HI 00805.382 _ Special Enrollment Periods for Exceptional Conditions_DRAFT

HI 00805.380 Special Enrollment Period (SEP) for Exceptional Conditions

Section 1837(m), 42 C.F.R. 407.23, 42 C.F.R. 406.27

1. Policy for when enrollment can occur

Beginning on or after 1/1/23, individuals who are eligible for Medicare on any basis can enroll (or re-enroll) in Medicare Part B Supplementary Medical Insurance (SMI) and Part A Premium Hospital Insurance (HI) during any months that fall within the duration of the specific exceptional conditions SEPs described below. The duration of each SEP can be found at the link to the specific SEP:

Individuals Impacted by an Emergency or Disaster HI 00805.381	This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who missed a Medicare enrollment period due to being impacted by a disaster or other emergency declared by a Federal, state, or local government entity.
Misrepresentation by Group Health Plan (GHP) or Employer HI 00805.382	This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who missed a Medicare enrollment period and can demonstrate that their employer or group health plan materially misrepresented information regarding timely enrollment in Medicare.
Termination of Medicaid Coverage HI 00805.383	This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who lost Medicaid eligibility and are eligible for Medicare.
Formerly Incarcerated Individuals HI 00805.384	This SEP affords individuals who missed a Medicare enrollment period due to being incarcerated and were released from incarceration an opportunity to enroll in premium Part A and/or Part B upon their release from a correctional facility.
Other Exceptional Conditions HI 00805.385	This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who missed any part of a Medicare enrollment period and can demonstrate that there were circumstances outside of the individual's control that prevented them from taking action to enroll in Medicare timely.

The above SEPs, with the exception of the SEP for Termination of Medicaid Coverage, are for those who missed a Medicare enrollment period due to an exceptional condition that took place on or after January 1, 2023.

B. Policy for SEP enrollment requests filed during the Initial Enrollment Period (IEP)

When the IEP takes precedence over an SEP

When a beneficiary enrolls in SMI, premium HI, or both, during the IEP, you must always process the enrollment as an IEP enrollment.

EXAMPLE: 

Mr. Warren attains age 65 in July 2023. His IEP begins April 1, 2023 and ends October 31, 2023.

There is a hurricane leading to a disaster declaration impacting the county he lives in on July 1, 2023, and is lifted November 30, 2023. Mr. Warren enrolls in SMI in October, which is the last month of his IEP.

The enrollment must be processed as an IEP enrollment, regardless of Mr. Warren being affected by a disaster declaration.

C. Policy when the SEP and GEP overlap

If an individual who missed a prior enrollment period due to an exceptional condition enrolls in an SEP during the month of January, February, or March, they can elect to have the enrollment processed as either a General Enrollment Period (GEP) or as an SEP enrollment¹.

If the individual chooses a GEP enrollment even if they are eligible for an SEP, coverage begins the first day of the month after the month of enrollment. Calculate the premium surcharge through the end of the enrollment month using HI 01001.010.

If the individual chooses an SEP enrollment, coverage options may vary based on the specific effective date of each exceptional condition SEP. The coverage effective date of each SEP can be found at the link to the specific SEP above.

If an individual is eligible for any exceptional condition SEP and chooses to enroll using the SEP, no Premium Part A and/or Part B premium surcharge is applicable.

1 http://policynet.ba.ssa.gov/poms.nsf/lnx/0600805030 HI 00805.030 Relationship Between Initial and General Enrollment Periods.