Discretionary SEP Scenarios

The Guidance on Eligibility, Enrollment, and Disenrollment states that "CMS has the legal authority to establish SEPs when an individual meets exceptional conditions specified by CMS." While certain exceptional conditions are defined specifically in the Guidance, this ruling does not preclude CMS from establishing other exceptional conditions at their discretion.

The following scenarios are examples where SHIP counselors successfully assisted beneficiaries to receive SEPs from CMS:

• A beneficiary sold a business he owned and thus lost the creditable coverage that he received from that business.
• A beneficiary who was receiving hospice care recovered and needed to enroll in a Part D plan.
• A beneficiary was recovering from surgery and was hospitalized during the Annual Enrollment Period, missing the yearly opportunity to reevaluate and change Part D plans.

If you have success stories of clients receiving SEPs as a result of your assistance, HAP would like to highlight your efforts on this page. Please submit a brief description of the scenario as well as your name and state.