Let's Take It Easy
Where can I find the SEP resource documents and what file is it?
TRN-REF-100 (Reliance Election Period Time Frame)
A couple years ago, Jane went back to work and dropped her MAPD plan for employer group coverage. Recently employment ended, and she lost that group coverage. What enrollment code would you use to enroll Jane into a MAPD?
What is
SEP- LEC – page 6 Loss of Employer Coverage
Today is May 30th. Caller has been on an MAPD for years, turns 65 on June 14th.
What is SEP-MRD for MA-only | IEP for MAPD/PDP
Note: They have another 7-month window: March 1st – September 30th to make changes.
Mary calls in and states that she needs to update her address.”
Note: What SEP/Type of SEP do you think might work?
What is SEP-MOV?
Extra Help
Note: Write a question you would possibly ask. No “What” is required in the answer.
What is Did you receive a yellow or green letter in the mail from Medicare stating you qualified for Low Income Subsidy assistance or Extra Help?
“yes”- if they received a letter stating they qualified for Extra Help, you can help them enroll with the LIS SEP
*REMEMBER: There are different levels of Extra Help that they can qualify for. Even if they make over the limit, they may still qualify if they take care of a dependent or have a job that puts them over the limit.
What page number on the Reliance Election Period Guide do you find the Election Period Hierarchy?
What is Page 5?
Take note: CMS will deny applications with the wrong enrollment/election. It is imperative to choose the correct enrollment/election period.
Michael is moving to his daughter's house a few miles from his current home – same city, same zip code, but different county. He wants a plan with OTC benefits. Can you help him?
What is “Yes if there is a plan available to her in the new area that is not available in her current area”?
SEP-MOV
Clarice called and said that she wanted a new plan that her primary doctor was in network, but she didn't worry too much about her prescriptions because the state pays for them. Does she have a SEP?
What is SPAP/PAP
Note: Individuals who belong to a qualified SPAP are eligible for an SEP to make one enrollment request at any time through the end of each calendar year (i.e. once per year). SPAP members may use this SEP to enroll in a Part D plan outside of existing enrollment opportunities, allowing them, for example, to join a Part D plan upon becoming a member of an SPAP or to switch to another Part D plan. A beneficiary may use this SEP to switch from an MAPD plan to another PDP or MAPD plan, from Original Medicare without a PDP to Original Medicare with a PDP or to an MAPD plan, from a PDP to another PDP or MAPD plan or from an MA-only plan to a PDP or MAPD plan.
In addition, individuals no longer eligible for SPAP benefits will have an SEP beginning either the month they lose eligibility or are notified of the loss, whichever is earlier, and ends two months after either the month of the loss of eligibility or notification of the loss, whichever is later.
Maryanne's plan was cancelled on Dec 31, due to termination of contract with CMS. She has both Medicare and Medicaid and called on March 15th. Medicare shows she is enrolled in a PDP plan, but she says she never enrolled in the plan.
How can you help Maryann?
What is SEP-DIFF
Note: Individuals who are enrolled into a plan by CMS or a State (i.e., through passive enrollment, auto-enrollment, facilitated enrollment, and reassignment) have a SEP to disenroll from their new plan or 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.
Moving
Note: Write a question you would possibly ask. No “What” is required in the answer.
What is Did you recently move?
“yes”- When did you move?/When did you notify Social Security that you moved? If they haven't notified Social Security yet, or if it's within the first 63 days of them notifying SS, use the Move SEP
When the term "Extra Help" is used what program are we talking about?
What is LIS (Low Income Subsidy)
Jim has an MAPD plan with limited dental but needs more dental coverage. He just found out her qualifies for Extra Help/LIS but not for Medicaid. SEP code to get an MAPD plan now with more dental coverage?
What is SEP-NLS
Caller saw ad that says there’s a plan with 5 stars in their area. Their current plan has only 3 stars. Codes and date range this SEP can be used?
What is SEP-5 Star - Election from 12/8 through 11/30
Janice calls ecstatic that she is finally retiring at the end of the next month. She states that she started her part A and part B Medicare at the beginning of last year when she originally thought she was retiring. Now she says she is ready to get on a MAPD, and her last day is March 31st. Can she get enrolled?
What is SEP-LEC (Losing Employer Group Coverage)
Loss of Current Coverage
Note: Write a question you would possibly ask. No What is required in the answer.
What is Did you receive a letter from your current insurance company that you no longer have coverage or that they are not offering any coverage in your area anymore?
“yes”- use SEP Loss of Creditable Coverage (LCC) or if available Loss of Employer Coverage (LEC)
“no”- move on to the next question
You are speaking to Mrs. Sanchez February 5th. She chose a different MAPD carrier during AEP but is not happy with her current coverage and is looking for a new MAPD.
What is SEP-OEP.
(Today is July 13th) Todd has no MAPD/PDP plan, has Part A&B since 2020, is newly eligible for Medicaid as of August 1st. How and when you can help them get enrolled in MAPD plan?
What is August 1st?
SEP-MCD
Donnie left a Program of All-Inclusive Care for the Elderly last January and wanted to get into the HMO he saw on television giving more OTC, does he have a SEP?
What is SEP-PACE
Note: Individuals may disenroll from MA/MAPD/PDP at any time to enroll in Program of All-inclusive Care for the Elderly (PACE). Additionally, individuals who disenroll from PACE have a SEP for up to two calendar months after the effective date of the PACE disenrollment to enroll in a MA, MAPD or PDP.
You are speaking with Ms. Black, a Wisconsin resident and she tells you that she has QMB+ and wants more out of her MAPD plan. She heard that people who have QMB+ can enroll in a better option.
Name that SEP?
What is SEP-INT
Note: full-benefit dually eligible individuals (FBDE, QMB+ or SLMB+ only) may use the integrated care SEP to enroll, once per month, into a fully integrated dual eligible special needs plan (FIDE SNP), highly integrated dual eligible special needs plan (HIDE SNP), or applicable integrated plan (AIP) AND the affiliated Medicaid Managed Care Organization (MCO).
Medicaid
Note: Write a question you would possibly ask. No “What” is required in the answer.
What is Do you get any help through your state Medicaid program?
“yes”- use SEP receiving/maintaining Medicaid or help on part B premium
*REMEMBER: There are different forms of Medicaid. Ask if they get help with food stamps (if they get food stamps they are usually within the income limits to qualify for Extra Help), or if they received a letter saying they are on a spend down/share-of-cost with Medicaid, or if they have partial Medicaid.
My effective date for Part A was last year and my effective date for delayed Part B is May 1st of this year. <date> is the last day I can sign up for an MA/MAPD plan without using an SEP Enrollment Period?
What is April 30th? SEP-ICEP
Note: With delayed Part B (different A&B effective dates) Applies only to MA/MAPD plans
Henry calls on July4th, very upset because his Cardiologist is no longer in network and needs to find a plan where he is. He also states that he was just diagnosed with diabetes and needs you to find him a specialist for that as well. Is there a SEP for him?
What is SEP-CSN
Note: SEP-CSN is for those individuals with severe or disabling chronic conditions to enroll in a CC-SNP designed to serve individuals with those conditions.
You are speaking with Mr. Reynolds on May 30th. He was released two weeks ago from incarceration after being in there for 2 years. He states that he wants the same plan he had before.
What is SEP-INC
Note: The SEP begins on the actual date of the release from incarceration or with the date the individual provides notification of such move and continues for two additional calendar months.
Freddie calls on April 4th and says that he got a letter saying that his plan was ending at the end of the month because he lost his Medicaid status due to his income increasing. He is worried and can't go without getting his prescriptions. Can you enroll Freddie in a new plan?
What is SEP-SNP (Loss of special needs status)Note:
CMS provides a SEP for individuals enrolled in a SNP who are no longer eligible for the SNP because they no longer meet the specific special needs status. This SEP begins when the period of deemed continued eligibility starts and ends the earlier of when the beneficiary makes an enrollment request or within three calendar months after the expiration of the period of eligibility.
VA Coverage
Note: Write a question you would possibly ask. No What is required in the answer.
What is Do you currently have VA or Tricare (military insurance)?
“yes”- use the SEP-OCC to enroll them into an MA-only plan designed with Veterans in mind.
(Note: if they get their Rx from VA and are disenrolling from Part D)