PDP Enrollment Outside of Enrollment Period

[islandbanker]

I met with a new client today who was eligible to enroll into a Part D plan in October 2022. He has Medicare A and B and a Plan G supplement. He does not recall if he enrolled into a Part D, but it is a fact that he has no Part D coverage at this time.

I have exhausted internet searches researching his dilemma, however it appears he is not eligible for any enrollment period other than the Annual Enrollment Period (October 15 - December 7) which he obviously missed. There are no 5 star PDP plans available in his area and he wants to keep his Plan G supplement so enrolling into a 5 star MAPD is not a desirable option.

Is there any way to obtain an enrollment exception from CMS or any insurance company? Has anyone encountered a similar issue and what was the outcome?

 

[goillini52]

I met with a new client today who was eligible to enroll into a Part D plan in October 2022. He has Medicare A and B and a Plan G supplement. He does not recall if he enrolled into a Part D, but it is a fact that he has no Part D coverage at this time.

I have exhausted internet searches researching his dilemma, however it appears he is not eligible for any enrollment period other than the Annual Enrollment Period (October 15 - December 7) which he obviously missed. There are no 5 star PDP plans available in his area and he wants to keep his Plan G supplement so enrolling into a 5 star MAPD is not a desirable option.

Is there any way to obtain an enrollment exception from CMS or any insurance company? Has anyone encountered a similar issue and what was the outcome?

I think he's SOL without a SEP, until AEP for a 01/01/2025 effective date.

Get him a GoodRX card.

 

[Ron Van D]

SingleCare app

 

[islandbanker]

The SingleCare app knocked a little over $100 off for a 30 day supply

Thank you!

 

[straightnochaser]

FEMA?

 

[DonP]

DST code will work . If you’re desperate i bet the pharmaceutical assistance sep would work . Call centers use it like candy

 

[merregregory]

New here, hello!
DonP, what is a DST code and the pharmaceutical assistance SEP you mentioned?

 

[Surancedawg]

New here, hello!
DonP, what is a DST code and the pharmaceutical assistance SEP you mentioned?

DST is an SEP you can use for MAPD and PDP enrollments. If the beneficiary, or someone the beneficiary relies on for advice, lives in an area that was subject to a federal, state or local gov't declared disaster or emergency during a recent enrollment period for which the beneficiary was eligible, the SEP-DST can be used. The qualifying disaster/emergency can be identified here: [EXTERNAL LINK] - Declared Disasters | FEMA.gov

To give you an example of how its used, my colleague, Shady Jones, had a client he enrolled this month in a PDP. After exhausting other possible SEPs, Shady "discovered" that his client's cousin, who is some kind of insurance whiz, was living in west Maui last year but his home was burned up in the fires they had there. The client wasn't able to reach his cousin through all of AEP. Voilà! He had a valid SEP.

Apparently, CMS and the carriers are growing concerned about the popularity of SEP-DST. If an agent used that SEP multiple times a year, it would probably arouse the suspicion of the carriers. With SEP-PAP enrollments, there's always the chance CMS or the carrier audited the enrollment and it would be easy for them to verify if the beneficiary gained or lost their State Pharmaceutical Assistance Plan benefit.