Page 48

47 | P a g e

Individuals who are enrolled into a plan by CMS or a State (i.e., through passive enrollment, auto-enrollment, facilitated enrollment, and reassignment) have an SEP to disenroll from their CMS/State-initiated assigned plan and enroll into a different plan. The SEP permits a one-time election within three months of the effective date of the assignment, or notification of the assignment, whichever is later. It allows the individual to make an election before the enrollment is effective in the receiving plan or after the coverage in the receiving plan starts. This SEP must be used within three months of the start of coverage in the receiving plan, except that in the case where the notice is sent after the coverage in the receiving plan starts, the SEP ends three months after the date of the notice. This SEP is provided so that an individual may exercise any mandatory “opt-out” right provided to the enrollee as part of the CMS or State-initiated enrollment.

Individuals passively enrolled due to a plan’s non-renewal or termination (outlined in § 40.1.6) may also be eligible for an SEP as outlined in § 30.6.10 of this Chapter.

30.6.31 – SEP for individuals involuntarily disenrolled from an MA-PD plan due to loss of Part B 42 CFR § 423.38(c)(33)

Individuals who are involuntarily disenrolled from an MA-PD plan due to loss of Part B but who continue to be entitled to Part A have an SEP to enroll in a PDP. Generally, MA enrollment requires the individual to have Medicare Part A and Part B, however, those individuals with Part A only can enroll in a PDP. The SEP begins when the individual is advised of the loss of Part B. The SEP ends two calendar months after the month in which the individual was advised of the loss of Part B.

30.6.32 – SEP for non-U.S. citizens who become lawfully present 42 CFR §§ 422.62(b)(16) and 423.38(c)(21)

CMS will provide an SEP for non-U.S. citizens who become lawfully present in the United States. The individual may use this SEP to request enrollment in any MA plan or Part D plan for which they are eligible, including an MA-PD. This SEP begins the month the individual attains lawful presence. The SEP ends two calendar months after the month lawful presence status begins.

30.6.33 – SEP for significant change in provider network 42 CFR §§ 422.62(b)(23) and 423.38(c)(30)

When CMS determines a change in a plan’s provider network to be significant, affected enrollees are eligible for an SEP that permits enrollment in another MA plan or disenrollment from the MA plan that has changed its network to original Medicare. Enrollees are eligible for the SEP when the enrollee is assigned to, currently receiving care from, or has received care within the past three months from a provider or facility being terminated from the MA (or MA- PD) plan’s provider network.