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 coverage 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 coverage entirely and did not enroll in Medicare on time.

To be eligible for this SEP, an individual must lose Medicaid coverage entirely on or after January 1, 2023. Individuals who are eligible for Medicaid, including a Medicare Savings 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 coverage 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.

1. 1. 

   A letter from the state Medicaid agency or Medicaid managed care plan showing the last day of Medicaid coverage, 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 loss of Medicaid coverage.

   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 last day of Medicaid coverage,

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.

1. 1. 

   The SEP starts upon notice of upcoming loss of all Medicaid coverage.

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 they will loose all Medicaid coverage on May 1, 2023, (i.e.,the last day of Medicaid coverage is April 30, 2023), The SEP starts on April 15, 2023, and ends on October 31, 2023.

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

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 loss of Medicaid coverage.

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. John has missed the 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 Mr. Smith that the eligibility for Medicare coverage was terminated on June 1st, 2024 (i.e., the last day of Medicaid coverage is May 31, 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 he no longer has any 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 the state Medicaid agency notifying Ms. Taylor the loss of eligibility for Medicaid coverage on June 1, 2023. (i.e., the last day of Medicaid coverage is May 31, 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. Ms. Taylor 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, the Medicare coverage would be effective June 1, 2023.

 

 

Option 2 - Retroactive: There is no retroactive option for Ms. Taylor. The earliest the coverage can start is June 1, 2023, the first day of the month when Ms. Taylor lost all Medicaid coverage. 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. Sam has missed the 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 the state Medicaid agency notifying Mr. Brown the loss of all eligibility for Medicaid coverage on June 1, 2024. (i.e., the last day of Medicaid coverage is May 31, 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. 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.

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. For a description of Medicare Savings Programs, see HI 00815.024B.

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. For background on state buy-in, see HI 00815.001.

For processing instructions, see Processing SEP Enrollments HI 00805.277.

HI 00805.277 Processing SEP Enrollments