Important Reminder: Proper Use of Special Election Periods (SEPs)
When assisting Medicare beneficiaries, it is critical that all enrollment activities are conducted with accuracy, integrity, and full adherence to CMS requirements. Recent industry observations indicate increased scrutiny around the use of Special Election Periods (SEPs), particularly where eligibility is not adequately supported.
Please review the guidance below and incorporate it into your enrollment practices.
Agent Responsibility When Using an SEP
Agents are responsible for ensuring that each enrollment is supported by a valid and properly verified election period. Special Election Periods are only available when specific eligibility criteria are met, and each SEP has defined qualification requirements and time frames.
Before submitting an enrollment using an SEP, agents must:
- Confirm the individual meets all eligibility criteria for the selected SEP.
- Verify applicable timing requirements and effective date rules.
- Ensure the election period selected accurately reflects the beneficiary’s situation.
- Maintain appropriate documentation or attestation supporting eligibility.
If an election period is missing or incorrect, it may result in delays or denials of enrollment.
Agent Responsibility When Using an SEP
Agents must never:.
- Persuade or coach a beneficiary to answer questions in a way that qualifies them for an SEP.
- Select an SEP based on what “might work” without confirming eligibility.
- Use an SEP as a workaround to facilitate enrollment outside of a valid election period.
These actions are unethical and may be viewed as fraudulent. All enrollment activity must reflect the beneficiary’s true circumstances and intent.
Click the link below to view/download or print a quick-reference chart on some of the most frequently misused SEP’s.
Compliance Brief – SEP Usage
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