Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)

HI 00805.387 - Exceptional Conditions Special Enrollment Period (SEP) for Other Exceptional Conditions

1. Background

This SEP for Other Exceptional Conditions provides an enrollment opportunity for individuals where conditions beyond their control caused them to miss an enrollment period and prevented them from timely enrolling in premium Part A or Part B or both during the Initial Enrollment Period (IEP), General Enrollment Period (GEP) or other prescribed SEPs. This SEP applies to individuals whose unique conditions do not qualify for one of the other SEPs.

2. Eligibility

To be eligible for this SEP, an individual must ensure that the following two conditions are met:

• They must demonstrate that conditions outside of their control that occur on or after January 1, 2023, caused them to miss an enrollment period, and

• Its determined that the conditions were exceptional in nature.

This includes, but is not limited to:

• A serious medical emergency that prevented the beneficiary from access to enroll in Medicare,

  • Example: Being in a coma or admitted for a long-term in-patient stay, during an enrollment period or suffering from long-term illness such as Dementia or Alzheimer or suffering that impacted their ability to enroll timely.

• A natural or emergency disaster in a foreign country where a beneficiary resides disrupts mailing and transportation processes during an enrollment period.

• An elderly or disabled individual experiencing involuntary restraint due to abuse or neglect from a caretaker.

Factors that are not eligible for the SEP

Eligibility for this SEP will only be granted in conditions that are truly exceptional in nature and will not be used to grant individual’s enrollment due to:

• forgetfulness,

• lack of knowledge;

• lapse in premium payments;

Note: The individual must have missed an enrollment period due to the exceptional condition to be eligible for this SEP.

3. Required Proof

Acceptable documentation may include:

• any official documents that provide evidence of the event or condition that led to a missed enrollment period, or

• the beneficiary’s statement of the event or condition.

Examples of official documents may include, but are not limited to:

• medical records detailing history of the emergency medical event during the enrollment period

• foreign address documentation, utility bills, rental/lease agreement, foreign identification card, etc. to show proof of living in area impacted by natural disaster

• news article or government notice detailing disaster or emergency event(s) that occurred within the individual’s geographic region

• records from a dispatch company detailing emergency calls in the event of reported abuse or kidnapping. For example, a police report.

4. Duration

The SEP duration will be determined by SSA on a case-by-case basis but not less than 6 months post the exceptional condition and SSA is notified by the applicant.

5. Calculation of Premium Surcharge

There will be no premium surcharge if enrolled based on this SEP.

6. Effective Date

The individual’s coverage begins the first day of the month following the month of enrollment.

7. Processing Instructions

See HI 00805.277 Processing SEP Enrollments for processing instructions.

8. References

HI 00805.277 Processing SEP Enrollments

SM 03040.XXX