. You are institutionalized.
4. You are enrolled in a State Pharmaceutical Assistance Program (EPIC for New York, PACE for Pennsylvania).
5. You have Medicaid, Medicare Savings Program, Supplemental Security Income or Low Income Subsidy (Extra Help).
6. You want to disenroll from a Medicare Private Health Plan with drug coverage for the first time (HMO and PPO).
7. You enroll in or disenroll from PACE (Program of All-Inclusive Care for the Elderly)
8. You permanently change your home address.
9. You have had Medicare eligibility issues.
10. You are eligible or lose eligibility for a Special Needs Plan (SNP)
11. You experience contract violations or enrollment errors.
12. Your plan no longer offers Medicare Drug Coverage.
13. You disenroll from your Medicare Advantage plan during the Medicare Advantage Disenrollment Period.
14. You qualify for a new Part D initial enrollment period because you are turning 65.
15. You want to enroll in a five-star Medicare Advantage or Part D plan.
16. You experience an ''exceptional circumstance.''
Now that is quite a list, especially since each one of those may involve a number of different circumstances. I will explain these as best I can. If you think you qualify for any of these, you should contact CMS at 1-800-MEDICARE or www.medicare.gov or contact the Medicare Rights center at www.medicarerights.org or 1-800-333-4114.
1. You have drug coverage and you have lost that coverage through no fault of your own. This does not mean you stop paying your premium. This could happen when the plan you are in changes its coverage and is no longer creditable, or it stops providing drug coverage at all.
This also applies when you are newly eligible for a creditable plan. A situation might be that your spouse gets a new job or new health insurance coverage which is creditable and you decide to enroll into that plan instead of Medicare Part D. This SEP gives you the right to do just that without any penalty later.
2. Changing your employer/union coverage is probably one of the most common situations we run into. This could result from a person deciding to retire on his own; his company leaving the area, thereby being out of a job or deciding you can't afford the premiums for the plan any longer. This also could be used to enroll in an employee sponsored plan. Most situations involve disenrolling from an employee plan, and therefore needing to sign up with a Medicare Part D plan. This SEP gives you a two-month period of time to pick a Part D plan and enroll in that plan.
3. This SEP happens when you move into or out of a ''qualified institutional facility.'' In our region, that is most likely a Skilled Nursing Facility. It is not an adult home or assisted living facility. When you move into a facility and you expect to be there awhile you can switch plans, join or disenroll once a month. I certainly don't recommend changing your drug plan that often, but you can. When you leave the facility, you have two months to switch plans, enroll in or disenroll from a Part D plan.
4. EPIC/PACE is probably the next most common SEP used. If you are enrolled in EPIC, become newly eligible for EPIC, or lose EPIC you are given a SEP to change your Medicare Part D. The first situation, for those who are currently enrolled, EPIC gives you a once per year opportunity to switch to a different plan (outside of the normal enrollment periods). The other two situations, where you are new to EPIC or you lose EPIC coverage, EPIC gives you an opportunity to join a Medicare Part D plan. This is not an opportunity to disenroll from Medicare Part D.
5. If you have Medicaid, the Medicare Savings Program or the Low Income Subsidy (Extra Help), you can switch your Medicare Part D plan on a monthly basis. As I said before, I do not recommend switching your plan this often, but if you find the plan you chose does not cover your medications you can find a plan that does provide the coverage you need and switch plans.
6. This SEP is only for first-time enrollees in a Medicare Advantage Plan. If you have joined a Medicare Advantage Plan for the first time ever and you don't like it, or don't feel it gives you the coverage you were promised, you can disenroll from the plan within the first 12 months you have coverage. At that time, you go back to Original Medicare and a Stand Alone Medicare Part D plan. This particular SEP is only good once a lifetime.
7. This SEP is probably not something you are going to come across. A PACE (not the Pennsylvania type) is not very common in our area. Cattaraugus County does have a PACE program and it is called Total Senior Care and is based in Olean. If you are newly enrolled in Total Senior Care or are leaving the care of this program, you have an opportunity to switch to leave your old insurance (and get the PACE) or disenroll from the PACE and enroll in an alternate Medicare Advantage Plan or Part D plan. There are no approved PACE programs in Chautauqua County.
8. You have permanently moved to a new location. If you move within our region (New York state), this does not necessarily give you an SEP. When you move within our state, you maybe eligible to switch your Part D plan if you are outside of your current plan's service area or have moved to an area where more plans are available to you. These two qualifiers would allow you to switch your plan if you are still in New York. An example: if you have an HMO with drug coverage and your new home (in Albany) does not have participating physicians in town with this plan. You have a right to switch plans the month before you move and two months after you move.
If you have moved to a location outside our region, you do qualify for this SEP. Once moved and settled, you should begin looking for your new plan. Once you notify your plan, you have two months to find and enroll in a new plan. If your plan is notified by CMS that you have moved, you will be disenrolled six months after the notification. You can change anytime within these six months or the following two months, giving you a total of eight months from the date you move to join or switch plans.
This SEP also can be used in unusual circumstances. This SEP also qualifies those who have moved back to the US from another country. This also qualifies those who have been released from prison to join a plan. (An individual in prison is not qualified to join Medicare or a Medicare Part D plan.) In this situation, the individual has three months, the month before the move/release, and the two months after.
The remainder of the SEPs I will review in my next article.
Janell Sluga is a geriatric care manager certified and works for Senior Life Matters, a program of Lutheran Senior Housing, and has worked in Chautauqua County with seniors for more than 18 years. She is HIICAP (Health Insurance Information, Counseling & Assistance Program) counselor-trained by Office for the Aging. She does not sell insurance or represent any insurance company. She is an unbiased source of insurance and education to help seniors choose the best option for them.
You may submit questions to be answered in later columns to Janell Sluga at Senior Life Matters, 737 Falconer St., Jamestown, NY 14701, or call 716-720-9797, or by email at firstname.lastname@example.org. Please remember that not all questions can be answered in this format, but as many as can be, will be.