3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events

AHIP Medicare Certification Exam

Track your progress as you read

Finished sections get a check mark.

1 Introduction

1.1 About the AHIP Medicare Certification Exam 1.2 How to Use This Study Guide

2 Chapter 2: Medicare Program Fundamentals

2.1 What Medicare Is: Program Structure & How Parts A–D Fit Together 2.2 Medicare Part A — Hospital Insurance 2.3 Medicare Part B — Medical Insurance 2.4 Medicare Eligibility Rules (Age 65, Disability, ESRD, ALS)

3 Chapter 3: Medicare Enrollment Periods

3.1 Initial Enrollment Period (IEP) 3.2 Annual Enrollment Period (AEP): October 15 – December 7 3.3 Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31 3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events 3.5 Late Enrollment Penalties (Part A, Part B, Part D)

4 Chapter 4: Medigap & Coordination of Coverage

4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights 4.2 Dual Eligibility & Medicare Savings Programs 4.3 How Original Medicare, MA, Part D & Medigap Interact

5 Chapter 5: Medicare Advantage Plan Types

5.1 Medicare Advantage (Part C) Overview: How MA Differs from Original Medicare 5.2 HMO & HMO-POS Plans 5.3 PPO Plans 5.4 PFFS Plans (Private Fee-for-Service) 5.5 MSA Plans (Medicare Medical Savings Accounts) 5.6 Cost Plans & Employer Group Waiver Plans (EGWPs)

6 Chapter 6: Special Needs Plans & MA Plan Design

6.1 Special Needs Plans (SNPs) Overview 6.2 D-SNP — Dual-Eligible Special Needs Plans 6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans 6.4 MA Benefits, MOOP & Supplemental Benefits 6.5 MA Star Ratings & Plan Quality

7 Chapter 7: Part D Structure & the 2026 Redesign

7.1 Part D Overview & Eligibility 7.2 Formularies & Drug Tiers 7.3 The 2026 Part D Benefit Redesign ($2,100 OOP Cap, $615 Max Deductible, Catastrophic Phase) 7.4 Medicare Prescription Payment Plan (Drug-Cost Smoothing)

8 Chapter 8: Part D Costs, Assistance & Appeals

8.1 Low-Income Subsidy (LIS) / Extra Help 8.2 Part D Late Enrollment Penalty & Creditable Coverage 8.3 Coverage Determinations, Exceptions & Appeals

9 Chapter 9: CMS Marketing Rules & Scope of Appointment

9.1 CMS Medicare Communications & Marketing Guidelines (MCMG) Overview 9.2 Scope of Appointment (SOA): the 48-Hour Rule & Exceptions 9.3 Permitted vs. Prohibited Marketing & Sales Activities 9.4 Marketing Events vs. Educational Events

10 Chapter 10: Enrollment & Disclosure Requirements

10.1 The Pre-Enrollment Checklist (PEC) 10.2 Enrollment Procedures & Application Requirements 10.3 Call Recording & Third-Party Marketing Organization (TPMO) Disclaimers 10.4 Agent & Broker Compensation Rules

11 Chapter 11: Marketing Conduct & Oversight

11.1 Cross-Selling Restrictions & Nominal Gift Value Rules 11.2 Marketing to Vulnerable Populations & Non-Discrimination in Sales 11.3 Website, Social Media & Advertising Compliance 11.4 Complaint Tracking Module (CTM) & Agent Oversight

12 Chapter 12: Understanding Fraud, Waste & Abuse

12.1 Defining Fraud, Waste & Abuse (and the Difference Between Them) 12.2 The False Claims Act 12.3 The Anti-Kickback Statute

13 Chapter 13: Compliance Laws & Screening

13.1 The Stark Law (Physician Self-Referral) 13.2 HIPAA Privacy & Security Basics 13.3 The OIG Exclusion List & Sanctioned-Provider Screening

14 Chapter 14: Reporting, Compliance Programs & Consequences

14.1 Detecting & Reporting FWA 14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training 14.3 Consequences & Corrective Action Plans

3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events

Key Takeaways Explain This Topic AI

SEPs are triggered by specific qualifying life events, not fixed calendar dates, and let a beneficiary enroll or change plans outside AEP and MA OEP.

Moving out of a plan's service area opens an SEP starting the month before the move (if reported in advance) and running 2 months after.

Losing employer or union group health coverage opens a 63-day SEP; if it is also the person's first time losing creditable drug coverage, it affects Part D late-enrollment penalty timing too.

Since 2025, full-benefit dually eligible individuals (Medicare + Medicaid) and those receiving Low-Income Subsidy (LIS/Extra Help) get a monthly SEP — up from the quarterly SEP that applied 2019-2024.

The 5-Star SEP allows a one-time switch into a 5-star-rated MA or Part D plan any time between December 8 and November 30 of the following year.

Last updated: July 2026

Why SEPs Matter on the Exam

Special Enrollment Periods are where AHIP scenario questions get the most specific, because SEPs are not a single rule — they are a whole family of event-triggered windows, each with its own trigger, length, and set of permitted changes. A typical exam question describes a life event ("Mrs. Kim moved to a different county in June" or "Mr. Diaz lost his employer coverage when he retired") and asks you to identify which SEP applies and what it allows. Getting the category of trigger right is the whole skill being tested.

The Core SEP Categories

SEP Trigger Window Length What It Allows

Permanent move out of service area Month before move (if reported in advance) through 2 months after Enroll in a new MA or Part D plan serving the new address

Loss of employer/union group coverage 63 days from the loss (or from notice of the loss) Enroll in MA or Part D; may also avoid the Part D late-enrollment penalty if the lost coverage was creditable

Gaining or losing Medicaid / Extra Help (LIS) Monthly (as of 2025) Enroll, disenroll, or switch MA/Part D plans once per calendar month, effective the first of the next month

Institutionalization (nursing home admission/discharge) Month of admission through 2 months after discharge Join, switch, or drop MA plans; monthly changes while institutionalized

Involuntary loss of coverage (plan leaves the area, contract non-renewal) Runs from the notice through the end of the following AEP or similar CMS-set window Enroll in a replacement MA or Part D plan

5-Star Plan SEP Once between December 8 and November 30 of the following year Switch into any 5-star-rated MA or Part D plan available in the service area

Extraordinary circumstances / federal error / disaster CMS-determined, case by case Enroll, disenroll, or correct enrollment as CMS directs

Dual Eligibility and LIS: The 2025 Change Agents Must Know

For years, full-benefit dually eligible beneficiaries (those with both Medicare and full Medicaid) and beneficiaries receiving the Low-Income Subsidy (LIS / Extra Help) used a quarterly SEP (one election per calendar quarter for the first nine months of the year), a rule that had been in place since 2019. Effective January 1, 2025 , CMS replaced that with an integrated, once-per-calendar-month SEP for these populations — they can now enroll in, disenroll from, or switch MA/Part D coverage every single month, with changes effective the first of the following month. This is a current, testable change: older training materials that still describe a quarterly dual-eligible SEP are now out of date.

Worked example: Mr. Thompson is dually eligible for Medicare and full Medicaid. In March, he wants to switch from one D-SNP (Dual-Eligible Special Needs Plan) to another. Under the current rule, he can do this immediately — he does not have to wait for a specific quarter to open, and he can do it again in April if needed.

The Move SEP in Detail

A permanent move outside a plan's service area is one of the most commonly tested SEPs. Key details:

If the beneficiary tells the plan before moving, the SEP begins the month before the move and runs for 2 months after the move.

If the beneficiary reports the move after it already happened, the SEP begins the month the plan is notified and runs 2 months after that.

A move to a new address that is still within the same plan's service area does not trigger this SEP — the plan hasn't actually changed availability.

The Employer Coverage Loss SEP

Losing group health coverage from an employer or union — most often at retirement — opens a 63-day SEP to enroll in Part D or Medicare Advantage. This SEP matters twice over: it lets the beneficiary enroll outside AEP, and if the lost employer coverage was "creditable" (as good as or better than standard Part D), enrolling within this window means the beneficiary avoids the Part D late-enrollment penalty entirely (Section 3.5).

The 5-Star SEP

CMS rates every MA and Part D plan on a 1-to-5 star quality scale annually (see Chapter 6 for Star Ratings). If a 5-star plan is available in a beneficiary's service area, that beneficiary gets a special one-time window — December 8 through November 30 of the following year — to switch into it, regardless of what other enrollment period is or isn't currently open. This SEP can only be used once per that window.

Common Exam Traps

Treating every life change as an SEP trigger — moving to a new address within the same service area, for example, is not a qualifying event.

Forgetting that the dual-eligible/LIS SEP is now monthly , not quarterly, as of 2025.

Confusing the 63-day employer-coverage-loss SEP with the general "loss of any coverage" — the SEP specifically requires the lost coverage to have been employer/union group coverage (or another qualifying source CMS defines) to trigger the window.

Assuming an SEP allows unlimited changes the way AEP does — most SEPs (aside from the monthly dual/LIS SEP) permit only the single change tied to the triggering event.