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The SEP for individuals who gain, lose, or have a change in their dual- or LIS-eligible status allows a “full-benefit dual eligible individual” or “other LIS-eligible individual” (see § 10) to enroll in or disenroll from a Part D plan one time if the individual gains, loses, or has a change in their Medicaid or subsidy-level status or LIS eligibility, including if the individual: • Becomes eligible for any type of assistance from the Title XIX program and individuals who qualify for LIS (but who do not receive Medicaid benefits); • Loses eligibility for any of the types of assistance described above; or • Has a change in the level of assistance the individual receives, (e.g., stops receiving Medicaid benefits but still qualifies for LIS; has a change in cost-sharing; or becomes eligible for additional Medicaid benefits). o For example, this may occur when an individual newly qualifies as needing nursing home level of care and thus becomes eligible for certain Medicaid long term supports and services or becomes eligible for full Medicaid after having previously been eligible for Medicaid coverage of Medicare premiums or cost- sharing.

An individual may make an election using this SEP within three months of any of the changes noted above, or notification of such a change, whichever is later.

NOTE: Use of this SEP does not count towards the SEP for subsidy-eligible individuals described in § 30.6.7.

30.6.9 – SEP for individuals who belong to a qualified SPAP or who lose SPAP eligibility 42 CFR §§ 422.62(b)(12) and 423.38(c)(17)

An individual who belongs to a qualified “State Pharmaceutical Assistance Program” (SPAP) (§ 10), or the state acting as their authorized representative, can request to enroll in a PDP or MA- PD plan once per calendar year. An individual is also eligible for this SEP for a limited time after losing eligibility for SPAP benefits. See Chapter 14 of the Medicare Prescription Drug Benefit Manual for information regarding qualified SPAPs.

This SEP begins when the individual is enrolled in the SPAP and, upon loss of eligibility for SPAP benefits, for an additional two calendar months after either the month of the loss of eligibility or notification of the loss, whichever is later.

30.6.10 – SEPs for individuals whose plan or contract is terminated or non-renewed, including service area reductions 42 CFR §§ 422.62(b)(1), 422.74(e)(2)(ii), and 423.38(c)(6)

This is an SEP that can be used when CMS, an MAO, or a Part D sponsor has terminated an individual’s MA or Part D plan contract, discontinued the plan in the area in which an individual resides (i.e., service area reduction), or notified an individual of an impending plan termination or an impending service area reduction. This SEP allows an eligible individual to enroll in an MA and/or Part D plan. See § 60.2.7 for further information on required involuntary disenrollments due to termination/non-renewal/service area reduction.