Update to the Internet Only Manual (IOM) Publication (Pub.) 100-01, IOM Chapter 2 Hospital Insurance and Supplementary Medical Insurance

The purpose of this change request (CR) is to update the Internet Only Manual (IOM) Publication (Pub.) 100-01 Chapter 2 to include recent changes from the Consolidated Appropriation’s Act, 2021 (CAA) to the Initial Enrollment Period (IEP), General Enrollment Period (GEP), Special Enrollment Period (SEP), add SEPs for Exceptional Conditions, and add information on how late enrollment penalties (LEP) are calculated. The current IOM gives a brief description of the IEP, GEP, and SEP, but needs to be updated to reflect CAA revisions to effective dates of the enrollment periods, and the durations of the previously established SEPs. With the exception of enrollment that occurs in the first four months of an individual’s IEP, beginning January 1, 2023 all enrollment periods will be effective the month after the month of enrollment. Previously established SEPs, newly established SEPs for Exceptional Conditions effective January 1, 2023, and information on how late enrollment penalties are calculated for Premium Part A and Part B are not in the current IOM Pub.100-01 Chapter 2 and need to be added.

The CAA changed the effective dates of Medicare enrollment so that individuals who become eligible for Medicare on or after January 1, 2023, and enroll in Part B during the last 3 months of their IEP, entitlement would begin the first day of the month following the month in which they enroll. Changes to the IEP effective date are in revised section 40.3.1 of IOM Pub. 100-01, Chapter 2.

The CAA also revised the effective dates for revised sections 1838(a)(2)(D)(ii) and 1838(a)(3)(B)(ii) of the Act to provide that individuals who enroll during the GEP beginning on or after January 1, 2023. Their entitlement would begin with the first day of the month following the month in which they enroll, instead of July 1st. Changes to the GEP effective date are in revised section 40.3.2 of IOM Pub. 100-01, Chapter 2.

This CR will add the following previously established SEPs to IOM Pub. 100-01 Chapter 2: SEP Related to Coverage Under Group Health Plans, SEP for International Volunteers, SEP for Certain TRICARE Beneficiaries, and the SEP for Beneficiaries for Whom Medicare is Now the Primary Payer (D-SEP). These SEPs correspond with new sections 40.3.3, 40.3.4, 40.3.5, and 40.3.6 in IOM Pub. 100-01, Chapter 2.

The CAA established the new authority for the Secretary of Health and Human Services to establish SEPs for individuals who are eligible to enroll in Medicare and meet such exceptional conditions as the Secretary may provide, effective January 1, 2023. This CR will update IOM Pub. 100-01, Chapter 2 with changes corresponding to CAA sections 1836, 1837, 1838, and 1839.

This CR will add the following newly established SEPs (effective January 1, 2023) to IOM Pub. 100-01 Chapter 2: SEP for Individuals Impacted by an Emergency or Disaster, SEP for Health Plan or Employer Representation, SEP for Formerly Incarcerated Individuals, SEP to Coordinate with Termination of Medicaid Coverage, and SEP for Other Exceptional Conditions. These SEPs for Exceptional Conditions correspond with new sections 40.3.7, 40.3.7.1, 40.3.7.2, 40.3.7.3, 40.3.7.4, and 40.3.7.5 in IOM Pub. 100-01 Chapter 2.

The CR will also add sections for the Late Enrollment Penalty (LEP) for Premium Part A in accordance with Statute 1818(c)(6), Reg. 42 CFR § 406.33, and the LEP for Premium Part B in accordance with Statute: 1839(b), Reg. 42 CFR § 408.22 – 408.26. Both LEP sections describe how the LEP is calculated, and which enrollees are excluded from LEPs. These LEPs correspond with renamed section 40.7.7 and new section 40.7.8 in IOM Pub. 100-01, Chapter 2.

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