Exceptional Circumstances for Medicare Special Enrollment Periods: What You Need to Know

Beginning in 2023, Medicare established new Special Enrollment Periods for Part B and premium Part A for those who experience an exceptional circumstance, such as losing Medicaid, living in an area impacted by disaster/emergency, or being released from incarceration.

This Q and A provides clarification on several circumstances and questions that have arisen as counselors have begun helping beneficiaries use the new enrollment opportunities. For more information on the Medicare Special Enrollment Periods for exceptional circumstances, please see NCOA’s exceptional circumstances SEP fact sheet.

Does the special circumstances Special Enrollment Period allow someone to sign up for Medicare premium Part A or Part B at any time?  

The special circumstances Special Enrollment Period (SEP) allows a person to sign up for Medicare premium Part A or Part B only if they were previously eligible but did not enroll into Medicare during their Initial Enrollment Period (IEP), a General Enrollment Period (GEP), or a Special Enrollment Period (SEP) because of an exceptional condition. Contacting Social Security is the first step to determine if someone is eligible for a SEP for exceptional conditions. The Social Security Administration (SSA) can be reached at 1-800-772-1213. TTY users should call 1-800-325-0778. 

What is the best method to request an exceptional circumstances SEP for Medicare premium Part A or Part B?  

Applicants may apply for Medicare coverage in person, by phone, or online. SSA employees will explain the documentation requirements, which may include completion of CMS form 10797, Application for Medicare Part A and B Special Enrollment Period (Exceptional Conditions). The form allows individuals to identify which exceptional circumstance they are seeking and to provide supporting documentation to support the request.  

Tell me more about the CMS form CMS-10797, Application for Medicare Part A and B Special Enrollment Period (Exceptional Conditions).  

The form allows individuals who, due to an exceptional circumstance, did not sign up for Medicare premium Part A or B during their Initial Enrollment Period (IEP), General Enrollment Period (GEP), or a prior Special Enrollment Period (SEP), to sign up without a late enrollment penalty using the SEP for Exceptional Conditions. People requesting a special exception SEP will need to provide:

• Medicare Number or Social Security number (SSN)
• Current address and phone number
• Qualifying documentation of eligibility for the SEP

Once the form is completed and signed, it can be sent to the local Social Security field office where a determination will be made. 

How is the beneficiary notified if their SEP has been approved or denied?

SSA is required to send a written notice to applicants explaining whether the SEP has been granted or denied. Although SSA is not required to process the SEPs in a specific timeframe, they aim to process these requests within 30 days from the time it is assigned to a technician. 

How is the approval of the SEP communicated to the Medicare Advantage/Part D plan, so they know the person has a SEP?

Per current practice, the Medicare Advantage (MA) or Part D plan would need to confirm that the individual had enrolled in premium Part A and/or Part B, as applicable, prior to the individual’s MA or Part D enrollment effective date. SSA will have to first process the individual’s premium Part A and/or Part B application and submit that information into SSA systems, which, in turn, would be populated in the Centers for Medicare & Medicaid Services (CMS) enrollment systems, for an MA or Part D plan to have access to that enrollment information.  

For MA enrollment, the SEP begins when the individual, using an exceptional condition SEP, submits their application for premium Part A and Part B, or Part B only if the individual is already entitled to Part A (or enrolls in premium-free Part A within the timeframe for use of this SEP).

For Part D enrollment, the SEP begins when the individual, using an exceptional condition SEP, submits their premium Part A or Part B application. The timeframe for use of both SEPs extends two months beyond the premium—Part A and/or Part B entitlement date, which will be visible to plans.

My client reports that his former employer did not supply any information on Medicare enrollment when he retired in December 2022. Is he eligible for the employer misinformation SEP?

The client is not eligible for the SEP for several reasons. First, the SEP only applies for misinformation conveyed after Jan. 1, 2023.  Second, according to the SEP guidance, no information on Medicare enrollment does not equate to misinformation. Individuals who received no information on Medicare enrollment from their employer or health plan do not qualify for this SEP.    

My client reports that their former employer, broker, or insurance agent advised them verbally that there was no need to sign up for Medicare at the time of retirement (Jan. 5, 2023), but they did not receive a written notice of any kind.  Does the new exceptions SEP provide relief in this situation? 

Beginning on or after Jan. 1, 2023, if an individual does not enroll in Part B during their IEP, GEP, or another SEP due to misinformation provided by their employer, group health plan, or agent or broker of a health plan, they may be eligible for this SEP. When possible, individuals are asked to provide a copy of a letter, email, form, or other documentation that verifies that misinformation that came directly from the employer, agent, broker, of a group health plan. The documentation must demonstrate that the misinformation was provided prior to the end of individual’s IEP, GEP, or another SEP. If no documentation is available, clients will need to provide a written explanation outlining the misinformation. CMS form 10797 includes a section to describe and attest to the misinformation circumstances.

Can the formerly incarcerated SEP be used for individuals who were enrolled in Medicare Part B prior to incarceration then lost Medicare Part B due to nonpayment while incarcerated?  

The recently released from Incarceration SEP can be used for individuals who were released from incarceration (after Jan. 1, 2023) when ANY of the following circumstances apply: 

• Medicare was terminated due to non-payment of premiums while the individual was incarcerated* (meaning the individual is in custody of penal authorities as defined in 42 CFR §411.4). 
• Medicare coverage was voluntarily terminated by the beneficiary while incarcerated. 
• An individual became eligible for premium Part A or Part B while incarcerated.

My client was on expansion Medicaid during her Medicare IEP.  She subsequently moved to a different state and enrolled into Medicare and continues to pay a late enrollment penalty. What kind of assistance can we offer this client?    

There may be situations where someone lost Medicaid during the COVID-19 public health emergency, enrolled in Medicare before Jan. 1, 2023, and has a late enrollment penalty. These individuals should contact Social Security to get the penalty removed. They should also be reimbursed for any penalties they have already paid.

If decisions are being made at the local level, what steps are being taken to ensure that the exception requests are being approved/denied uniformly?

Social Security representatives are trained to use Program Operations Manuals such as HI 00805.382 and HI-00805.387, which ensure uniform enrollment decisions for all applicants.  

NCOA continues to consult with CMS and SSA on questions on the exceptional circumstances SEP and will provide additional information as it becomes available. If you have additional questions or concerns, please contact centerforbenefits@ncoa.org.