Effective Dates: 10/10/2024 - Present Previous | Next

TN 113 (10-24)

HI 00805.277 Processing Special Enrollment Period (SEP) Enrollments

A. Determining the effective date of Special Enrollment Period (SEP) enrollment requests for Supplementary Medical Insurance (SMI) and premium-Hospital Insurance (HI)

A beneficiary can only choose the effective date for a Special Enrollment Period (SEP) in limited circumstances when the beneficiary is or was covered by a group health plan (GHP or LGHP) based on current employment, as outlined in HI 00805.276.

The enrollment request for supplementary medical insurance (SMI), or premium-hospital insurance (HI), for individuals applying under a GHP/LGHP SEP should include the statement “I want Part B coverage to begin (MM/YY)” on the CMS-40B form if:

  • •

    the aged beneficiary files the request while currently covered under a GHP based on current employment;

  • •

    the disabled beneficiary files the request while currently covered under a large group health plan (LGHP) based on current employment status; or

  • •

    the beneficiary files the request during the first month after such coverage ends.

NOTE: 

LGHP refers exclusively to disabled beneficiaries who are under age 65. A GHP for someone aged is of any size, so it may be an LGHP, or it may not. Refer to HI 00805.266.

Example of a beneficiary choosing the effective date in an SEP enrollment request:

Morgan has entitlement to Social Security benefits since age 62. Morgan refused SMI when first eligible in August 2010 because they were still covered under a GHP based on their current employment status. Morgan decides to retire at the end of September 2014, applies for SMI in July 2014, and signs a statement requesting an effective date of October 2014.

NOTE: 

Individual Coverage Health Reimbursement Arrangement, or ICHRA’s are not eligible for this SEP.

B. Field Office (FO) procedure for processing SEP enrollment requests

1. Documentation:

  1. a. 

    Obtain the beneficiary’s enrollment request. For a listing of SMI and Premium-HI enrollment forms, see and HI 00805.075 and HI 00801.138 which include the CMS-40B or CMS-4040 and CMS-10797.

  2. b. 

    Obtain the proper evidentiary documentation, which may be:

    • •

      Group Health Plan - Evidence of GHP or LGHP coverage based on current employment, see HI 00805.295, which includes the CMS-L564. For definitions of GHP, LGHP, and current employment, see HI 00805.266.

    • •

      Exceptional Conditions - Evidence that the individual experienced an exceptional condition per HI 00805.382 through HI 00805.387. The preferred form is the CMS-10797.

    • •

      International Volunteers – Evidence requirements located in HI 00805.355 - Evidentiary Requirements for the SEP or Premium-Surcharge Rollback for International Volunteers.

  3. c. 

    Load the enrollment request and SEP evidence to Evidence Portal (EP).

2. In-person claims and telephone claims:

a. For initial claims in MCS, if the person indicates potential eligibility for an Exceptional Conditions SEP

Complete the Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Conditions) form CMS-10797 using form attestation per GN 00201.015, and develop evidence per the POMS sections HI 00805.383 through HI 00805.387.

  1. 1. 

    After identifying the claimant per GN 00203.020, follow the attestation procedure and read the appropriate “Start of the interview” script from GN 00201.015F. Note: When the attestation script is performed at the beginning of the interview for a benefit application, it is not necessary to perform the script specifically for the CMS-10797.

  2. 2. 

    Go to a fillable PDF copy of CMS-10797.

  3. 3. 

    Record the applicant’s responses on the CMS-10797.

  4. 4. 

    Read the statement printed in the Sign Your Application section of the CMS-10797 form.

  5. 5. 

    In the Signature block on page 4, type “ATTEST” along with the office code and name of the interviewer

    • •

      If you cannot complete the Signature block, click on the “Add Text” to the Signature Block. The tool “Add Text” is located on your tool bar on the right-hand side of the PDF form.

    • •

      If Attachment 1 of the CMS-10797 is completed, also type “ATTEST” along with the office code and name of interviewer on page 5.

  6. 6. 

    From GN 00201.015F - Read the appropriate “End of the interview” script, and be sure to include the CMS-10797. Read the appropriate “obtain proper applicant’s affirmation of intent to file and understanding of penalty clause” script and include the CMS-10797.

    NOTE: 

    When the attestation script is performed at the end of the interview for a benefit application, it is not necessary to perform the script specifically for the CMS-10797. Clarify that the signature includes and applies to both the underlying form and Attachment 1 of the CMS-10797 (if Attachment 1 of the CMS-10797 is used as evidence). The applicant should understand that they are signing and certifying the information provided on the form and Attachment 1.

  7. 7. 

    Load the CMS-10797 into EP under “CMS-10797 Exceptional Conditions SEP” dropdown. Create a MCS issue of “10797” to show receipt of the form on the Development Worksheet (DW01). On the next line of the DW01, create an issue of “ATTEST” for the form attestation and show the same receipt date.

  8. 8. 

    When Attachment 1 of the CMS-10797 is completed, create another MCS issue of “10797-5” to document receipt of Attachment 1 of the CMS-10797. On the next line of the DW01, create an issue of “ATTEST” for the form attestation and show the same receipt date.

  9. 9. 

    Give or mail the CMS-10797 form and the form attestation cover notice to the beneficiary for their review and retention (see GN 00201.015L for the notice exhibit).

b. For initial claims in MCS when the applicant indicates potential eligibility for an SEP for International Volunteers:

  1. 1. 

    Document the International Volunteer enrollment on the MCS Application Remarks Screen.

  2. 2. 

    Load the evidence into EP under “OTHER-Other Document” dropdown. In the Comment Box, type INTVOL SEP Enrollment.

  3. 3. 

    Create a MCS issue of “INTVOL” on the DW01 to show request date. In the receipt date field, enter the date the evidence was received.

3. Internet Claim (iClaim):

Individuals filing for Retirement or Medicare-Only claims via iClaim can indicate if they want to file for SMI and review the Exceptional Conditions.

  1. a. 

    If the applicant indicated potential eligibility for an Exceptional Conditions SEP via iClaim, complete steps in HI 00805.277B.2.a. for claims with Exceptional Conditions and develop evidence as instructed in the POMS references HI 00805.382 through HI 00805.387 for the SEP selected.

  2. b. 

    If the applicant indicated potential eligibility for an SEP for International Volunteers via iClaim, develop and process per HI 00805.355 and steps in HI 00805.277B.2.b. for claims for International Volunteers.

4. Changes to the SEP information before the claim is processed:

If the person makes any changes to their SEP responses, such as:

a. Decides to refuse SMI entirely -

Action: For an initial claim, this will generate an amendment on an MCS application that requires another signature through MCS. Technician needs to document the discussion in a RPOC, store the amendment and send it.

b. Changes the type of SEP they are pursuing

Action: Repeat steps in this section.

c. If not eligible for an SEP, but would still like to enroll in Part B -

Action: Document the changes on a Report of Contact (RPOC).

For example: I explained to the individual that they are not eligible for any of the SEPs. The individual understands that they are not eligible for an SEP and still wishes to enroll in Part B via the GEP (or deemed GEP, if an initial claim).

5. Post Entitlement Enrollments -

a. For all post entitlement enrollment requests for Exceptional Conditions under the Special Enrollment Period (SEP):

  1. 1. 

    Obtain a pen-and-ink signed Form CMS–10797 Application for Medicare Part A and B - Special Enrollment Period (Exceptional Conditions). Mailed, emailed, and faxed applications are acceptable.

    Load the SEP enrollment request along with the appropriate proofs into Evidence Portal (EP) under “CMS-10797 Exceptional Conditions SEP” dropdown.

  2. 2. 

    Process the SEP enrollment request through POS.

b. For all post entitlement for International Volunteers, develop and process per HI 00805.355

HI 00805.350 states that to qualify for the INTVOL SEP, the person must no longer satisfy the eligibility requirements, therefore, a future International Volunteer Stop Date may not be entered on the screen. See MS 02003.008.

NOTE: 

If you receive an unsigned or improperly completed application form, follow instructions in HI 00805.060D.

6. Processing:

Take the following actions to process an SEP enrollment after documentation has been obtained:

  1. a. 

    Determine the proper process based on the beneficiary’s circumstances.

    Follow one of the specified processes listed below based on the beneficiary’s circumstance:

    1. 1. 

      Beneficiary is a qualified railroad retirement beneficiary (QRRB)

      Refer Railroad Retirement Board (RRB) annuitants that inquire about SMI enrollment to the nearest RRB field office. Identify the nearest RRB field office using the zip code locater found at this link: RRB Field Office. Provide the beneficiary with the nearest office and explain to the beneficiary that the RRB will process their SEP request

    2. 2. 

      Beneficiary filing for SMI only or HI and SMI (including premium-HI) and has no prior entitlement

      GHP SEP – When a beneficiary is filing an initial application for SMI only or for HI and SMI (including premium-HI) simultaneously, process the award via the Modernized Claims System (MCS).

      SMI only for Exceptional Conditions – When a beneficiary is filing an initial application for SMI only, process the award via the Modernized Claims System (MCS).

      SMI and premium – HI for Exceptional Conditions – process the award via the Modernized Claims System (MCS).

      International Volunteers – Process through MCS.

    3. 3. 

      Beneficiary filing for monthly benefits or HI

      If a beneficiary files for HI and SMI after the Initial Enrollment Period (IEP), process the SMI award as part of the monthly benefit claim or the HI claim via MCS.

      Example of processing the SEP enrollment request in an initial claim for monthly benefits:

      Adell, who attained age 65 in February 2012, has coverage under a GHP based on Adell employment since 1998. In October 2014, Adell files an application for monthly benefits and HI because they plan to retire at the end of that calendar year. Adell elects SMI coverage effective January 2015. We process the SEP enrollment via MCS as part of the monthly benefit claim.

    4. 4. 

      Beneficiary entitled to HI

      If the beneficiary is already entitled to HI, process the SMI SEP enrollment via the Post-entitlement Online System (POS).

      • •

        We generally use form CMS-40B (Application for Enrollment in Medicare - Part B (Medical Insurance)) for these enrollments. Form CMS-40B is for individuals who have Medicare Part A, but not Part B.

      • •

        Occasionally, applicants may choose to use form CMS-4040 (Request for Enrollment in Supplementary Medical Insurance). Form CMS-4040 is for individuals who wish to enroll in Medicare Part B but are NOT entitled to Social Security or Railroad Retirement Board benefits.

        NOTE: 

        Obtain a CMS-L-564 form (Request for Employer Information), if needed.

      • •

        For an SEP based on Exceptional Conditions, the preferred form is the CMS-10797, Application for Medicare Part A and Part B – Special Enrollment Period (Exceptional Conditions).

      • •

        A signed and dated statement such as, “I want to enroll for Part B of Medicare” is also acceptable.

      • •

        Note the necessary evidence for the applicable SEP is still required, regardless of the form used for enrollment.

    5. 5. 

      Beneficiary entitled to SMI and filing for premium-HI

      GHP SEP enrollment requests for beneficiaries already e entitled to SMI and are filing for premium-HI must be input via POS. The Form CMS-18 (Application for Hospital Insurance) is normally used in this situation, however, a simple signed and dated statement such as, “I want to enroll for Part A of Medicare” is also acceptable.

      Premium- HI for Exceptional Conditions – Process the enrollment -via POS.

    6. 6. 

      Enrollments that the PC process

      If the PC is processing the enrollment due to a processing limitation:

      • •

        Annotate “SEP Enrollment” at the top of the enrollment request and coverage start date

      • •

        Fax the enrollment request, evidence, and any clarifying documentation to the PC of jurisdiction via Paperless for the SMI (or premium-HI) award.

      • •

        Monitor the request until the PC processes the SMI (or premium-HI) award and the MBR/HIQR are updated.”

    7. 7. 

      Online and fax enrollments for Medicare Part B under an SEP for the working aged (GHP SEP) Only:

      The following are service delivery channels for beneficiaries to utilize for enrollments in Medicare Part B under the SEP provisions:

      a. Apply online

      Working beneficiaries age 65 or older who qualify for an SEP based on GHP may apply online by visiting Medicare Part B. Under the online process for Medicare Part B SEP enrollment, beneficiaries are required to provide an eSignature to submit the forms online.

      NOTE: 

      The online application does not allow beneficiaries to save and revisit the application.

      b. Apply by fax or mail

      Working beneficiaries aged 65 or older who qualify for an SEP may apply by fax or mail by downloading and completing the:

      • •

        Application for Enrollment in Medicare Part B (Medical Insurance) (CMS-40B); or

      • •

        Application for Enrollment in Supplementary Insurance (CMS-4040) and 

      • •

        Request for Employment Information (CMS-L564). Refer to HI 00805.295 Evidence of GHP or LGHP Coverage Based on Current Employment Status for secondary proofs if the CMS-L564 cannot be provided.

The beneficiary can fax or mail these forms to their servicing FO. The address and fax numbers can be obtained by accessing Social Security Office Locator from the SSA.gov website.

NOTE: 

The online service does not apply to the Exceptional Conditions SEPs nor International Volunteers.

C. Processing Center (PC) procedure for processing SEP enrollment requests:

PCs will process SEP enrollment requests using POS or Manual Adjustment, Credit and Award Data Entry (MACADE) using current processing instructions. Review the documents in the Evidence Portal (EP) prior to input to establish the correct entitlement date for SMI or Premium-HI.

D. Teleservice Center (TSC) procedure for responding to SEP enrollment requests :

See:

TC 24001.050 Special Enrollment Period (SEP) For the Aged and Disabled

TC 24001.052 Disability Special Enrollment Period (D-SEP)

TC 24001.054 Special Enrollment Period (SEP) for International Volunteers

TC 24001.050 Special Enrollment Period (SEP) for Exceptional Conditions

E. References

  • •

    HI 00801.138 Application for Premium HI

  • •

    HI 00805.075 Prescribed Enrollment Forms

  • •

    HI 00805.266 Description of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions

  • •

    HI 00805.276 SMI Effective Date for SEP Enrollments

  • •

    HI 00805.295 Evidence of GHP or LGHP Coverage Based on Current Employment Status

  • •

    HI 00805.310 Disability SEP Enrollments

  • •

    HI 00805.350 Special Enrollment Period for International Volunteers

  • •

    HI 00805.382 Special Enrollment Period (SEP) for Exceptional Conditions

  • •

    SM 00706.265 Exhibits of Form CMS-40B

  • •

    SM 00840.000 MACADE Menus

  • •

    SM 00850.000 HI/SMI Coding in MADCAP

  • •

    SM 03040.065 Special Enrollment Period (SEP)

  • •

    TC 24001.050 Special Enrollment Period (SEP) For the Aged and Disabled

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805277
HI 00805.277 - Processing Special Enrollment Period (SEP) Enrollments - 10/10/2024
Batch run: 10/10/2024
Rev:10/10/2024