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.

Before processing enrollments, technicians must confirm that eligibility for another Special Enrollment Period (SEP) does not apply, the individual is not in their Initial Enrollment Period (IEP) nor is filing for End Stage Renal Disease (ESRD).

Do not use the OEC SEP in lieu of Equitable Relief. If Equitable Relief applies, see HI 00830.001.

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

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  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

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  It is determined that the conditions were exceptional in nature.

This includes, but is not limited to:

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  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.

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

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  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:

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  Forgetfulness;

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  lack of knowledge; or

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  lapse in premium payments.

Acceptable documentation may include:

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

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  the beneficiary’s statement of the event or condition.

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

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

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

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

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

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

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  The SEP begins when SSA is notified by the applicant.

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  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.

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

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

See HI 00805.277 Processing SEP Enrollments for processing instructions.

Technicians are required to include remarks when processing enrollment for the Other Exceptional Conditions SEP.

These remarks should include:

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  What the exceptional condition is

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  When it occurred (must be after 01/01/2023), and

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  How the exceptional condition caused the individual to miss an enrollment period.

  Example: Bob missed the 2023 General Enrollment Period (GEP) due to the diagnosis of Dementia. Bob was diagnosed back on 02/23/2023, and deemed unable to make complex decisions regarding medical, legal or financial matters. Bob meets the criteria for the OEC SEP.

  • –

    What: “diagnosed with dementia”  

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      Identify the exceptional condition.

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    When: “diagnosed 02/23/23 and missed the 2023 GEP” 

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      Identify the missed enrollment period.

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    How: “lacked capacity to make complex decisions regarding medical, legal or financial matters”  

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      Identify how/why the exceptional condition caused the individual to miss the enrollment period.

Identify how/why the exceptional condition caused the individual to miss the enrollment period.

HI 00805.277 Processing SEP Enrollments