Explanation of Selected MA SEPs

There are a number of Special Enrollment Periods (SEPs) available to those beneficiaries enrolled in Medicare Advantage (MA). These SEPs are opportunities for specific sets of beneficiaries to disenroll from Medicare Advantage to join Original Medicare outside of the Annual Enrollment Period. This fact sheet addresses two of these MA SEPs. The first is called a SEP65 and the MA Enrollment Guidance says:

30.4.5 - SEPs for Beneficiaries Age 65 (SEP65)

MA eligible individuals who elect an MA plan during the initial enrollment period (IEP) for Part B surrounding their 65th birthday have an SEP. This "SEP65" allows the individual to disenroll from the MA plan and elect the Original Medicare plan any time during the 12-month period that begins on the effective date of coverage in the MA plan. The IEP is established by Medicare and begins 3 months before and ends 3 months after the month of the individual’s 65th birthday.

The second SEP is the Medigap guaranteed issue right, which applies only to those who dropped their Medigap policies to join MA plans. Section 30.4.4 of the MA Enrollment Guidance says:

6. SEP for Individuals Who Dropped a Medigap Policy When They Enrolled For the First Time in an MA Plan, and Who Are Still in a "Trial Period"

[...] Accordingly, there is an SEP for individuals who are eligible for "guaranteed issue" of a Medigap policy under §1882(s)(3)(B)(v) of the Act upon disenrollment from the MA plan in which they are enrolled. This SEP allows a qualified individual to make a onetime election to disenroll from their first MA plan to join the Original Medicare Plan at any time of the year. The SEP begins the month the individual disenrolls from the MA-PD plan and continues for two additional months. The effective date would be dependent upon the situation.

By definition, these SEPs preclude specific other populations (those who enroll in MA for the first time when initially eligible for Medicare because of disability and those who enroll in MA for the first time after being in Original Medicare for any period of time and did not have a Medigap). The disabled are excluded from the SEP65 because they are not enrolling in MA during the IEP for their 65th birthday. Those without Medigap are excluded because the SEP is only for those who dropped Medigap to get into an MA plan.