Need Help on an SEP

Aug 14, 2007

  1. insurance0707
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    insurance0707 Guru

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    I am having problems with an SEP for a Medicare advantage plan. Can anyone tell me if this would qualify for SEP?

    A 70 year old woman has insurance coverage through the county where she worked. The county was paying for it. She's retired. She recently received a letter from the county telling her now that she is 70 years old she will now have to pay the premium. The county will no longer pay it for her. They said if you'd like to continue with this coverage the monthly premium wil be $1072. She cannot afford this! The snag seems to be they're not discontinuing her coverage, she can keep it but cannot afford it. Is there any SEP for her due to this circumstance?

    All responses appreciated!
     
  2. GreenSky
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    From my experience, it does not matter who cancels the group plan. The fact that coverage ends initiates the SEP.

    I think the law only states that coverage terminates. It does not say if that termination was involuntary or voluntary.

    The termination notice from the carrier should not even mention the reason.

    Rick
     
    GreenSky, Aug 14, 2007
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  3. Guest
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    Guest Guest

    hmm tough one.
    I would say yes. It likely would qualify under reduction in coverage. Might even be considered involuntary losing coverage too.

    SEP Begins with the month s/he is notified of a loss in creditable coverage (including a reduction in coverage so that it is no longer creditable).
     
    Guest, Aug 14, 2007
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  4. insurance0707
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    The letter she received says....The County Clerk's office received your letter dated July 20th stating that you will be terminating your health insurance coverage through the county, etc. etc. etc.

    I was told that if the employee terminates it may not qualify for an SEP. If the company terminates than it would qualify for an SEP. No one seems to know the correct answer on this. I'm hoping your's is the correct answer Greensky!
     
  5. Guest
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    Guest Guest

    Actually the law is adamant about the fact that it has to be involuntary (from CMS bulletin):

    SEP Qualifications:
    [FONT=&quot]Beneficiaries who Involuntarily Lose Creditable Coverage

    (underline is CMS's emphasis, not mine)

    [/FONT]
     
    Guest, Aug 14, 2007
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  6. insurance0707
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  7. insurance0707
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    On the charts for SEP's, you'll notice # 2 states they can disenroll or enroll into a Part D prescription plan during the time you're allowed to make changes on your group coverage.

    In this case, it sounds like they are allowed to make changes in December each year. However, the group plan is making a change....making her pay a premium when she never had to pay one before
     
  8. midwestbroker
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    Do the SEP.

    I have had clients in the same situation, and the SEP for LEC (loosing employer coverage) has worked no problem.

    They have 63 days to enroll.

    You may want to tell them to not notify their current carrier, run the app, and when it is approved, to cancel the coverage.
     
  9. insurance0707
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    The insurance company that I'm using requires a credible coverage letter with the application. I received one from her former employer but they state on it that she is terminating the coverage. Here is your group #, start date, end date and that it did cover prescriptions and medical. It also lets her know in December they can make changes on their group coverage.

    It sounds like the county is losing alot of people on the group plan when they make them start to pay their own premuims...who can afford $1000 a month on social security! That's all she gets. It will eat up more than half of her ss check. They are purposely stating she is terminating it and that she can make changes in December. Two of the qualifications for an SEP. I did notice on the link that i've listed there is an SEP for unusual circumstances to be determined by Medicare. We could try for that one, but who knows how long it would take to get a confirmation
     
  10. fostever
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    I think you should be good to go with an SEP since they are now pricing her out of her credible coverage. Just make sure it is in her best interest when considering the PCP and network with referrels in an M.A. plan. If she can afford a suppliment, that is an option to give more choice.
     
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