TN 25 (04-12)

A. Policy for general eligibility requirements

An individual is eligible to enroll under the Special Enrollment Period (SEP) provisions if he or she meets one of the following requirements.

1. No previous Supplementary Medical Insurance (SMI) enrollment

If the individual did not enroll in the initial enrollment period (IEP), he or she must be covered under a group health plan (GHP) based on his or her own or a spouse’s current employment status in the first month of eligibility for SMI and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on his or her own, or a family member’s current employment status.

The first month of eligibility for SMI is the fourth month of the IEP, as explained in HI 00805.015.

2. Previous SMI entitlement

If the individual enrolled during an IEP and later terminated SMI coverage, he or she must be covered under a GHP based on his or her own, or a spouse’s, current employment status the month of SMI termination and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on his or her own, or a family member’s current employment status.

NOTE: If the individual previously enrolled during the GEP, he or she must have enrolled in SMI or have coverage under a GHP or LGHP in the first month of eligibility for SMI.

3. Subsequent SEP

If the individual enrolled in SMI during an SEP, and later terminated SMI coverage, he or she must be covered under a GHP based on his or her own, or a spouse’s, current employment status the month of SMI termination and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on his or her own, or a family member’s current employment status.

NOTE: There is no limit on the number of subsequent SEPs. However, to have a subsequent SEP, the individual must enroll during the earlier SEPs available to him or her. Enrollment during a GEP that falls within an SEP (with a choice of the July 1 date of entitlement based on the GEP) satisfies the requirement for an "earlier SEP enrollment.”

B. Reference

HI 00805.275 SEP Enrollments--Break in Employment or GHP/LGHP Coverage