"CMS has the legal authority to establish SEPs when an individual or group of individuals meets exceptional conditions specified by CMS, including [SEPs] on a case-by-case basis."Under the section of "SEPs for Exceptional Conditions", CMS lists the following established 20 established "exceptional" SEPs:
1. SEP EGHP (Employer/Union Group Health Plan)And the last Special Enrollment Period in this section, "20. SEP for Other Exceptional Circumstances", offers even broader guidance for granting an SEP in extraordinary situations:
2. SEP for Individuals Who Disenroll in Connection with a CMS Sanction
3. SEP for Individuals Enrolled in Cost Plans that are Non-renewing their Contracts
4. SEP for Individuals in the Program of All-inclusive Care for the Elderly (PACE)
5. SEP for Institutionalized Individuals
6. SEP for Individuals Who Enroll in Part B during the Part B General Enrollment Period (GEP)
7. SEP for Individuals Who Gain, Lose, or Have a Change in their Dual or LIS-Eligible Status
8. Part D SEPs to Coordinate With MA Enrollment Periods
9. SEP for Individuals who belong to a Qualified SPAP or who lose SPAP eligibility
10. SEP for Disenrollment from Part D to Enroll in or Maintain Other Creditable Coverage
11. SEP for Individuals disenrolling from a Cost plan who also had the Cost plan optional supplemental Part D benefit
12. SEP to Enroll in an MA Plan, PDP or Cost Plan With a Plan Performance Rating of Five (5) Stars
13. SEP for Non-U.S. Citizens who become Lawfully Present
14. SEP for CMS and State-Initiated Enrollments
15. SEP for Providing Individuals Who Requested Materials in Accessible Formats Equal Time to Make Enrollment Decisions
16. SEP for Government Entity-Declared Disaster or Other Emergency
17. SEP for Individuals Enrolled in a Plan Placed in Receivership
18. SEP for Individuals Enrolled in a Plan That Has Been Identified by CMS as a Consistent Poor Performer
19. SEP for Individuals Who Enroll in Medicare premium-Part A or Part B using an Exceptional
Condition SEP, as Described in 42 CFR Parts 406.27 and 407.23
CMS will establish an SEP, on a case by case basis, for individuals whom CMS determines have experienced exceptional circumstances related to enrollments into or disenrollments from Part D plan that are not otherwise captured in regulation. Consistent with current practice, CMS will consider granting an enrollment or disenrollment opportunity in situations such as the following:
• Circumstances beyond the beneficiary’s control that prevented them from submitting a timely request to enroll or disenroll from a plan during a valid election period. This is inclusive of, but not limited to, a serious medical emergency of the beneficiary or his or her 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 a beneficiary provides a verbal or written allegation that his or her enrollment in a 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 a beneficiary states that they were enrolled into a plan without his or her knowledge or consent, and requests cancellation of the enrollment or disenrollment from the plan.
• A SEP may be warranted to ensure beneficiary access to services and where without the approval of an enrollment exception, there could be adverse health consequences for the beneficiary. 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 and documentation to determine eligibility for the SEP for exceptional circumstances. CMS’ review can be in response to an individual beneficiary’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 would take effect 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 would be based on the beneficiary’s circumstances and may be either prospective or retroactive." [highlighting and emphasis added]