Basic SEP Question for PDP

[beachbum2012]

So if you choose 'SEP' on a PDP or MAPD application, there are several reasons you can pick as the reason for the SEP. One of them is "losing/leaving coverage from an employer or union". Does this extend to retiree coverage too? I have a prospect I met with yesterday who has an MAPD retiree health plan from the hospital she retired from. She wants to leave it and get a medsupp and PDP, and I just wanted to make sure this SEP reason covered voluntary disenrollment from a retiree plan. She may not be able to get a medsupp just yet as she has some pending tests, so I wouldn't be able to use 'AEP' as her enrollment period. I've always wondered about this particular SEP reason in general.

 

[TwoCents]

So if you choose 'SEP' on a PDP or MAPD application, there are several reasons you can pick as the reason for the SEP. One of them is "losing/leaving coverage from an employer or union". Does this extend to retiree coverage too? I have a prospect I met with yesterday who has an MAPD retiree health plan from the hospital she retired from. She wants to leave it and get a medsupp and PDP, and I just wanted to make sure this SEP reason covered voluntary disenrollment from a retiree plan. She may not be able to get a medsupp just yet as she has some pending tests, so I wouldn't be able to use 'AEP' as her enrollment period. I've always wondered about this particular SEP reason in general.

You refer to the retiree plan as an MAPD. So does this mean that it has a CMS contract like H1234-800? The last 3 should always be in the 800s or higher for group Medicare plans. I don't think the SEP differentiates between the coverage being a retiree plan or a plan for active employees like it does if she were enrolling into Original Medicare (major difference there).

From the CMS PDP enrollment guidance:
1. SEP EGHP (Employer/Union Group Health Plan) - An SEP exists for individuals enrolling in employer/union group-sponsored Part D plans, for individuals to disenroll from a Part D plan to take employer/union-sponsored coverage of any kind, and for individuals disenrolling from employer/union-sponsored coverage (including COBRA coverage) to enroll in a Part D plan. The SEP EGHP may be used when the EGHP allows the individual to make changes to their plan choices, such as during the employer’s or union’s “open season,” or at other times the employer or union allows.
This SEP is available to individuals who have (or are enrolling in) an employer or union plan and ends 2 months after the month the employer or union coverage ends.

This should be the part that applies to your client: for individuals disenrolling from employer/union-sponsored coverage (including COBRA coverage) to enroll in a Part D plan.

 

[beachbum2012]

Cool thanks. I believe the contract number ended in an 8xx number. I just know that I looked up the available MAPDs in Michigan and her card showed an H number that wasn't in the list. Also, her premium for her HMO was a lot higher than those available from the same company.