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Special Enrollment Period (SEP)

For beneficiaries moving in, residing or leaving the facility

 

What Are Your Options?

  • Enroll in a Medicare Advantage Plan or a Medicare prescription drug plan.
  • Change from your current plan to a different Medicare Advantage Plan or prescription drug plan.
  • Leave your Medicare Advantage Plan and return to Original Medicare.
  • Cancel your Medicare prescription drug coverage.

 

When Can You Make Changes?

You can make these changes for as long as you reside in the facility and for an additional two months after the month you leave the facility.

Individual Medicare Advantage 

Medicare Advantage Plans also known as Part C, are offered by private insurance companies approved by Medicare. They combine Part A (hospital insurance), Part B (medical insurance), (MA) and sometimes prescription drug coverage (Part D) (MAPD) into one plan. Plans often include additional benefits not covered by Original Medicare, such as routine vision, dental, hearing services, and wellness programs. To enroll, individuals must be eligible for Medicare Parts A and B and continue to pay their Part B premium. Network restrictions may apply, meaning beneficiaries may need to use doctors and facilities within the plan’s network. Medicare Advantage plans also require prior-authorizations for many services, such as MRI’s, procedures and SNF (Skilled Nursing Facility) rehab stay. Beneficiaries with a Medicare Advantage plan may also consider Medigap (or Supplement) policies if transitioning back to Original Medicare. Medigap policies do not work alongside Medicare Advantage plans, so a switch to Original Medicare is necessary to be eligible.

Individual Dual

Individual Dual Special Needs Plans (DSNP) are a type of Medicare Advantage Plan designed for individuals eligible for both Medicare and Medicaid. These plans provide all the benefits of an Individual Medicare Advantage plan but include coverage tailored to dual-eligible individuals. Plans often feature ancillary benefits such as transportation to medical appointments, over-the-counter allowances, fitness programs, and dental/vision care. DSNPs coordinate Medicare and Medicaid benefits, making them an option for managing dual coverage. Enrollees must be eligible for both Medicare and Medicaid, and Medicaid covers their Part B premium. 

Managed Long-Term Care (MLTC)

Managed Long-Term Care (MLTC) refers to a Medicaid-funded system of care that provides services for individuals who need long-term care. It includes services like home care, adult day care, case management, home-delivered meals, and nursing home care. MLTC is available to individuals who qualify for Medicaid and have been assessed as needing long-term care support. The goal is to help individuals live independently in their communities or remain in their homes while receiving necessary care. Once eligible, individuals can select an approved MAP (Medicare Advantage Plus) plan. 

Institutional Special Needs Plan (I-SNP)

Institutional Special Needs Plans (I-SNP) are a type of Medicare Advantage plan specifically designed for individuals who reside in a skilled nursing facility or require comparable level of institutional care. Plans are managed by private insurance companies that contract with Medicare to provide coordinated care tailored to needs of beneficiaries in institutional settings. To qualify for an I-SNP, individuals must have Medicare Parts A and B and meet the criteria for institutional care, which may be determined through an assessment.

Chronic Condition Special Needs Plan (C-SNP)

Chronic Condition Special Needs Plans (C-SNPs) are a type of Medicare Advantage plan designed to provide specialized care for individuals with specific chronic conditions, such as diabetes, heart disease, or chronic lung disorders. Plans are managed by private insurance companies contracted with Medicare and focus on coordinated care to address the unique needs of beneficiaries managing chronic health conditions. To qualify for a C-SNP, individuals must have Medicare Parts A and B and a diagnosis of the chronic condition(s) covered by the plan. Eligibility may be determined through an assessment conducted by the plan.

Medicaid

Qualifying for Medicaid opens additional coverage opportunities tailored to meet beneficiary’s needs. Medicaid beneficiaries may choose:

 

Dual Special Needs Plan (DSNP):

  • Combines Medicare and Medicaid benefits for comprehensive coverage.
  • Includes additional services like transportation, dental, and vision care.

Original Medicare + Medicaid:

  • Medicaid covers premiums, deductibles, and coinsurance.
  • Minimizes out-of-pocket costs for Medicare-covered services.

Additional Benefits:

  • Assistance with Part B premiums through Medicare Savings Program.

Medigap/Supplement

Medigap, or Medicare Supplement, is private insurance that helps cover out-of-pocket costs like deductibles, copayments, and coinsurance that Original Medicare doesn’t pay. Medigap plans are available to those with Medicare Parts A and B but do not include prescription drug coverage (Part D). These plans cannot be used with Medicare Advantage (Part C) plans.

Eligibility depends on being enrolled in Parts A and B, and one may face medical underwriting unless they’re in a guaranteed-issue period. If one is in the first six months of Medicare Part B enrollment, they can sign up for Medigap without medical underwriting. 

Medicare Parts A and B

Medicare Part A and Part B make up Original Medicare, the federal health insurance program primarily for those 65 and older, or for certain younger individuals with disabilities.

  • Medicare Part A: Known as hospital insurance, it covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most people don’t pay a premium for Part A if they or their spouse paid Medicare taxes while working.
  • Medicare Part B: Known as medical insurance, it covers outpatient care, doctor’s visits, preventive services, and other medically necessary services. Part B has a monthly premium, which varies based on income. The base premium in 2025 is $185/month.