[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR407.20]



[Page 265-266]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 407_SUPPLEMENTARY MEDICAL INSURANCE (SMI) ENROLLMENT AND ENTITLEMENT

--Table of Contents

 

         Subpart B_Individual Enrollment and Entitlement for SMI

 

Sec. 407.20  Special enrollment period related to coverage under group 

health plans.



    (a) Terminology--(1) Group health plan (GHP) and large group health 

plan (LGHP). These terms have the meanings given them in Sec. 411.101 

of this chapter except that the ``former employee'' language of those 

definitions does not apply with respect to SEPs for the reasons 

specified in Sec. 406.24(a)(3) of this chapter.

    (2) Special enrollment period (SEP). This term has the meaning set 

forth in Sec. 406.24(a)(4) of this chapter. In order to use a SEP, an 

individual must meet the conditions of paragraph (b) and of paragraph 

(c) or (d) of this section, as appropriate.

    (b) General rule. All individuals must meet the following 

conditions:

    (1) They are eligible to enroll for SMI on the basis of age or 

disability, but not on the basis of end-stage renal disease.



[[Page 266]]



    (2) When first eligible for SMI coverage (4th month of their initial 

enrollment period), they were covered under a GHP or LGHP on the basis 

of current employment status or, if not so covered, they enrolled in SMI 

during their initial enrollment period; and

    (3) For all months thereafter, they maintained coverage under either 

SMI or a GHP or LGHP. (Generally, if an individual fails to enroll in 

SMI during any available SEP, he or she is not entitled to any 

additional SEPs. However, if an individual fails to enroll during a SEP 

because coverage under the same or a different GHP or LGHP was restored 

before the end of that particular SEP, that failure to enroll does not 

preclude additional SEPs.)

    (c) Special rule: Individual age 65 or over. For an individual who 

is or was covered under a GHP, coverage must be by reason of the current 

employment status of the individual or the individual's spouse.

    (d) Special rules: Disabled individual.\4\ Individuals entitled on 

the basis of disability (but not on the basis of end-stage renal 

disease) must meet conditions that vary depending on whether they were 

covered under a GHP or an LGHP.

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    \4\ Under the current statute, the SEP provision applicable to 

disabled individuals covered under an LGHP expires on September 1998. 

Unless Congress changes that date, the last SEP available under those 

provisions will begin with June 1998.

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    (1) For a disabled individual who is or was covered under a GHP, 

coverage must be on the basis of the current employment status of the 

individual or the individual's spouse.

    (2) For a disabled individual who is or was covered under an LGHP, 

coverage must be as follows:

    (i) Before August 10, 1993, as an ``active individual'', that is, as 

an employee, employer, self-employed individual (such as the employer), 

individual associated with the employer in a business relationship, or 

as a member of the family of any of those persons.

    (ii) On or after August 10, 1993, by reason of current employment 

status of the individual or a member of the individual's family.

    (e) Effective date of coverage. The rule set forth in Sec. 

406.24(d) for Medicare Part A applies equally to Medicare Part B.



[61 FR 40346, Aug. 2, 1996]