SEP Filing: On December 30, 2024, Mr. Brown files the application for the exceptional condition
SEP based on loss of Medicaid eligibility and includes the appropriate documentation.
He is not eligible for this SEP because he filed outside the six-month time limit
of this SEP.
EXAMPLE: Beth Lee is enrolled in Medicaid and turned 65 in February 2022. She has missed her
IEP and was not enrolled in Medicare under a state buy-in agreement.
Termination Notice: Ms. Lee receives a notice dated October 1, 2023, from her state Medicaid agency
notifying her that that she will lose all Medicaid coverage on November 15, 2023 (i.e.,
the last day of Medicaid coverage is November 14, 2023).
SEP Duration: Ms. Lee’s exceptional condition SEP begins October 1, 2023 (the date of her notification
from the state) and will run until May 31, 2024.
SEP Filing: On October 6, 2023, Ms. Lee files the application for the exceptional condition
SEP based on loss of Medicaid coverage and includes the appropriate documentation.
Option 1 – Prospective: Effective date to begin the first of the month after the month
of enrollment. If Ms. Lee chooses this option, her Medicare coverage would be effective
November 1, 2023.
Option 2 – Retroactive: There is no retroactive option for Ms. Lee. The earliest her
coverage can start is November 1, 2023, the first day of month she has lost Medicaid
coverage. November 1 is the effective date of coverage in option 1.
EXAMPLE: Javier Lopez is enrolled in Medicaid and turned 65 in February 2022. He has missed
his IEP and was not enrolled in Medicare under a state buy-in agreement.
Termination Notice: Mr. Lopez receives a notice dated October 1, 2023, from his state Medicaid agency
notifying him that that he will lose all Medicaid coverage on November 15, 2023 (i.e.,
the last day of Medicaid coverage is November 14, 2023). SEP Duration: Mr. Lopez’s
exceptional condition SEP begins October 1, 2023 (the date of his notification from
the state) and will run until May 31, 2024.
SEP Filing: On November 10, 2023, Mr. Lopez files the application for the exceptional condition
SEP based on loss of Medicaid coverage and includes the appropriate documentation.
Option 1 – Prospective: Effective date to begin the first of the month after the month
of enrollment. If Mr. Lopez chooses this option, his Medicare coverage would be effective
December 1, 2023.
Option 2 – Retroactive: Effective date retroactive to November 1, 2023 (first day
of the month he no longer has any Medicaid coverage). If Mr. Lopez chooses this option,
his Medicare coverage would be effective November 1, 2023, and he will be responsible
for paying Medicare premiums back to the date of coverage.