TN 25 (04-12)
HI 00805.275 Special Enrollment Period (SEP) Enrollments
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 they are 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.
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.
EXAMPLE: Mr. Warren attains age 65 in July 2009. His IEP begins April 1, 2009 and ends October 31, 2009. He is covered under a GHP until he retires September 30, 2009. Mr. Warren enrolls in SMI in October, which is the last month of his IEP and the first month of the SEP.
SMI coverage begins January 2010 under the IEP rules, which take precedence. If Mr. Warren had waited until November 2009 to enroll, his SMI coverage would begin December 2009, since he enrolled in the second month following the last month of GHP coverage based on current employment status.
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 (born Febuary12, 1945) was first eligible for Medicare effective October 2006 based on disability. She refused SMI because she had coverage under her husband’s GHP, based on his current employment status.
Ms. Smith’s IEP based on age 65 attainment is November 2009 through May 2010. She files an SEP enrollment request in November 2009, requesting a SMI start date of December 2009, the month her husband is retiring.
Since she filed the enrollment request prior to February 2010 (the month she 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 July 1. Calculate the premium surcharge using the months through the end of the GEP. 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 he or she has coverage under any group health plan 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 he had LGHP coverage based on his own employment and GHP coverage based on his wife’s current employment. The coverage under his LGHP ended when he retired in January 2010, but he remains covered under his wife’s GHP.
Mr. Robinson can enroll in SMI anytime while covered under the GHP based on his wife’s current employment status or during the 8-month period that begins the month following the month he 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, he or she 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), he or she 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. He is entitled to HI-only, effective March 2008.
In March 2011, the employer notifies Barry that the number of hours he is currently working does not qualify him 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
Michele, age 67 and covered under a GHP for many years based on her own employment, retired on November 15, 2010. However, in March 2011, Michele begins working and has GHP coverage.
Michele retains full SEP enrollment rights because less than 8 months elapsed between her retirement and subsequent coverage under a GHP. This means that she can enroll at anytime while covered under the GHP or during the 8-month period that follows the last month she 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 his or her 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 his or her 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 her son, Michael, both disabled beneficiaries, have been covered under her working husband’s LGHP since they first became eligible for Medicare in 1995. They did not enroll in SMI.
In February 2010, her husband’s 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)