Page 33

32 | P a g e

otherwise stated, an SEP is considered “used,” and is no longer available, upon the effective date of enrollment in the new plan, or when the SEP time frame ends, whichever comes first. For example, if an SEP exists for an individual from May–July, then a plan must receive an enrollment request from that individual within that time frame (May 1–July 31). If an individual makes an enrollment request in May, for a June 1 effective date, the SEP cannot be used to change plans after June 1.

The term “coordinating SEP” refers to an SEP that is specific to MA or Part D which coordinates with another SEP such that making an election using one allows the simultaneous use of the “coordinating” other. For example, using an MA SEP may allow the use of the coordinating Part D SEP to make a Part D election at the same time as the MA election.

30.6.1 – SEP for individuals age 65 (SEP65) Social Security Act §§ 1851(e)(4) and 1860D-1(b)(3)(E); 42 CFR §§ 422.62(c), 422.62(d)(2), and 423.38(c)(5)

MA eligible individuals who elect an MA plan (other than an MSA plan) during the initial enrollment period (IEP) for Part B surrounding their 65th birthday have an SEP. This “SEP65” allows the individual to disenroll from this MA plan and elect Original Medicare any time during the 12-month period that begins on the effective date of coverage in the MA plan.

The IEP for Part B is established by Medicare and begins three months before and ends three calendar months after the month of the individual’s 65th birthday. Individuals entitled to Medicare prior to age 65 are not eligible for the SEP65.

Coordinating Part D SEP:

If the individual using the SEP65 is disenrolling from an MA-PD plan, they may (but are not required to) use this SEP to enroll in a stand-alone PDP. This coordinating SEP must be used at the same time the SEP65 is used.

30.6.2 – SEP for individuals whose Medicare entitlement determination was made retroactively 42 CFR § 422.62(b)(10)

An individual who becomes entitled retroactively to Medicare (e.g., if a determination is administratively delayed, not made timely by SSA, or not received timely by the individual) and has not been provided an opportunity to elect an MA plan (MA-only, MA-PD) during their MA ICEP, may elect an MA plan.

This SEP begins the month the individual receives the notice of the retroactive Medicare entitlement determination and ends two calendar months after the month the individual receives the notice. The effective date would be the first of the month following the month in which the election is made but would not be earlier than the first day of the month in which the notice of the Medicare entitlement determination is received by the individual.