Medicare Special Enrollment Periods (SEPs)
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Background
People dually eligible for Medicare and Medi-Cal can change their Medicare Advantage and Medicare drug coverage for any reason. The usual times to make changes are the Medicare Open Enrollment Period (October 15 – December 7) or the Medicare Advantage Open Enrollment Period (January 1 – March 31). In addition, Medicare Special Enrollment Periods (SEPs) allow dually eligible members to make changes at other times of the year. The full list of SEPs is available on the CMS website.
If you have questions or need help making enrollment changes, call 1-800-MEDICARE (1-800-633-4227).
Changes in Medicare SEPs for LIS and Dually Eligible Individuals for 2025
- Medicare already allows individuals who gain or lose Medi-Cal eligibility, or who move to a location where their current plan is unavailable, to change their Medicare Advantage or Prescription Drug Plan, through a SEP.
- Starting January 1, 2025, Medicare will allow dually eligible and low-income subsidy (LIS) eligible members to make a monthly election to:
- Switch from Medicare Advantage to Original Medicare with a stand-alone prescription drug plan.
- Switch between stand-alone prescription drug plans if enrolled in Original Medicare.
- In addition, a new type of SEP for integrated care will allow dually eligible members to choose a Medi-Medi Plan or SCAN Connections once-per-month, in any month of the year. Members can continue to enroll in PACE in any month of the year, if they meet PACE enrollment criteria.
- The quarterly SEP for dually eligible members will be discontinued in 2025.
- Dually eligible members will not be able to enroll in, or change, Regular Medicare Advantage plans or other Special Needs Plans outside of the usual times, except if a different SEP applies, such as moving out of the plan's service area.
- CMS released an additional resource to provide an overview of the new SEPs for dually eligible and LIS-only eligible individuals.
Medi-Cal Matching Plan Policy
In 2025 the Medi-Cal Matching Plan Policy will continue in 17 counties. Under this policy, a member's Medicare plan choice is the lead, and the Medi-Cal plan follows. This means that for dually eligible members that choose to enroll in any type of Medicare plan in those 17 counties (including Medi-Medi Plans), their Medi-Cal plan must align with their Medicare plan choice, if there is a Medi-Cal plan affiliated with their Medicare plan. The Medi-Cal Matching Plan Policy does not change or impact a member's Medicare plan choice.
Example Scenarios for 2025
Member 1 in Los Angeles County has Original (Traditional) Medicare and a Part D
Prescription Drug plan, plus a Medi-Cal managed care plan. In April 2025 this member uses the new SEP
for integrated care to enroll in a Medi-Medi Plan. They will be automatically enrolled in the
Medi-Cal plan that is aligned with their new Medicare plan. This member can also change back to Original
Medicare with a Part D Drug plan in any month after April 2025, and enroll in
any Medi-Cal plan.
Member 1 cannot enroll in a regular Medicare Advantage plan in April 2025, unless there are other SEP circumstances. Generally, Member 1 must wait until the Medicare Open Enrollment Period in fall 2025 if they want to enroll in a regular Medicare Advantage plan, effective January 1, 2026.
Member 2 in San Francisco County is enrolled in a regular Medicare Advantage plan, and a matching Medi-Cal plan. In May 2025 this member changes to Original Medicare and a Part D Drug plan, and can choose any Medi-Cal plan in their county. If this member remains in their Medicare plan in May 2025, they will also remain in their matching Medi-Cal plan.
Member 2 cannot enroll in a different Medicare Advantage plan in May 2025, unless there are other SEP circumstances. Generally, Member 2 must wait until the Medicare Open Enrollment Period in fall 2025 if they want to enroll in a different Medicare Advantage plan, effective January 1, 2026.
