Effective Dates: 03/07/2023 - Present Previous | Next

TN 77 (03-23)

HI 00805.270 General Eligibility Requirements for the Special Enrollment Period - Group Health Plans

A. Policy for general eligibility requirements

An individual is eligible to enroll under the Group Health Plan/Large Group Health Plan (GHP/LGHP) Special Enrollment Period (SEP) provisions if the individual meets one of the following requirements.

1. No previous Supplementary Medical Insurance (SMI) enrollment

If the individual did not enroll in the initial enrollment period (IEP), the individual must be covered under a group health plan (GHP) based on own or a spouse’s current employment status in the first month of eligibility for SMI and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on own, or a family member’s current employment status.

The first month of eligibility for SMI is the fourth month of the IEP, as explained in HI 00805.015.

2. Previous SMI entitlement

If the individual enrolled during an IEP and later terminated SMI coverage, the individual must be covered under a GHP based on own , or a spouse’s, current employment status the month of SMI termination and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on own, or a family member’s current employment status.

NOTE: If the individual previously enrolled during the GEP, the individual must have enrolled in SMI or have coverage under a GHP or LGHP in the first month of eligibility for SMI.

3. Subsequent SEP

If the individual enrolled in SMI during an SEP, and later terminated SMI coverage, the individual must be covered under a GHP based on own, or a spouse’s, current employment status the month of SMI termination and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on own, or a family member’s current employment status.

NOTE: There is no limit on the number of subsequent SEPs. However, to have a subsequent SEP, the individual must enroll during the earlier SEPs available to the individual. Enrollment during a GEP that falls within an SEP satisfies the requirement for an "earlier SEP enrollment.”

B. Reference

HI 00805.275 SEP Enrollments-Break in Employment or GHP/LGHP Coverage

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805270
HI 00805.270 - General Eligibility Requirements for the Special Enrollment Period - Group Health Plans - 03/07/2023
Batch run: 10/10/2024
Rev:03/07/2023