Many individuals are enrolled in Medicaid when their Initial Enrollment Period (IEP) for premium Part A or Part B begins.  While some individuals stay eligible for Medicaid after they qualify for Medicare, other individuals lose Medicaid eligibility entirely.

Individuals transitioning from Medicaid to Medicare coverage are at risk for gaps in coverage and losing access to critical health care. Administrative delays may keep individuals in Medicaid for multiple months after they first qualify for Medicare and become ineligible for Medicaid benefits.

Individuals who retain Medicaid after qualifying for Medicare may miss their IEP because they continue to be covered by Medicaid and may think they do not need or cannot afford Medicare at that time.

If they lose Medicaid coverage outside of the Medicare General Enrollment Period (GEP), they may need to wait months to enroll in Medicare and be subject to a premium surcharge when they can eventually enroll.

This SEP would help promote continuity of coverage for individuals who lose Medicaid eligibility and did not enroll in Medicare on time.

To be eligible for this SEP, an individual must lose Medicaid eligibility entirely on or after January 1, 2023. Individuals who are eligible for Medicaid, including a Medicare Saving Program, are ineligible for this SEP. See HI 00805.385.G.

Starting January 1, 2023, individuals are eligible for this SEP once they are notified of an upcoming Medicaid eligibility termination. States must send individuals notice of an upcoming Medicaid termination at least 10 days in advance.

Example: If the state sends the individual a notice dated April 15, 2023, informing them of their Medicaid termination effective May 1, 2023, the individual first qualifies for this SEP on April 15, 2023.

1. 1. 

   A letter from the state Medicaid agency or Medicaid managed care plan stating the Medicaid termination date, OR

2. 2. 

   If the individual does not provide documentation, the SSA employee will attempt to contact the appropriate public assistance office to obtain verification of Title XIX termination status.

   1. a. 

      A telephone call or electronic communication (email, fax, etc).

      1. i.  

         Verify the correct public assistance office contact information

      2. ii.  

         If the public assistance office does not respond and verification has not been obtained, notify the individual that SSA was unable reach the public assistance office to verify the Medicaid termination and that they have 30 days to obtain documentation and provide it to SSA, or they do not qualify for this SEP

3. 3. 

   Document the telephone contact via a SSA-5002 Report of Contact, and load the document or email it in Evidence Portal (EP). The documentation must contain the following information:

1. a. 

   The Medicaid termination effective date

2. b. 

   The Medicaid case number, and

3. c. 

   The location of the public assistance office furnishing the information and the name of the contact person.

1. 1. 

   The SEP starts upon notice of upcoming termination of Medicaid eligibility.

2. 2. 

   The SEP ends six months after the Medicaid termination.

   Example: If the state sends an individual a notice on April 15, 2023, informing them of a Medicaid termination effective May 1, 2023, the SEP starts on April 15, 2023, and ends on October 31, 2023.

There is no premium surcharge if an individual enrolls pursuant to this SEP.

Individuals have the option to choose an entitlement date:

Option1: Individuals enrolling in this SEP can choose a prospective entitlement to begin the first day of the month following the month of enrollment.

Option 2: Individuals enrolling in this SEP can opt for a retroactive entitlement date back to the first day of the month of their termination from Medicaid coverage, so long as their enrollment is on or after January 1, 2023.

Note: An individual who elects retroactive entitlement will be responsible for paying Medicare premiums back to the date of coverage.

 

Example 1: John Smith is enrolled in Medicaid and turns 65 in February 2024. He has missed his IEP and was not enrolled in Medicare under a state buy-in agreement.

Termination Notice: Mr. Smith receives a notice dated May 15, 2024 from his state Medicaid agency notifying him that he will lose all eligibility for Medicaid coverage on June 1, 2024.

SEP Duration: Mr. Smith’s exceptional condition SEP begins May 15, 2024 (the date of his notification from the state) and will run until November 30, 2024.

SEP Filing: On September 10, 2024, Mr. Smith files the application for the exceptional condition SEP based on loss of Medicaid eligibility and includes the appropriate documentation. His effective date options are:

- Option 1 - Prospective: Effective date to begin the first of the month after the month of enrollment. If Mr. Smith chooses this option, his Medicare coverage would be effective October 1, 2024.

- Option 2 - Retroactive: Effective date retroactive to June 1, 2024 (first day of the month of the termination of Medicaid coverage). If Mr. Smith chooses this option, his Medicare coverage would be effective June 1, 2024, and he will be responsible for paying Medicare premiums back to the date of coverage.

Example 2: Jane Taylor is enrolled in Medicaid and turns 65 in February 2022.  She has missed her IEP and was not enrolled in Medicare under a state buy-in agreement.

Termination Notice: Ms. Taylor receives a notice dated May 15, 2023, from her state Medicaid agency notifying her that that she will lose all eligibility for Medicaid coverage on June 1, 2023.

SEP Duration:  Ms. Taylor’s exceptional condition SEP begins May 15, 2023 (the date of her notification from the state) and will run until November 30, 2023.

SEP Filing: On May 28, 2023, Ms. Taylor files the application for the exceptional condition SEP based on loss of Medicaid eligibility and includes the appropriate documentation. Her effective date options are:

 

- Option1 – Prospective: Effective date to begin the first of the month after the month of enrollment. If Ms. Taylor chooses this option, her Medicare coverage would be effective June 1, 2023.

- Option 2 - Retroactive: There is no retroactive option for Ms. Taylor. The earliest her coverage can start is June 1, 2023, when she lost Medicaid. June 1 is the effective date of coverage in option 1.

Example 3: Sam Brown is enrolled in Medicaid and turns 65 in February 2024. He has missed his IEP and was not enrolled in Medicare under a state buy-in agreement.

Termination Date: Mr. Brown receives a notice dated May 15, 2024, from his state Medicaid agency notifying him that he will lose all eligibility for Medicaid coverage on June 1, 2024.

SEP Duration: Mr. Brown’s exceptional condition SEP begins May 15, 2024 (the date of his notification from the state) and will run until November 30, 2024.

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.

Individuals who still are eligible for Medicaid, including a Medicare Savings Program, and have not received notice of an upcoming Medicaid termination are not eligible for this SEP. See HI 00815.024B for a description of Medicare Savings Programs.

This is because States include most individuals who are enrolled in Medicaid, including a Medicare Savings Program, in their state buy-in agreements with the Centers for Medicare & Medicaid Services (CMS). Part A Buy-in States enroll individuals included in their buy-in agreements in premium Part A and/or Part B and pay premiums on their behalf at any time of the year without regard to Medicare enrollment periods or premium surcharge. This process is known as state buy-in. See HI 00815.001 for background on state buy-in.

See HI 00805.277 Processing SEP Enrollments for processing instructions.

HI 00805.277 Processing SEP Enrollments