Medicare Advantage Emergency-Related SEPs

Has a natural disaster or emergency occurred near you recently? Your clients may qualify for a Special Enrollment Period.

CMS provides a Special Enrollment Period (SEP) for individuals who need to enroll in, disenroll from, or switch Medicare Advantage or prescription drug plans but are affected by a disaster or other emergency declared by a federal, state, or local government entity like FEMA, the president, or a governor.

Note: A disaster SEP, sometimes known as a FEMA SEP, is only available to beneficiaries who were affected during the incident period and may have missed a valid election period during the time of the incident period. This SEP shouldn’t be used as a marketing tool to generate new enrollments. See the full rule here that allows and establishes parameters for CMS to open up SEPs for those impacted by declared emergencies.

Who Qualifies for Emergency and Disaster-Related SEPs?

In order to utilize a PDP and Medicare Advantage SEP triggered by an emergency or disaster, individuals must:

• Reside (including resided at the start of the incident date) in an area where a federal, state, or local government entity has declared a disaster or other emergency.
• Have had another valid election period (e.g., Initial Enrollment Period) at any time during the incident period.
• Have missed an enrollment during that other valid election period due to the disaster or other emergency.

In addition, the SEP is available to those individuals who don’t live in the affected areas but who do rely on help making health care decisions from one or more individuals who live in the affected areas.

What Steps Do Agents Need to Follow?

If your client believes they may qualify for one of these SEPs and wants to enroll, disenroll, or switch Medicare Advantage or PDP plans, your client should:

• Be able to show proof that they lived/live in an impacted area at the start of the incident period.
• Confirm that they had another election period available during the time of the incident period.
• Confirm that the beneficiary lived in a county that has been declared a disaster or emergency by a federal, state, or local government entity.

Once you’ve verified their eligibility, proceed with the application. During the application process, select these two enrollment reasons:

• Affected by an emergency or major disaster (as declared by FEMA or a government entity).
• Election period enrollee was eligible for and not able to use due to the declared disaster or emergency. Provide dates when applicable (e.g., change in residence).

The enrollment will be submitted to CMS using this election code. If it’s determined that this election isn’t appropriate, the carrier will reach out to inform you, and the member will receive a Request for Information (RFI) to determine if another enrollment period is available to them.

Please note that enrollments made using a Medicare disaster SEP are effective the first of the month following the enrollment.

We strive to keep you updated on relevant news and information, and we’ll update this post when new SEPs become available. Check back if something happens in your area that you think might lead to a declared emergency.

Editor’s Note: This post was originally published in December 2022. It has been updated to include the latest disaster SEPs available in 2024.