Highmark Senior Markets has recently observed an increase in agents submitting enrollments outside of AEP/OEP windows, citing the ongoing COVID-19 pandemic as justification for an automatic SEP under CMS guidelines. In many instances these enrollments are in violation of CMS guidance, which specifically requires an additional eligibility period.
These enrollments may not conform to regulatory standards requiring verification that an individual:
The full text of this specific regulation/guidance can be found below. If you have any questions about this guidance, please reach out to your local Channel Sales Representative.
SEP for Government Entity-Declared Disaster or Other Emergency
42 CFR 422.62(b)(18)
(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)
A SEP exists for individuals affected by a disaster or other emergency declared by a Federal, state or local government entity who were unable to, and did not make an election during another valid election period. This includes both enrollment and disenrollment elections. Individuals are eligible for this SEP if they:
- Reside, or resided at the start of the SEP eligibility period described in this guidance, in an area for which a federal, state or local government entity has declared a disaster or other emergency or they do not reside in an affected area but rely on help making healthcare decisions from one or more individuals who reside in an affected area; and
- Were eligible for another election period at the time of the SEP eligibility period; and 47
- Did not make an election during that other valid election period due to the disaster or other emergency.
The SEP starts as of the date the declaration is made, the incident start date or, if different, the start date identified in the declaration, whichever is earlier. The SEP ends 2 full calendar months following the end date identified in the declaration or, if different, the date the end of the incident is announced, whichever is later.
This regulation can be found in Chapter 2 Section 30 of the CMS Medicare Managed Care Manual, which can be accessed by clicking here.
