TN 113 (10-24)

HI 00805.275 Special Enrollment Period (SEP) Enrollments - Group Health Plans

A. Policy for when enrollment can occur

Beginning 03/95, individuals who are age 65 or over, or disabled, can enroll (or re-enroll) in (SMI) and Premium HI:

  • during any month (including a partial month) in which the individual enrolled in a group health plan (GHP) or a large group health plan (LGHP) based on current employment status; For the definition of LGHP see HI 00805.266A; or

  • in any of the 8 consecutive months following the last month, during any part of which, the individual was enrolled in the GHP based on current employment status.

For SEP purposes, we consider a partial month of GHP and LGHP coverage based on current employment status to be a full month of coverage.

NOTE: The requirements for GHP coverage do not apply to “disabled family members” other than a spouse. Other family members can have an SEP only based only on LGHP coverage.

NOTE: 

Individual Coverage Health Reimbursement Arrangement, or ICHRA’s are not eligible for this SEP.

B. Policy for SEP enrollment requests filed during the initial enrollment period

1. When the IEP takes precedence over an SEP

The SEP is for those who do not enroll in SMI during the initial enrollment period (IEP). With the exception of the situation described in HI 00805.275B.2, when a beneficiary enrolls in SMI or Premium-HI, or both, during the IEP, you must always process the enrollment as an IEP enrollment. This is true even though the beneficiary has the option of choosing an entitlement date up to 3 months in the future when enrolling during an SEP. Follow IEP coverage rules found in HI 00805.165 B.1.

2. When an SEP enrollment is allowed during the IEP

A DIB beneficiary whose SMI entitlement ends for any reason prior to age 65 has a new IEP at age 65. DIB individuals who file an SEP enrollment request during the IEP based on attainment of age 65 are allowed to enroll under the SEP provisions if the request is filed prior to the age-65 attainment month. You must process a request filed during the last 4 months of the IEP (age 65 or later) as an IEP enrollment.

Example of SEP occurring during IEP

Ms. Smith(Claimant) (born February 12, 1958) was first eligible for Medicare effective October 2016 based on disability. The claimant refused SMI because the claimant had coverage under the spouse’s GHP, based on their current employment status.

Ms. Smith’s IEP based on age 65 attainment is November 2022 through May 2023. The claimant files an SEP enrollment request in November 2022, requesting a SMI start date of December 2022, the month the claimant spouse is retiring.

Since Ms Smith filed the enrollment request prior to February 2023 (the month attains age 65), we can process the SEP enrollment.

C. Policy when the SEP and GEP overlap

An individual who enrolls in an SEP month that occurs in January, February, or March can elect to have the enrollment processed either as a general enrollment period (GEP) enrollment or as an SEP enrollment.

If the individual chooses a GEP enrollment, coverage begins the first of the month following the month of enrollment (unless the enrollment is based on an initial establishment of HI). Calculate the premium surcharge using the months through the end of the month of enrollment. However, subtract the months of GHP or LGHP coverage from the premium surcharge calculation.

D. Policy for individuals covered under more than one GHP

An individual, who has coverage under two GHPs, LGHPs, or a combination of the two, can enroll in SMI anytime, as long as the coverage is based on current employment status. The individual can also enroll during the 8-month period that begins the month following the last month they have coverage under any group health plans based on current employment status.

NOTE: A disabled adult child or family member, other than a spouse covered under both a GHP and an LGHP, may enroll only based on the LGHP coverage.

Example of coverage under more than one GHP

Mr. Robinson has never enrolled in SMI because Mr Robinson had LGHP coverage based on own employment and GHP coverage based on spouse current employment. The coverage under LGHP ended when mr Robinson retired in January 2010, but remains covered under spouse's GHP.

Mr. Robinson can enroll in SMI anytime while covered under the GHP based on spouse’s current employment status or during the 8-month period that begins the month following the month no longer has coverage under the GHP based on current employment status.

E. Policy for SEP enrollment when the worker dies

As previously stated, a spouse or family member can enroll in SMI anytime while covered under the worker’s GHP or LGHP based on current employment status. When a surviving spouse or family member has coverage under the worker’s GHP or LGHP at the time the worker died, they can enroll during the 8-month period that begins the month following the month of the worker’s death.

F. Policy for SEP when GHP or LGHP coverage terminates retroactively

When an individual receives notification that the GHP or LGHP coverage has terminated retroactively (for any reason), they may enroll in SMI during the 8-month period that begins the first month following the month of notification.

Example of when GHP or LGHP coverage terminates retroactively

Barry, who attained age 65 in March 2008, was employed at the Higgins Corporation and covered under the company’s GHP since January 1998. Barry is entitled to HI-only, effective March 2008.

In March 2011, the employer notifies Barry that the number of hours currently working does not qualify Barry for the GHP coverage offered by the company and that the GHP coverage is terminating retroactive to January 1998.

Barry may enroll in SMI during the period of April 2011 through November 2011. Exclude all months of coverage under the GHP from March 2008 through March 2011 from the premium surcharge calculation.

G. Policy when there is a break in employment or GHP or LGHP coverage

The SEP provisions permit an 8-month period after the month GHP or LGHP coverage based on current employment status ends to enroll in SMI (or Premium-HI). Therefore, when employment or GHP or LGHP coverage ends, but before the 8-month period expires, a beneficiary is once again covered under a GHP or LGHP based on current employment status, the SEP is deemed not to have occurred. This protects the individual’s rights to an SEP or to a subsequent SEP.

Example of break in employment

The claimant , age 67 and covered under a GHP for many years based on the claimant own employment, retired on November 15, 2010. However, in March 2011, Michele (Claimant) begins working and has GHP coverage.

The claimant retains full SEP enrollment rights because less than 8 months elapsed between the retirement and subsequent coverage under a GHP. This means that claimant can enroll at anytime while covered under the GHP or during the 8-month period that follows the last month has coverage under the GHP based on current employment status.

H. Policy when an LGHP becomes a GHP

An LGHP becomes a GHP when it is no longer a “large plan,” as described in HI 00805.266A.3. When this situation occurs, family members (other than a disabled worker and spouse) who did not enroll while the plan was an LGHP can only enroll during the 8-month period that begins the month following the last month the GHP was an LGHP. The worker and spouse can enroll any time while covered under the GHP based on current employment status or during the 8-month period that begins the month following the month the GHP coverage or employment ends, whichever occurs first.

Example of when an LGHP becomes a GHP

Leslie and son, Michael, both disabled beneficiaries, have been covered under Leslie's working spouse LGHP since they first became eligible for Medicare in 1995. They did not enroll in SMI.

In February 2010, Leslie's spouse employer reduced the staff to less than 100 employees for the balance of that year. Based on the reduction, the LGHP became a GHP effective January 01, 2011.

While Leslie can enroll under the SEP provisions at any time while covered under the GHP based on current employment status, Michael can only enroll January 2011 through August 31, 2011 (the 8-month period following the last month the GHP was an LGHP).

I. References

HI 00805.015B Initial Enrollment Period

HI 00805.266 Definitions of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions

HI 00805.740 SEP and Premium Surcharge Provisions for the Aged Prior to the 1986 Amendments

HI 00805.750 SEP and Premium Surcharge Requirements in Effect for the Aged Prior to August 1986.

HI 00805.751 SEP and Premium Surcharge Requirements for the Aged Effective 8/86

HI 00805.752 SEP Enrollment Requirements for Disabled Beneficiaries Covered Under an LGHP Prior to the 1994 Amendments (Disabled Active Individuals)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805275
HI 00805.275 - Special Enrollment Period (SEP) Enrollments - Group Health Plans - 10/10/2024
Batch run: 10/10/2024
Rev:10/10/2024