Information for Individuals who Qualify for. Medicare Only

Transcription

1 Information for Individuals who Qualify for Medicare Only How to enroll in Medicare An individual can only enroll into Medicare Parts A and B during certain times: Initial Enrollment Period (3-1-3): o Turning 65: If an individual is not receiving Social Security benefits (disability or retirement benefits) when they turn 65, s/he must actively enroll in Medicare by contacting the Social Security Administration during her/his Initial Enrollment Period. An individual s Initial Enrollment Period is a 7 month time period that includes the 3 months before, the month of, and 3 months after the person s 65 th birthday. An individual s Medicare effective date will depend on when s/he enrolls during the Initial Enrollment Period. Here is a chart that shows when an individual s Medicare coverage will begin, based on when s/he enrolls in Medicare: If an individual has already been receiving Social Security benefits (disability or retirement benefits) when s/he turns 65, s/he will be automatically enrolled in Medicare Parts A & B. Individuals in this situation will receive a Medicare card in the mail three months before their 65 th birthday. Their Medicare effective date will be the first day of the month of their 65 th birthday. o Qualifying for Medicare due to disability: If an individual has been receiving Social Security Disability benefits for 24 months, s/he will automatically be enrolled in Medicare Parts A & B. They will receive a Medicare card in the mail three months before their 25th month of Page 1

2 disability benefits. Their Medicare effective date with be the first day of her/his 25 th month of disability benefits. Special Enrollment Periods: Certain individuals may qualify for an opportunity to enroll in Medicare outside of their initial enrollment period, due to a change in circumstances involving their health coverage (e.g., moving, gaining or losing access to Medicaid, loss of employer coverage, etc.). A list of the circumstances that allow someone to qualify for a Medicare Special Enrollment Period is available on the Medicare website here: General Enrollment Period: If an individual does not enroll in Medicare during their Initial Enrollment Period and does not qualify for a Special Enrollment Period, s/he can only enroll during the annual General Enrollment Period from January 1-March 31 st (with coverage beginning July 1 st ). If an individual does not enroll into Medicare when s/he is first eligible, penalties may apply. Enrollment for Medicare Parts A & B is handled by the Social Security Administration. To apply, an individual can call the Social Security Administration at , apply online ( or visit any Social Security office. Medicare Coverage Options When enrolling in Medicare, a beneficiary must decide how to receive their Medicare benefits. Medicare beneficiaries can either receive their Medicare benefits through Original Medicare (with the option of purchasing a Medicare Supplement plan), or they can choose to receive their benefits through a Medicare Advantage plan. To compare the benefits of a Medicare Supplement plan with those of a Medicare Advantage plan, please see the Medicare Rights Center s comparison chart here: Advantage.pdf?nrd=1 A beneficiary will also need to consider joining a Medicare Part D plan for prescription drug coverage. An individual can either receive prescription coverage through a standalone Medicare Part D plan that covers only prescription drugs or by enrolling in a Medicare Advantage plan that includes prescription drug coverage. If a Medicare beneficiary does not enroll in a Part D plan when s/he is first eligible, penalties may apply. Page 2

3 An individual can only join a Medicare Part D plan during certain times of the year: Initial Enrollment Period (See the rule described above.) Annual Enrollment Period The annual open enrollment period for stand-alone Medicare Part D prescription drug plans and Medicare Advantage plans is October 15 December 7 of each year. During this time, an individual can enroll in a plan for the first time, switch plans, or disenroll. The change in coverage will be effective January 1 st. Special Enrollment Periods Some special circumstances allow an individual the opportunity to enroll, switch plans, or disenroll from their Part D plan during other times of the year. These opportunities are called Special Enrollment Periods (SEP s). For information about Part D SEP s, see the Medicare Rights Center s list of Special Enrollment Periods for Medicare Advantage and Medicare Part D Plans here: A Senior Health Insurance Program (SHIP) counselor can assist consumers in finding the right Medicare coverage for them. To locate a SHIP counselor in Illinois, visit the Illinois Department on Aging website here: or contact the SHIP hotline at For more information about Medicare, visit the Medicare website at or call Medicare ( ). Beneficiaries and counselors can also compare health and drug plans using Medicare s online Plan Finder tool found at Tips for Current Medicare Beneficiaries with Disabilities who are Turning 65 Individuals who are already receiving Medicare benefits before turning 65 years old will have the opportunity to re-evaluate and change their coverage once they turn 65. They will receive a second 7 month (3-1-3) Initial Enrollment Period to enroll in a Medicare Part D prescription drug plan or switch plans. They can choose between a stand-alone prescription drug plan or a Medicare Advantage Plan. Also, if an individual has a late enrollment penalty for not enrolling in Medicare when s/he was first eligible, the penalty will be waived once they turn 65 years old. Page 3

4 Medicare beneficiaries who are turning 65 will also receive another 6 month open enrollment period to enroll into a Medicare Supplement plan. During this time, these individuals will not be subject to any medical underwriting. In most cases, if beneficiaries are already enrolled in Medicare Supplement policies, they should see their Medicare Supplement premiums decrease once they turn 65. Tips: Transitioning from Employer Based Coverage (With or Without Medicare) to Medicare Only Once an individual disenrolls from a group health insurance plan offered through a current employer or their employer based health coverage comes to an end, s/he will need to re-evaluate her/his Medicare coverage. These individuals need to ensure they enroll in Medicare Part B and prescription drug coverage in a timely fashion to avoid a lapse in coverage or financial penalties for not enrolling in Medicare when they should. They should also consider their Medicare Supplement enrollment options, because an individual will only be able to enroll in any plan of their choice during certain times without being subject to medical underwriting. (See details about transitioning from employer based coverage into Medicare A, B, D, and Supplement plans below.) Medicare Part A & B Special Enrollment Period Employer Based Coverage If an individual with employer based coverage did not enroll in Medicare Part A and/or Part B during their Initial Enrollment Period, s/he may be eligible for a Special Enrollment Period. An individual will receive a Special Enrollment Period to enroll in Medicare Part A and/or Medicare Part B at any time while they are still enrolled in a group health plan offered through a current employer (or through a spouse s current employer). An individual will also receive an eight month Special Enrollment Period to enroll in Medicare Part A and/or Medicare Part B beginning the date their employer group health insurance (or their spouses) ends or their employment ends, whichever happens first. If an individual misses their Special Enrollment Period to enroll into Medicare Parts A and/ or Part B, they must wait until the General Enrollment Period (between January 1 st and March 31 st each year) to enroll. If someone enrolls during the General Enrollment Period, their coverage will begin July 1 st and they may be subject to a late enrollment penalty. Medicare Part D Special Enrollment Period If an individual disenrolls from or loses their employer based coverage, s/he should enroll in a Medicare Part D plan for prescription coverage. An individual will receive a 63 day Special Enrollment Period to enroll in a stand-alone Page 4

5 Medicare Part D prescription drug plan or Medicare Advantage plan (beginning the day their employer based coverage ends). If an individual misses their Special Enrollment Period to enroll in prescription drug coverage, s/he must wait until the Medicare Part D Annual Enrollment Period from October 15 th - December 7 th to enroll in a plan (with coverage beginning January 1 st ), and s/he may be subject to a late enrollment penalty. Medicare Supplement Guaranteed Issue Rights Six Month Medicare Supplement Open Enrollment Period: If individuals delay enrolling in Medicare Part B coverage while receiving coverage through a current employer or union group health plan, their six month Medigap Open Enrollment Period will also be delayed until they enroll in Medicare Part B. A beneficiary s Open Enrollment Period for a Medicare Supplement Plan begins the day her/his Medicare Part B coverage takes effect. If a beneficiary enrolls in Medicare Part B while having employer or retiree coverage, her/his Medicare Supplement Open Enrollment Period begins the day s/he enrolls in Part B. During this six month open enrollment period, a beneficiary can enroll in a Medicare Supplement policy at any time without being denied coverage or being subject to medical underwriting. Guaranteed Issue Right for individuals with Employer Based Coverage that is Secondary to Medicare: If an individual s Part B enrollment took place more than six months ago and Medicare is primary, that individual may have missed their six month Medigap Open Enrollment Period completely. These individuals can still enroll in a Medicare Supplement Plan, but they may be subject to medical underwriting. However, if a beneficiary enrolled in Medicare Part B already and has secondary coverage through an employer group health plan, retiree coverage, COBRA coverage or union coverage (secondary coverage is coverage that pays after Medicare pays), that beneficiary will have a Guaranteed Issue right with Medigap Plans A, B, C, F, K, or L through any insurance company once their employer coverage ends. If a beneficiary qualifies for this Medicare Supplement Guaranteed Issue right, s/he should apply for a Medigap policy no later than 63 days after the latest of these 3 dates: 1. Date the employer/group coverage ends Page 5

6 2. Date on the notice that says their group coverage is ending 3. Date on a claim denial, if this is the only way you know that your coverage ended For more information on how Medicare works with employer or retiree coverage, see our Make Medicare Work Coalition Medicare and Employer Based Coverage Toolkit here: Tips on Transitioning from the Health Insurance Marketplace to Medicare Coverage: In most cases, an individual should enroll in Medicare when they are first eligible (during their Initial Enrollment Period. Once an individual is eligible for premium-free Medicare Part A coverage, that individual will not be eligible to receive advanced premium tax credits (APTC s) or cost-sharing reductions (CSR s) to help with the cost of a Marketplace plan. If an individual does not enroll in Medicare when s/he is first eligible, they will have to wait until the Medicare General Enrollment Period from January 1-March 31 st to enroll, and their coverage will not begin until July 1 st. In addition, if an individual does not sign up for Medicare when they are first eligible, they may need to pay penalties for as long as they are on Medicare. (See sections on Medicare Enrollment and Medicare Coverage Options above for links to information about these penalties.) A qualified Health Plan through the Marketplace is not mandated to notify beneficiaries when it is time for them to enroll in Medicare, so it is important for the beneficiary to know when their Initial Enrollment Period begins. Beneficiaries should take the following into steps into consideration when transitioning from the Marketplace to Medicare coverage: 1. Enroll in Medicare Parts A and B and a Medicare prescription drug plan during your Initial Enrollment Period. (See Medicare Enrollment section above.) 2. Drop your qualified health plan through the Marketplace at least 14 days before you want your coverage to end (usually the date when your Medicare coverage begins). 3. There may be some situations where a Medicare beneficiary will want to continue their Marketplace coverage after their Medicare coverage begins. For example, an individual may want to complete a plan of care with their current qualified health plan through the Marketplace. An individual can drop their Page 6

7 Marketplace coverage at any time after their Medicare coverage begins. If a beneficiary decides to keep their Marketplace coverage after their Medicare effective date, they will not receive any premium tax credits or reduced cost-sharing they may have received before their Medicare coverage began. In addition, their Marketplace coverage will not supplement their Medicare coverage in any way. Beneficiaries will have to decide which coverage they would like to use. Medicare and Marketplace coverage cannot be used together. For more information on the relationship between Medicare and the Health Insurance Marketplace, please see the Centers for Medicare and Medicaid Services (CMS) fact sheet here: Marketplace/Overview1.html Tips on Transitioning from ACA Adult Medicaid to Medicare Coverage Only (For individuals who no longer qualify for full Medicaid benefits) Some individuals enrolled in ACA Adult Medicaid will no longer qualify for Medicaid once they enroll in Medicare. In most cases, this is because the income and asset eligibility limits for ACA Adult Medicaid (covers individuals years old) are more generous than the income and asset limits for the AABD category of Medicaid (covers individuals age 65 and older and certain people with disabilities). In other cases, individuals may lose their Medicaid coverage due to a change in income/assets. Unfortunately, these individuals may experience higher out of pocket costs once they enroll into Medicare. However, many of these individuals may qualify for benefit programs that coordinate with Medicare, so it is very important to screen for and enroll in these benefit programs as soon as possible. If a Medicare beneficiary does not qualify for these benefits now, it is important to periodically check their eligibility for the programs as their income and asset levels change. The following information includes tips on how to align enrollment into public benefit programs with enrollment into Medicare. Medicare Savings Program (MSP): The Medicare Savings Program is split into three eligibility categories based on a beneficiary s income and asset levels. These categories are called Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB or SLIB), and Qualified Individual (QI or QI-1) programs. The QMB program pays Medicare Part A & B premiums, deductibles, and co-insurance amounts; the Page 7

8 SLMB and QI-1 programs only pay for the Medicare Part B premium. MSP (all categories) will also cover an individual s Medicare Part B late enrollment penalty if a beneficiary did not enroll in Medicare when they were first eligible. MSP program eligibility information is available on the Medicare website here: In Illinois, a beneficiary must be enrolled in Medicare Part A to be eligible for Medicare Savings Programs, so a beneficiary must wait until their Medicare Part A is effective to apply for the program. The program application has been known to take several months to process in Illinois. An individual must pay their premiums and cost sharing amounts while they wait for approval for the MSP program. However, once approved for MSP, a beneficiary may be eligible to receive reimbursement for the Part B premiums they paid (and Part A premiums, if the person is approved for QMB and must pay a Part A premium). Eligibility for premium reimbursement will depend on which Medicare Savings Program the beneficiary was approved for: o QMB: If a beneficiary is approved for QMB, their QMB eligibility begins the first day of the month after their application is approved. A beneficiary is eligible to receive reimbursement for the premiums they paid beginning the month after their application approval. For example: Jon applies for the Medicare Savings Program in July and was approved for QMB in September (with coverage beginning October 1). Jon s Medicare Part B premiums continued to be deducted from his Social Security check through November. Because Jon s QMB coverage began October 1st, and he will receive reimbursement for the Medicare Part B premiums that he paid for October and November. o SLMB or QI-1: If a beneficiary is approved for SLMB or QI-1, eligibility for these programs can be retroactive up to three months before the month of the Medicare Savings Program application. The state will automatically reimburse the Medicare Part B premiums the beneficiary paid for up to 3 months before the month of the application if the person met the eligibility requirements during the 3 months before they applied and indicates on their application that they wish to be evaluated for the 3 months of retroactive coverage. Page 8

9 Example: Mary applied for the Medicare Savings Program in June and was approved for SLMB in August. The Department of Human Services reviewed Mary s case, and saw that Mary was receiving Medicare benefits and eligible for SLMB during the months of March, April, and May. The state will automatically reimburse Mary for the Medicare Part B premiums that she paid during those three months before she applied for the program, in addition to any Part B premiums that she paid in August and beyond. The Illinois Department of Human Services (DHS) processes applications for the Medicare Savings Program. To apply, a beneficiary can complete an online application at a paper application (available here: or visit a local DHS Family and Community Resource Center (FCRC) to apply in person. Note: A fourth Medicare Savings Program is available for individuals who are under 65, disabled, working, lost their premium-free Medicare Part A coverage, and do not qualify for Medicaid. This MSP is called the Qualified Disabled Working Individual (QDWI) program and pays for the Medicare Part A premium only. Eligibility information for the QDWI program is also available on the Medicare website here: The Social Security Administration refers QDWI cases to the DHS, so if an individual thinks s/he may be eligible for QDWI, s/he should speak to a representative at her/his local Social Security office for assistance. Individuals can find a local Social Security office by calling (TTY ) or by visiting the Social Security website: Extra Help (also known as Low Income Subsidy or LIS): The Extra Help program helps pay for an individual s Medicare Part D costs, including the Part D premium, deductible, and co-payments. The program will also pay for an individual s Medicare Part D late enrollment penalty if they did not enroll into a Part D plan when they were first eligible. The Extra Help program is split into two eligibility categories - Full Extra Help and Partial Extra Help. The level of Extra Help a beneficiary receives depends on their income and assets. To view program eligibility for each level of Extra Help please see this Medicare Rights Center chart: Costs/Extra-Help-Chart.pdf?nrd=1. Page 9

10 A beneficiary must wait until their Medicare is effective to apply for Extra Help. The program can take up to 2-3 months to be approved, so the beneficiary must pay their Medicare Part D costs while they are waiting for approval. However, the Medicare Part D plan will reimburse the individual up to the Extra Help premium and co-payment assistance levels back to the date of the Extra Help application. The Social Security Administration processes applications for the Extra Help program. To apply for the program, submit an application online, call Social Security at (TTY ) to apply over the phone or request an application, or apply at a local Social Security office. Medicaid Spenddown: The Medicaid Spenddown program helps individuals who are over the asset and/ or income eligibility limits to qualify for AABD Medicaid. Medicaid Spenddown eligibility is determined on a month-to-month basis. If a person can show that he or she met their Spenddown amount for that month, Medicaid will cover the individual s remaining medical care during that month. If the individual would like coverage for a full month instead of the remainder of the month in which they submitted the application, s/he must indicate that they want Medicaid coverage for a future month. Medicaid coverage can also be retroactive up to three months, as long as the individual met eligibility guidelines and their Spenddown amount for those months prior to the application. An individual s monthly Spenddown amount depends on a person s income and/or assets and is determined by the Department of Human Services. To apply for the Medicaid Spenddown program, use the Illinois Department of Human Services Application for Benefits Eligiblity (ABE) system or apply in person at one of the local DHS Family and Community Resource Center (FCRC) offices. For more information on using the ABE system, please visit the following link for a toolkit created by AgeOptions and a team of local community stakeholders that includes training materials, forms, best practices and other helpful information on utilizing the ABE system to apply for public benefits: The Medicaid Spenddown program can also be utilized to help individuals access benefits through the Extra Help program. If an individual qualifies for one month of Medicaid Spenddown, they automatically qualify for Extra Help for assistance with prescription drug costs. For information on how to receive Extra Help through Medicaid Spenddown, please view the MMW brief here: MedicaidandManagedCare.html#SpenddownBrief Page 10