Identification Number:
HI 00805 TN 70
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Full Transmittals
Program:Medicare,Medicaid
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. 70, 12/20/2022

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

 

Summary of Changes

HI 00805.385 Exceptional Conditions Special Enrollment Period (SEP) for Termination

 

HI 00805.386 Exceptional Conditions Special Enrollment Period (SEP) for Formerly Incarcerated

 

HI 00805.387 Exceptional Conditions Special Enrollment Period (SEP) for Other Exceptional

 

HI 00805.385 Exceptional Conditions Special Enrollment Period (SEP) for Termination of Medicaid Eligibility

 

A. Background

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.

B. Eligibility

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.

C. Proof

  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.

D. Duration

  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.

E. Calculation of Premium Surcharge

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

F. Effective Date

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.

G. Individuals who are not eligible for 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.

Note: Group Payer states do not include the payment of Part A premiums for Qualified Medicare Beneficiaries (QMB)under their buy-in agreements. In Group Payer states, individuals who receive notice of an upcoming Medicaid termination and are not yet determined by the State to be a QMB can use this SEP to enroll in Premium-Part A through the conditional enrollment process. See HI 00801.140B for a description of the conditional enrollment process.

 

H. Processing Instructions

See HI 00805.277 Processing SEP Enrollments for processing instructions.

I. References

HI 00805.277 Processing SEP Enrollments

HI 00805.386 Exceptional Conditions Special Enrollment Period (SEP) for Formerly Incarcerated

 

A. Background

Section 1862(a)(2) and (3) of the Social Security Act generally prohibits Medicare payment for covered services while the recipient is incarcerated, as the incarcerated individual is provided healthcare through their penal institution (see HI 00620.070C).  Further, section 202(x)(1)(A) of the Act prohibits the payment of Old-Age, Survivors, and Disability Insurance (OASDI) benefits to individuals who are incarcerated (see GN 02607.160).

For example, if an individual turns 65 and qualifies for Medicare while incarcerated (meaning the individual is in custody of penal authorities as described in this POMS) and is not yet receiving OASDI benefits, that individual is not automatically enrolled in Medicare Part A. If these formerly incarcerated individuals do not enroll or reenroll into Medicare, they may go months without health insurance coverage upon their release.

For example, upon their release such individuals would only be able to enroll in Medicare during the General Enrollment Period (GEP) which could result in a significant delay in coverage. Further, delaying enrollment means that they may incur a premium surcharge for premium Part A and/or a premium surcharge for Part B for the rest of their lives.

These instructions provide an SEP for these individuals. These only provide provisions for incarcerated individuals released on or after January 1, 2023 a special enrollment opportunity. Individuals released prior to January 1, 2023 are not covered under the regulations.

B. Eligibility

Definition: For the purposes of these instructions, incarcerated refers to individuals who are in custody including, but not limited to:

  • individuals who are under arrest;

  • incarcerated, imprisoned;

  • escaped from confinement;

  • under supervised release;

  • on medical furlough;

  • required to reside in mental health facilities;

  • required to reside in halfway houses;

  • required to live under home detention;-, or

  • confined completely or partially in any way under a penal statute or rule.

    To be eligible for this SEP, an individual would have to:

  • Demonstrate that they are eligible for Medicare, and

  • Due to being incarcerated (as defined above), failed to enroll or reenroll in Medicare premium Part A or Part B during another enrollment period in which they were eligible to enroll while they were incarcerated and

  • There must be a record that the individual has been officially released from incarceration, as defined above, on or after January 1, 2023, either through the appropriate discharge documents or data available to SSA.

C. Evidence

Use normal processing instructions for handling of verification of inmate’s official release documents in GN 02607.840.

D. Duration

  1. 1. 

    This SEP duration would begins the day of the individual’s release from incarceration, as defined above, as long as it is on or after January 1, 2023.

  2. 2. 

    The duration end date will be the last day of the 12th month after the individual is released from incarceration.

    Example:Mrs. Q was incarcerated when she turned 65 and therefore missed her IEP. She was released from jail on March 13, 2023. Mrs. Q has until March 31, 2024, to enroll under the SEP for Formerly Incarcerated Individuals.

    Note:Count the 12 months starting with the month after the month of release. In the example above, count starting from April 1, 2023, until the last day of the 12th month, which will be March 31, 2024.

E. Calculation of Premium Surcharge

There will be no premium surcharge if enrolled pursuant to this SEP.

F. Effective Date

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 retroactive to the first day of the month of their release from incarceration, so long as it their enrollment is on or after January 1, 2023.

 

  • If the application is filed within the first full 6 months of the SEP, the effective date is retroactive to the date of their release from incarceration.

  • If the application is filed in the last 6 months of the SEP, the coverage effective date is retroactive to the 6th month before the month of enrollment.

Example 1: Bob Miller is incarcerated in July 2016 at the age of 59. He turns 65 in March 2022 but fails to enroll in his IEP while incarcerated. Mr. Miller is released from incarceration on June 12, 2023. His SEP begins the day he is released and will run until June 30, 2024. Mr. Miller provides the appropriate documentation of his release, and enrolls on July 22, 2023. His effective date options are:

- Option 1: Effective date to begin the first of the month after the month of enrollment. If Mr. Miller chooses this option, and enrolls the day he is released from incarceration, his coverage would be effective August 1, 2023.

- Option 2: Retroactive: Effective date retroactive to June 1, 2023 (or the earliest date of eligibility, if later than the month of release). If Mr. Miller chooses this option, he will be responsible for paying Medicare premiums back to the date of coverage.

Example 2: Carla Bennings is incarcerated in February 2020 at the age of 67. At the time of her incarceration she was enrolled in Part A and B. During incarceration, she was terminated from Part B for failure to pay premiums. She did not attempt to reenroll in Part B while in prison. She was released from prison on April 15, 2023 and files for SEP on November 4, 2023. Her effective date options are:

- Option 1: Effective date to begin the first of the month after the month of enrollment. If Ms. Bennings chooses this option, and enrolls the day she is released from incarceration, her coverage would be effective December 1, 2023.

- Option 2: Retroactive: Effective date retroactive to May 1, 2023 since it can only be 6 months retroactive. If Ms. Bennings chooses this option, she will be responsible for paying Medicare premiums back to the date of coverage.

G. Processing

See HI 00805.277 Processing SEP Enrollments for processing instructions.

 

H. References

GN 02607.840 Retirement, Survivors, and Disability Insurance (Title II) Reinstatement Policies for Prisoners

HI 00805.277 Processing SEP Enrollments

HI 00805.387 Special Enrollment Period (SEP) for Other Exceptional Conditions

 

A. Background

This SEP for Other Exceptional Conditions provides an enrollment opportunity for individuals where conditions beyond their control caused them to miss an enrollment period and prevented them from timely enrolling in premium Part A or Part B or both during the Initial Enrollment Period (IEP), General Enrollment Period (GEP) or other prescribed SEPs.  This SEP applies to individuals whose unique conditions do not qualify for one of the other SEPs.

B. Eligibility

To be eligible for this SEP, an individual must ensure that the following two conditions are met:

  • They must demonstrate that conditions outside of their control that occur on or after January 1, 2023, caused them to miss an enrollment period, and

  • It is determined that the conditions were exceptional in nature.

This includes, but is not limited to:

  • A serious medical emergency that prevented the beneficiary from access to enroll in Medicare,

    Example: Being in a coma or admitted for a long-term in-patient stay, during an enrollment period or suffering from long-term illness such as Dementia or Alzheimer or suffering that impacted their ability to enroll timely.

  • A natural or emergency disaster in a foreign country where a beneficiary resides disrupts mailing and transportation processes during an enrollment period.

  • An elderly or disabled individual experiencing involuntary restraint due to abuse or neglect from a caretaker.

Factors that are not eligible for the SEP

Eligibility for this SEP will only be granted in conditions that are truly exceptional in nature and will not be used to grant individual’s enrollment due to:

  • Forgetfulness;

  • lack of knowledge; or

  • lapse in premium payments.

Note: The individual must have missed an enrollment period due to the exceptional condition to be eligible for this SEP.

C. Required Proof

Acceptable documentation may include:

  • any official documents that provide evidence of the event or condition that led to a missed enrollment period, or

  • the beneficiary’s statement of the event or condition.

Examples of official documents may include, but are not limited to:

  • medical records detailing history of the emergency medical event during the enrollment period

  • foreign address documentation, utility bills, rental/lease agreement, foreign identification card, etc. to show proof of living in area impacted by natural disaster

  • news article or government notice detailing disaster or emergency event(s) that occurred within the individual’s geographic region

  • records from a dispatch company detailing emergency calls in the event of reported abuse or kidnapping. For example, a police report.

D. Duration

The SEP duration will be determined by SSA on a case-by-case basis:

  • The SEP begins when SSA is notified by the applicant.

  • The SEP ends on a case-by-case basis, but not less than 6 months after the month that SSA is notified by the applicant.

    Example: A person who is eligible for Medicare is experiencing involuntary restraint and misses their IEP. The person escapes their abuser on June 12, 2023. The person spends some time in recovery. The person contacts SSA on January 3, 2024, to enroll in Part B and provides documentation. The SEP duration will be determined on a case-by-case basis, however, since the applicant contacted SSA on January 3, 2024, the SEP end date will be no earlier than July 31, 2024.

E. Calculation of Premium Surcharge

There will be no premium surcharge if enrolled based on 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 Processing SEP Enrollments for processing instructions.

H. References

HI 00805.277 Processing SEP Enrollments


HI 00805 TN 70 - Supplementary Medical Insurance Entitlement - 12/20/2022