Medicare Advantage Emergency-Related SEPs

Has a natural disaster or emergency occurred near you recently? Your clients may qualify for a Special Enrollment Period.

CMS provides a Special Enrollment Period (SEP) for Medicare beneficiaries who need to enroll in, disenroll from, or switch Medicare Advantage or prescription drug plans but are affected by a disaster or other emergency declared by a federal, state, or local government entity like FEMA, the president, or a governor.

Note: A disaster SEP for Medicare enrollees is only available to those beneficiaries who were affected during the incident period and may have missed a valid election period during the time of the incident period. The beneficiary can only use this SEP if they did not make an election during that other valid election period due to the disaster or other emergency. This SEP shouldn’t be used as a marketing tool to generate new enrollments. See the full rule here that allows and establishes parameters for CMS to open up SEPs for those impacted by declared emergencies.

Source: https://www.fema.gov/disaster

Who Qualifies for Emergency and Disaster-Related SEPs?

To utilize a disaster PDP or Medicare Advantage SEP for enrollment, individuals must tick these three boxes:

• Reside (including resided at the start of the incident date) in an area where a federal, state, or local government entity has declared a disaster or other emergency or major disaster; or do not reside in an affected area but rely on help making health care decisions from one or more individuals who reside in qualified disaster areas.
• Have had another valid election period (e.g., Initial Enrollment Period) at the time of the SEP eligibility period.
• Have missed an enrollment during that other valid election period due to the disaster or other emergency.

When Does a Disaster SEP Start and End?

An emergency SEP begins the earliest of these dates:

• The date the declaration is made
• The incident start date
• The start date identified in the declaration

When the SEP ends depends on several factors and can be extended if the disaster declaration has been renewed.

Generally, the SEP ends two full calendar months:

• Following the end date identified in the emergency declaration
• Or, if different, the date the end of the incident is announced
• Or, if different, the date the incident automatically ends under applicable state or local law

If the incident end date is not otherwise identified, the incident end date is either one year after the SEP start date or the date of a renewal or extension of the declaration, whichever is later.

The maximum length of an emergency SEP, if the incident end date is not otherwise identified, is 14 full calendar months after the SEP start date (or the date of a renewal or extension of the declaration).

What Steps Do Agents Need to Follow for Emergency Medicare Enrollments?

Familiarize yourself with these steps. You are responsible for checking your client’s eligibility for this SEP prior to use.

If your client believes they may qualify for one of these SEPs and wants to enroll, disenroll, or switch Medicare Advantage or PDP plans, make sure you:

• Ask the beneficiary if they can show proof that they lived/live in an impacted area at the start of the SEP eligibility period or rely on help making health care decisions from friends or family members who lived/live in affected areas.
• If they do not have proof, ask them to verbally attest.
• Confirm that they had another valid election period available during the time of the incident period and did not make an election during that other valid election period due to the disaster or other emergency.
• Confirm that the beneficiary lived in a county that has been declared an emergency or major disaster or rely on help making health care decisions from friends or family members who lived/live in the affected areas.

Once you’ve verified their eligibility, proceed with the application. During the application process, select these two enrollment reasons:

• Affected by an emergency or major disaster (government entity or FEMA declared disasters only).
• Election period enrollee was eligible for and not able to use due to the declared disaster or emergency. Provide dates when applicable (e.g., change in residence).

On applications, use election code SEP DST. The enrollment will be submitted to CMS using this election code. If it’s determined that this 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 that enrollments made using a Medicare disaster SEP are effective the first of the month following the enrollment. For enrollment requests where more than one enrollment effective date is possible, agents will need to determine the applicant’s desired effective date.

We strive to keep you updated on relevant news and information and update this post monthly with new FEMA SEPs for Medicare; however, we do not guarantee that all emergency SEPs are still available or are listed here. Please check with your specific state and insurance carriers. For any updates to eligible counties for a FEMA disaster declaration, refer to the FEMA website.