Determining Enrollment Period and Effective Date Sample Clauses

Determining Enrollment Period and Effective Date. The agent must determine the type of enrollment period that applies to the prospective enrollee (e.g. by the prospective enrollee’s date of birth, Medicare card, a letter from SSA, and the date the completed enrollment form is received), and therefore, the effective date of coverage. There are three valid enrollment periods for which an individual may enroll in a PDP, they are: the Initial Enrollment Period for Part D (“IEP”); the Annual Coordinated Election Period (“AEP”); and Special Enrollment Periods (“SEP”). The IEP is the period during which an individual is first eligible to enroll in a Part D plan. The beneficiary has a 7-month period that begins 3 months before the month an individual meets the eligibility requirements to enroll in a Medicare D Plan and ends 3 months after the month of eligibility. A beneficiary who was eligible for Medicare prior to age 65 (such as for disability or renal failure) has a second IEP for Part D based on attaining age 65. The AEP occurs October 15 through December 7 of every year. During this timeframe an individual can enroll in or change his/her plan for an effective date of January 1st of the following year. Individuals are limited to one AEP enrollment choice during this timeframe. The SEP is the period that an individual can enroll based on special circumstances. Examples of an SEP are: • Change in residence to a different region; • Involuntary loss of creditable coverage; • Dual eligibility; • Other low income subsidies; • Institutionalization; and • MA “open enrollment periods.” Unless otherwise required by CMS Guidance, verbal confirmation is acceptable from the beneficiary regarding the conditions that make him or her eligible for the SEP and shall be documented as the SEP reason in the application form and in the portal. In face-to-face or telephone enrollments, the agent may advise the prospective enrollee of the proposed effective date, but must stress that this is only a proposed effective date, and that the prospective enrollee will hear directly from the plan to confirm the actual effective date of enrollment.
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Related to Determining Enrollment Period and Effective Date

  • Open Enrollment Period Open Enrollment is a period of time each year when you and your eligible dependents, if family coverage is offered, may enroll for healthcare coverage or make changes to your existing healthcare coverage. The effective date will be on the first day of your employer’s plan year. Special Enrollment Period A Special Enrollment Period is a time outside the yearly Open Enrollment Period when you can sign up for health coverage. You and your eligible dependents may enroll for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days of the following events: • you get married, the coverage effective is the first day of the month following your marriage. • you have a child born to the family, the coverage effective date is the date of birth. • you have a child placed for adoption with your family, the coverage effective date is the date of placement. Special note about enrolling your newborn child: You must notify your employer of the birth of a newborn child and pay the required premium within thirty -one (31) days of the date of birth. Otherwise, the newborn will not be covered beyond the thirty -one (31) day period. This plan does not cover services for a newborn child who remains hospitalized after thirty-one (31) days and has not been enrolled in this plan. If you are enrolled in an Individual Plan when your child is born, the coverage for thirty- one (31) days described above means your plan becomes a Family Plan for as long as your child is covered. Applicable Family Plan deductibles and maximum out-of-pocket expenses may apply. In addition, if you lose coverage from another plan, you may enroll or add your eligible dependents for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days following the date you lost coverage. Coverage will begin on the first day of the month following the date your coverage under the other plan ended. In order to be eligible, the loss of coverage must be the result of: • legal separation or divorce; • death of the covered policy holder; • termination of employment or reduction in the number of hours of employment; • the covered policy holder becomes entitled to Medicare; • loss of dependent child status under the plan; • employer contributions to such coverage are being terminated; • COBRA benefits are exhausted; or • your employer is undergoing Chapter 11 proceedings. You are also eligible for a Special Enrollment Period if you and/or your eligible dependent lose eligibility for Medicaid or a Children’s Health Insurance Program (CHIP), or if you and/or your eligible dependent become eligible for premium assistance for Medicaid or a (CHIP). In order to enroll, you must provide required information within sixty (60) days following the change in eligibility. Coverage will begin on the first day of the month following our receipt of your application. In addition, you may be eligible for a Special Enrollment Period if you provide required information within thirty (30) days of one of the following events: • you or your dependent lose minimum essential coverage (unless that loss of coverage is due to non-payment of premium or your voluntary termination of coverage); • you adequately demonstrate to us that another health plan substantially violated a material provision of its contract with you; • you make a permanent move to Rhode Island: or • your enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of error, misrepresentation, or inaction by us or an agent of HSRI or the U.S. Department of Health and Human Services (HHS).

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