Staying Compliant: Special Enrollment Periods

Our compliance team has come up with a "How To" guide on how SEP's work and what you need to do to ensure you remain compliant. 

Staying Compliant - Special Enrollment Period (SEP)

One of the most complicated Medicare enrollment periods is the Special Enrollment Period (SEP). A SEP allows your clients to change their Medicare coverage outside the standard enrollment periods. Not everyone on Medicare will become eligible for a SEP. The length of and the effective date of the client's new coverage vary depending on the circumstances that trigger their SEP. Additionally, those who do become eligible may need to provide proof that they qualify.

The most common Special Enrollment Periods for Medicare are:

• A client moves out of their plan’s service area
• The plan no longer services the client's area
• A client moves in or out of a nursing home
• A client loses or gains Medicaid coverage
• A client is approved for (or loses) Extra Help benefits
• A client was recently released from jail
• A client was recently diagnosed with a chronic or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan available for that condition.
• A client is impacted by an Emergency or Disaster declared by the state or federal government.

Today’s Topic

Emergency and Disaster-related SEP

What is an Emergency and Disaster-related Special Enrollment Period?

An Emergency and Disaster-related SEP exists when a disaster or other emergency was declared by the local, state, or federal government, and the beneficiary was unable to and did not make an election during another valid election period as a result. This includes both enrollment and disenrollment elections.

Who Qualifies for an Emergency and Disaster-related SEP?

Individuals will be considered “affected” and eligible for a disaster-related SEP if they:

• Reside, or resided at the start of the incident period, in an area for which an emergency or a major disaster was declared.
• Had another valid election period at the time of the incident period; and
• Did not make an election during that other valid election period.

In addition, the SEP is available to individuals who don’t live in the affected areas but do rely on help making healthcare decisions from one or more individuals who live in the affected areas.

What Steps Need to be Followed for an Emergency and Disaster-related SEP?

If an individual believes they may qualify for a SEP, as an agent, you should:

• Confirm that they had another election period available during the time of the incident period and did not make a valid election during that period.
• Confirm that the beneficiary lived in a county that has been declared a disaster or emergency by a federal, state, or local government entity.

Once you’ve verified their eligibility, proceed with the application and be sure to select the following enrollment reason:

• I was affected by an emergency or major disaster (as declared by Federal Emergency Management Agency (FEMA) or by a Federal, state, or local government entity). One of the other statements here applied to me, but I was unable to make my enrollment request because of the disaster.

The enrollment will then be submitted to CMS using this election code. If it’s determined that the election isn’t appropriate, the carrier will reach out to inform you, and the member will receive a Request for Information (RFI) to determine if another enrollment period is available to them.

PLEASE NOTE:

Emergency and disaster-related SEPs are only available to beneficiaries who were affected during the incident period and may have missed a valid election period during the time of the incident.

SEPs should not be used as a marketing tool to generate new enrollments.