Identification Number:
HI 00805 TN 69
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 05 – Supplementary Medical Insurance Entitlement
Transmittal No. 69, 12/19/2022

Audience

PSC: BET, BTE, CR, CST, CTE, DEC, EHI, LCC, PAS, PCS, PETL, RECONR;
OCO-OEIO: BET, BIES, CCRE, CR, CTE, EIE, ERE, FCR, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DEC, PAS, PETE, PETL;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

The POMS updates are required to support the legislative changes mandated in the Consolidated Appropriations Act 2021 (CAA), specifically the creation of Special Enrollment Periods for exceptional conditions.

Summary of Changes

HI 00805.382 Special Enrollment Periods (SEP) for Exceptional Conditions

Created new POMS section to support the legislative changes mandated in the Consolidated Appropriations Act 2021 (CAA)

HI 00805.383 Exceptional Conditions Special Enrollment Period (SEP) for Individuals Impacted

Created new POMS section to support the legislative changes mandated in the Consolidated Appropriations Act 2021 (CAA)

HI 00805.384 Exceptional Conditions Special Enrollment Period (SEP) for Group Health Plan (GH

Created new POMS section to support the legislative changes mandated in the Consolidated Appropriations Act 2021 (CAA)

HI 00805.382 Special Enrollment Period (SEP) for Exceptional Conditions

CITATIONS:

Section 1837(m), 42 C.F.R. 407.23, 42 C.F.R. 406.27

 

A. Policy for when enrollment can occur

Beginning on or after January 1, 2023, individuals who are eligible for Medicare on any basis can enroll (or re-enroll) in Medicare Part B Supplementary Medical Insurance (SMI) and Part A Premium Hospital Insurance (HI) during any months that fall within the duration of the specific exceptional conditions SEPs described below. The duration of each SEP can be found at the link to the specific SEP:

Individuals Impacted by an Emergency or Disaster

HI 00805.383

This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who missed a Medicare enrollment period due to being impacted by a disaster or other emergency declared by a Federal, state, or local government entity.

Misrepresentation by Group Health Plan (GHP) or Employer

HI 00805.384

This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who missed a Medicare enrollment period and can demonstrate that their employer or group health plan materially misrepresented information regarding timely enrollment in Medicare.

Termination of Medicaid Coverage

HI 00805.385

This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who lost Medicaid eligibility and are eligible for Medicare.

Formerly Incarcerated Individuals

HI 00805.386

This SEP affords individuals who missed a Medicare enrollment period due to being incarcerated and were released from incarceration an opportunity to enroll in premium Part A and/or Part B upon their release from a correctional facility.

Other Exceptional Conditions

HI 00805.387

This SEP affords an opportunity to enroll in premium Part A and/or Part B to individuals who missed a Medicare enrollment period and can demonstrate that there were circumstances outside of the individual's control that prevented them from taking action to enroll in Medicare timely.

The above SEPs, with the exception of the SEP for Termination of Medicaid Coverage, are for those who missed a Medicare enrollment period due to an exceptional condition that took place on or after January 1, 2023.

B. Policy for SEP enrollment requests filed during the Initial Enrollment Period (IEP)

When the IEP takes precedence over an SEP

When a beneficiary enrolls in SMI or premium HI, or both, during the IEP, you must always process the enrollment as an IEP enrollment.

EXAMPLE:

Mr. Warren attains age 65 in July 2023. His IEP begins April 1, 2023 and ends October 31, 2023.

There is a hurricane leading to a disaster declaration impacting the county Mr. Warren lives in on July 1, 2023, and is lifted November 30, 2023. Mr. Warren enrolls in SMI in October, which is the last month of his IEP.

The enrollment must be processed as an IEP enrollment, regardless of Mr. Warren being affected by a disaster declaration.

C. Policy when the SEP and GEP overlap

If an individual who missed a prior enrollment period due to an exceptional condition enrolls in an SEP during the month of January, February, or March, they can elect to have the enrollment processed as either a General Enrollment Period (GEP) or as an SEP enrollment[1].

If the individual chooses a GEP enrollment even if they are eligible for an SEP, coverage begins the first day of the month after the month of enrollment. Calculate the premium surcharge through the end of the enrollment month using HI 01001.010.

If the individual chooses an SEP enrollment, coverage options may vary based on the specific effective date of each exceptional condition SEP. The coverage effective date of each SEP can be found at the link to the specific SEP above.

If an individual is eligible for any exceptional condition SEP and chooses to enroll using the SEP, no Premium Part A and/or Part B premium surcharge is applicable.

HI 00805.383 Exceptional Conditions Special Enrollment Period (SEP) for Individuals Impacted by an Emergency or Disaster Declared by Federal, State or Local Government Entities

 

A. Introduction

Medicare entitlement and enrollment decisions may be transmitted through letters delivered by the U.S. Postal Service. Beneficiaries may elect to enroll in premium Part A and/or Part B by mailing their enrollment decision to SSA.

The severity and duration of extreme weather-related events and other emergencies can be difficult to accurately predict, but may strip individuals of their ability to carry out day-to-day activities. These events can result in disruptions in mail delivery, field office closures due to disruptions in electricity or phone access, and operational delays, any of which can prevent individuals from submitting their enrollment application in a timely manner.

B. Eligibility

An SEP is available to those who were not able to enroll in premium Part A, Part B, or both due to a weather-related event or other emergency that began January 1, 2023, or later.

Eligible individuals are those who:

  • During a weather-related emergency or disaster, were in an enrollment period, and

  • Either the individual, the individual’s representative payee, legal guardian or person providing care, resided in areas for which a Federal, state, or local government entity declared a disaster or other emergency.

NOTE: The person must have missed an enrollment period because of an emergency or disaster declared by Federal, state or local government entities. For individuals who missed an enrollment period because of an emergency or disaster outside the U.S. and its territories, please refer to HI 00805.387 Exceptional Conditions Special Enrollment Period (SEP) for Other Exceptional Conditions..

C. Proof

  1. 1. 

    Technicians may obtain proof of a disaster declaration:

    • directly from the individual, or

    • by verifying other websites or sources, such as:

      • the Federal Emergency Management Agency’s website, https://www.fema.gov/disaster/declarations, to view the declared disasters;

      • the state’s official website where you can view the declaration;

      • other local government website or paper version of the declaration; and

      • SSA’s Emergency Messages (EM), Administrative Messages (AM), Operational Bulletins (OB) instructions that state that a disaster or emergency was invoked.

  2. 2. 

    Technicians must obtain proof of residence that displays a recent date that proves residency in the affected area.

NOTE: Proof of residence is also applicable to the individual’s representative payee, legal guardian or person providing care.

Examples of primary proof of residence can include but are not limited to:

  • medical records,

  • title or deed to real estate,

  • rent receipts or rental lease,

  • unemployment records,

  • utility bills,

  • state driver’s license or ID,

  • mail addressed to the claimant at an address in the affected area,

  • telephone directory listing,

  • tax assessment notice,

  • marriage certificate,

  • divorce decree(s),

  • summer camp or campground registration,

  • fishing, hunting, or boating license purchased in the affected area,

  • birth certificate of the claimant’s child,

  • school records,

  • records that show participation in a social program,

  • local bank record or check-cashing card,

  • record of volunteer activity, and

  • religious, fraternal, or social organization records.

NOTE: If primary evidence is not available, refer to section D of HI 00803.040 for ways to develop for secondary evidence.

D. Duration

The SEP begins the earlier of:

  • the date an emergency or disaster is declared, or

  • the start date identified in the declaration.

The SEP ends at the end of the month six months after the end date which is the later of:

  • the date identified in the disaster or emergency declaration, or

  • the end date of any extensions or the date when the declaration has been determined to have ended or has been revoked, or

  • the date of the declaration, if such date is after the end of the disaster.

Example: A natural disaster occurs and the individual’s state declares it as such on March 1, 2023. The emergency declaration ends on June 25, 2023. Therefore, the SEP begins on March 1, 2023 and ends on December 31, 2023.

E. Calculation of premium surcharge

There will be no late enrollment penalty (LEP) if enrolled pursuant to this SEP.

F. Effective date

The individual’s coverage begins the first day of the month following the month of enrollment.

G. Processing instructions

See HI 00805.277 for processing instructions.

H. Reference

HI 00805.277 Processing SEP Enrollments

HI 00805.384 Exceptional Conditions Special Enrollment Period (SEP) for Group Health Plan (GHP) or Employer Misrepresentation

 

A. Background

Often, the primary source of information about Medicare for working individuals is their employer or the carrier of their GHP. Despite the Centers for Medicare & Medicaid Services' (CMS) efforts to provide information to the working population, the potential for the dissemination of misinformation exists. In some cases, individuals may receive erroneous information from their employer or GHP that results in the individual not engaging in timely Part B enrollment and consequently being assessed a premium surcharge.

B. Eligibility

  1. 1. 

    This SEP applies for individuals whose non-enrollment in premium Part A or Part B is unintentional, inadvertent, or erroneous and results from material misrepresentation or reliance on incorrect information provided by an employer, or GHP, or brokers or agents of private health plans, or anyone authorized to act on behalf of such organization. Note that the agents or brokers of private health plans are not required to be direct employees of the health plan in order to qualify as sources of misinformation for the purposes of this SEP.

  2. 2. 

    To be eligible for this SEP, an individual must demonstrate that they:

 

  1. a. 

    Did not enroll in premium Part A or Part B during their IEP, GEP or another SEP in which they were eligible based on information received from an employer, GHP, or brokers or agents of private health plans that may have been a source of misinformation, and

  2. b. 

    An employer, GHP, or brokers or agents of a private health plan materially misrepresented information or provided incorrect information relating to enrollment in premium Part A or Part B. The material misrepresentation or incorrect information must have occurred on or after January 1, 2023.

NOTE: The person must have missed an enrollment period to be eligible for this SEP.

C. Proof

  1. 1. 

    Primary Proof

    The individual will be required to provide documentation of the relevant misrepresentation to SSA. The documentation must show the:

    • information was provided directly from an employer, GHP, or agent or brokers of a private health plan prior to their IEP, GEP or another SEP, and

    • inaccuracy that caused the individual not to enroll timely.

    Example: The individual receives a letter (or GHP website public notice) from their employer or GHP that materially misrepresents the Medicare enrollment process which caused them to not enroll in Medicare during their IEP.

    NOTE: Form CMS-L564 (Request for Employment Information) is not required for this SEP enrollment.

  2. 2. 

    Secondary Proof

    Alternatively, a written and signed statement from the beneficiary is sufficient evidence for eligibility for this SEP.

    The written statement must include a detailed account of the incident including:

  • the name and title of the person who provided the misinformation;

  • the name of the company;

  • the approximate date in which the misinformation was provided; and

  • a description of what misinformation was provided.

D. Duration

The SEP duration begins the day the individual contacts SSA about being misinformed and ends on the last day of the month six months later.

Example: An individual discovers they received erroneous information from their GHP. They contact SSA with supporting documentation on May 16, 2023, then the individual’s SEP begins on May 16, 2023 and ends on November 30, 2023. The individual has until November 30, 2023 to enroll under the GHP or Employer Misrepresentation SEP.

E. Calculation of premium surcharge

There will be no premium surcharge when enrolled based on this SEP.

F. Effective date

The individual’s coverage begins the first day of the month following the month of enrollment.

Example: The individual enrolls on May 16, 2023. Coverage will begin on June 1, 2023.

G. Processing instructions

See HI 00805.277 Processing SEP Enrollments for processing instructions.

H. Reference

HI 00805.277 Processing SEP Enrollments


HI 00805 TN 69 - Supplementary Medical Insurance Entitlement - 12/19/2022