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• Circumstances beyond the individual’s control that prevented them from submitting a timely request to enroll in or disenroll from a plan during a valid election period. This is inclusive of, but not limited to, a serious medical emergency of the individual or their authorized representative during an entire election period, a change in hospice status, or mailed enrollment or disenrollment requests returned as undeliverable on or after the last day of an enrollment period. • Situations in which an individual provides a verbal or written allegation that their enrollment in an MA or Part D plan was based upon misleading or incorrect information provided by a plan representative or State Health Insurance Assistance Program (SHIP) counselor, including situations where an individual states that they were enrolled into a plan without their knowledge or consent, and requests cancellation of the enrollment or disenrollment from the plan. • An SEP may be warranted to ensure access to services, and when, without the approval of an enrollment exception, there could be adverse health consequences for the individual. This is inclusive of, but not limited to, maintaining continuity of care for a chronic condition and preventing an interruption in treatment.

CMS will review supporting details to determine eligibility for the SEP for exceptional circumstances. CMS’s review can be in response to an individual’s request for an exception to the current enrollment rules, as well as CMS’ determination that an exception is warranted for a group of beneficiaries.

The SEP begins once CMS makes its determination and the enrollee has been notified. The effective date for an enrollment or disenrollment election using an approved enrollment exception is based on the individual’s circumstances and will be effective the first of the month and may be either prospective or retroactive. The earliest prospective enrollment effective date is the first day of the calendar month following the month in which the election is made.

30.7 – Effective Dates of Coverage 42 CFR §§ 422.68 and 423.40

With the exception of some SEPs or, when election periods overlap, individuals may not request their enrollment effective date. Furthermore, except for the EGHP SEP, the effective date is generally not prior to the receipt of an enrollment request by the plan. An enrollment cannot be effective prior to the date the individual or their authorized representative completed the enrollment request. The effective date for an enrollment into an MA plan may not be earlier than the first day of the individual’s entitlement to both Medicare Part A and Part B; for Part D plans, the effective date may not be earlier than the first day that the individuals is entitled to Medicare Part A and/or enrolled in Part B.

To determine the proper effective date, plans must determine which election period applies to each individual before the enrollment may be transmitted to CMS. The election period may be determined by reviewing information such as the individual’s date of birth, Medicare card, a letter from SSA, or by the date the enrollment request is received by the plan.

Once the election period is identified, the plan must determine the effective date.