TN 27 (11-14)
HI 00805.277 Processing SEP Enrollments
A. Determining effective date of special enrollment period (SEP) enrollment requests for supplementary medical insurance (SMI) and premium-hospital insurance (HI)
A beneficiary can only choose the effective date of an SEP enrollment in limited circumstances, as outlined in HI 00805.276. The enrollment request for supplementary medical insurance (SMI), or premium-hospital insurance (HI), should include the statement “I want Part B (and Part A, if applicable) coverage to begin (MM/YY)” if:
the aged beneficiary files the request while currently covered under a group health plan (GHP) based on current employment;
the disabled beneficiary files the request while currently covered under a large group health plan (LGHP) based on current employment status; or
the beneficiary files the request during the first month after such coverage ends.
For evidence requirements for GHP or LGHP coverage, see HI 00805.295. For definitions of GHP, LGHP and current employment, see HI 00805.266.
Example of a beneficiary choosing the effective date in a SEP enrollment request:
Mrs. Morgan has entitlement to social security benefits since age 62. She refused SMI when first eligible in August 2010 because she was still covered under a GHP based on her current employment status. She decides to retire at the end of September 2014, applies for SMI in July 2014 and signs a statement requesting an effective date of October 2014.
B. Field office (FO) procedure for processing SEP enrollment requests
Obtain the beneficiary’s SEP enrollment request and evidence of GHP or LGHP coverage based on current employment. For a listing of SMI and Premium HI enrollment forms, see HI 00805.075 and HI 00801.138. For information on evidence of GHP or LGHP coverage, see HI 00805.295.
Take the following actions to process a SEP enrollment:
1. Determine the proper process based on the beneficiary’s circumstance
Follow one of the specified processes based on the beneficiary’s circumstance:
a. Beneficiary is a qualified railroad retirement beneficiary (QRRB)
Refer Railroad Retirement Board (RRB) annuitants that inquire about SMI enrollment to the nearest RRB field office. Obtain the appropriate RRB field office and search using the Zip code locator. Tell the beneficiary that the RRB will process the SEP request.
b. Beneficiary filing for SMI only or SMI and HI (including premium-HI)
When a beneficiary is filing an initial application for SMI only or for SMI and HI (including premium-HI) simultaneously, process the award via the Modernized Claims System (MCS).
c. Beneficiary filing for monthly benefits or HI
If a beneficiary files for HI and SMI after the IEP, process the SMI award as part of the monthly benefit or the HI claim via MCS.
Example of processing the SEP enrollment request in an initial claim for monthly benefits:
Mr. Adell, who attained age 65 in February 2012, has coverage under a GHP based on his own employment since 1998. In October 2014, he files an application for monthly benefits and HI because he plans to retire at the end of that calendar year. Mr. Adell elects SMI coverage effective January 2015. We process the SEP enrollment via MCS as part of the monthly benefit claim.
d. Beneficiary entitled to HI
If the beneficiary is already entitled to HI, process the SMI SEP enrollment via the Post-entitlement Online System (POS). Although we generally use Form CMS-40B (Application for Enrollment in Part B (Medical Insurance)) for these enrollments, a signed and dated statement such as, “I want to enroll for Part B of Medicare” is also acceptable.
e. Beneficiary entitled to SMI and filing for premium-HI
SEP enrollment requests for beneficiaries who already have entitlement to SMI and are filing for premium-HI must be input via POS. The Form CMS-18 (Application for Hospital Insurance) is normally used in this situation, however, a simple signed and dated statement such as, “I want to enroll for Part A of Medicare” is also acceptable.
2. Enrollments that the Processing Center (PC) process
If the PC is processing the enrollment:
Annotate “SEP Enrollment” at the top of the enrollment request.
Send the enrollment request, evidence, and any clarifying documentation to the PC for the SMI (or premium-HI) award.
C. Processing Center (PC) procedure for processing SEP enrollment requests
PCs will process SEP enrollment requests using POS or Manual Adjustment, Credit and Award Data Entry (MACADE) using current processing instructions. Review the documents in the Claims File Records Management System (CFRMS) prior to input to establish the correct entitlement date for SMI or Premium-HI.
D. Teleservice Center (TSC) procedure for responding to SEP enrollment requests
1. Handling inquiries
Carefully question the beneficiary who inquires about enrollment in SMI or premium-HI under the SEP provisions to determine the status of employment and GHP or LGHP coverage, as defined in HI 00805.266.
a. Beneficiary currently covered under GHP or LGHP
If the aged beneficiary has current coverage under a GHP or the disabled beneficiary has current coverage under a LGHP based on current employment status, tell the beneficiary that:
enrollment in SMI or premium-HI may occur during any month he or she has the GHP or LGHP coverage based on current employment status; and
coverage may begin the month the enrollment application is filed, or in any of the following three months.
NOTE: If the disabled beneficiary has LGHP coverage on a basis other than current employment status, refer to HI 00805.310.
b. Beneficiary in first month after GHP or LGHP coverage or current employment ends
If the beneficiary is in the first month after their current employment status ends or their GHP or LGHP coverage based on current employment status ends, tell the beneficiary that:
c. Beneficiary in second through eighth months after GHP or LGHP coverage or current employment ends
If the beneficiary is in the second through the eighth month after their current employment status ends or their GHP or LGHP coverage based on current employment status ends, tell the beneficiary that:
enrollment in SMI or premium-HI may occur during the current month or during any of the remaining months of the SEP; and
coverage will begin the month following the month he or she files the enrollment application.
2. Processing requests for SEP enrollment
To process an SEP enrollment request, follow one of the specified processes based on the beneficiary’s circumstance:
a. Beneficiary already entitled to HI
Take the following actions to process an SEP request:
Offer the beneficiary the option to have the Form CMS-40B (Application for Medicare Part B (Medical Insurance)) and Form CMS-L564 (Request for Employment Information) mailed to them or to visit Medicare.gov to get the forms by clicking on the tab “Forms, Help & Resources” and selecting “Get Medicare Forms.” This tab is located on the top of the screen at the far right. (Medicare.gov/forms-help-and-resources/forms/medicare-forms.html) This is where the beneficiary can find the forms for completion. For information on Form CMS-40B, see HI 00805.075 and for Form CMS-L564, see HI 00805.295.
If the beneficiary wants the forms mailed:
send the forms and provide a FO return envelope; and
Mark the top of the enrollment form with “SEP Enrollment.” If the beneficiary files while still covered under the GHP or LGHP, or during the first month after coverage or employment based on current employment status ends, make sure the Remarks section of the form CMS-40B includes the statement, “I want Part B (and Part A, if applicable) coverage to begin (MM/YY).”
Explain to the beneficiary that he or she should mail or take the completed form to their local FO for processing.
For evidence requirements for GHP or LGHP coverage, see HI 00805.295.
Example of TSC processing an SEP request for SMI:
Mr. Martin, age 68, filed for Part A of Medicare when he attained age 65. He refused SMI because he was working and covered under his employer’s group health plan. Mr. Martin decides to retire effective June 30, 2013. He wants SMI coverage effective July 2013. When Mr. Martin contacts the TSC about enrolling in SMI in April 2013, the TSC tells him that he may file an enrollment request in advance, (i.e. during April 2013, May 2013 or June 2013) and request SMI coverage effective July 2013. Mr. Martin may also wait until July 2013 to file the enrollment application for SMI coverage effective July 2013.
Mr. Martin asks to have the forms mailed to him. The TSC sends the Forms CMS-40B and CMS-L564 to Mr. Martin to complete and return to the FO. Since Mr. Martin has requested that the coverage begin July 2013, the form CMS-40B contains the statement, “I want Part B coverage to begin July 2013.”
If Mr. Martin wants coverage to begin August 2013, he may file an application for SMI as early as May 2013.
b. Beneficiary not entitled to HI
Make a claims referral per TC 24001.050D.2. On the referral, show the remarks, “SEP Enrollment”.
HI 00801.138 Application for Premium HI
HI 00805.075 Prescribed Enrollment Forms
HI 00805.266 Description of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions
HI 00805.276 SMI Effective Date for SEP Enrollments
HI 00805.295 Evidence of GHP or LGHP Coverage Based on Current Employment Status
HI 00805.310 Disability SEP Enrollments
SM 00706.265 Exhibits of Form CMS-40B
SM 00840.000 MACADE Menus
SM 00850.000 HI/SMI Coding in MADCAP
SM 03040.065 Special Enrollment Period (SEP)
TC 24001.050 Special Enrollment Period (SEP) For the Aged and Disabled