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.
Mr. Brown is not eligible for this SEP because he filed outside the six-month time
limit of this SEP.
EXAMPLE: Beth Lee is enrolled in Medicaid and turned 65 in February 2022. Beth has missed the
IEP and was not enrolled in Medicare under a state buy-in agreement.
Termination Notice: Ms. Lee receives a notice dated October 1, 2023, from the state Medicaid agency
notifying of the loss Medicaid coverage on November 15, 2023 (i.e., the last day of
Medicaid coverage is November 14, 2023).
SEP Duration: Ms. Lee’s exceptional condition SEP begins October 1, 2023 (the date of the notification
from the state) and will run until May 31, 2024.
SEP Filing: On October 6, 2023, Ms. Lee files the application for the exceptional condition
SEP based on loss of Medicaid coverage and includes the appropriate documentation.
Option 1 – Prospective: Effective date to begin the first of the month after the month
of enrollment. If Ms. Lee chooses this option, her Medicare coverage would be effective
November 1, 2023.
Option 2 – Retroactive: There is no retroactive option for Ms. Lee. The earliest the
coverage can start is November 1, 2023, the first day of month she has lost Medicaid
coverage. November 1 is the effective date of coverage in option 1.
EXAMPLE: Javier Lopez is enrolled in Medicaid and turned 65 in February 2022. Javier missed
his IEP and was not enrolled in Medicare under a state buy-in agreement.
Termination Notice: Mr. Lopez receives a notice dated October 1, 2023, from his state Medicaid agency
notifying the loss of all Medicaid coverage effective November 15, 2023 (i.e., the
last day of Medicaid coverage is November 14, 2023). SEP Duration: Mr. Lopez’s exceptional
condition SEP begins October 1, 2023 (the date of his notification from the state)
and will run until May 31, 2024.
SEP Filing: On November 10, 2023, Mr. Lopez files the application for the exceptional condition
SEP based on loss of Medicaid coverage and includes the appropriate documentation.
Option 1 – Prospective: Effective date to begin the first of the month after the month
of enrollment. If Mr. Lopez chooses this option, his Medicare coverage would be effective
December 1, 2023.
Option 2 – Retroactive: Effective date retroactive to November 1, 2023 (first day
of the month that Mr. Lopez no longer has any Medicaid coverage). If Mr. Lopez chooses
this option, his Medicare coverage would be effective November 1, 2023, and Mr. Lopez
will be responsible for paying Medicare premiums back to the date of coverage.