ENROLLMENT PERIODS

Question 1

ENROLLMENT PERIOD
Medicare Supplement (Medigap):

Answer 1

Its’s recommended that beneficiaries buy a Medicare Supplement (Medigap) policy during their 6-month Medigap open enrollment period because, during that time, they can buy a Medical Supplement policy available for open enrollment that is sold in their state, even if they have health problems. This period automatically starts the month they’re 65 or older and enrolled in Medicare Part B.

Virtually all Medigap carriers permit applications to be submitted three months prior to the beneficiary’s 65th birthday month and/or Part B effective date. Some carriers permit applications to be submitted as early as six months prior to/after said dates with open enrollment considerations.

Question 2

ENROLLMENT PERIOD
Client-Specific Enrollment Periods
Initial Enrollment Period:

Answer 2

The client’s Initial Enrollment Period lasts from 3 months before the month of their 65th birthday to 3 months after their 65th birthday.

Question 3

Medicare Supplement (Medigap) Open Enrollment Period, generally:

Answer 3

If a Medicare beneficiary applies for Medicare Supplement coverage AFTER their open enrollment period, they will have to pass medical underwriting unless they’re eligible for guaranteed issue considerations due to a special situation.

The term “open enrollment period” in this context refers to the Medigap open enrollment period, which is a six-month period that starts the first month you’re 65 or older and enrolled in Medicare Part B. During this period, you can buy any Medigap policy sold in your state, even if you have health problems.

If you apply for a Medicare Supplement plan after this open enrollment period, you may be subject to medical underwriting unless you’re eligible for guaranteed issue rights due to certain situations. This could potentially result in higher premiums or denial of coverage.

Question 4

When is the Medicare Supplement (Medigap) Open Enrollment Period?

Answer 4

The Medigap Open Enrollment Period, is a six-month period that starts the first month you’re 65 or older AND enrolled in Medicare Part B.

Question 5

Do you have to be enrolled in Medicare part B to enroll in a Medicare Supplement (Medigap) policy?

Answer 5

Yes. The Medigap Open Enrollment Period, is a six-month period that starts the first month you’re 65 or older AND enrolled in Medicare Part B.

Formula:
Medigap Policy = Be 65 + Enrolled In Part B within 6 months of turning 65.

New York Exception Note: In New York, you have continuous open enrollment for Medigap policies, meaning you can enroll at any time, and you cannot be denied coverage or charged more based on your health status. So while the general rules apply, New York has additional protections for Medicare beneficiaries.

Question 6

Does New York have its own rules for Medigap policy enrollment?

Answer 6

Yes, New York is a state that has its own rules for Medigap policy enrollment. Here are some key features of New York’s Medigap enrollment rules:

-Continuous Open Enrollment: In New York, all Medicare beneficiaries are eligible for continuous open enrollment for Medigap policies. This means you can enroll in a Medigap plan at any time, year-round.

-Guaranteed Issue: You cannot be denied coverage or charged more based on your medical history41. This applies to people with Medicare who are under 65, as well as to those over 65.

-Community-Rated Premiums: In New York, all Medigap plans are community-rated. This means that your Medigap premiums vary depending on where in New York you live but are unaffected by your age or health status.

Question 7

Medicare Advantage/PDP Enrollment Period, generally (1):

Answer 7

To enroll in a Medicare Advantage or PDP plan, the beneficiary is required to have a valid
election or enrollment period (separate and distinct from their Med Supp open enrollment).

For beneficiaries that are new to Medicare and have the same Parts A & B effective date, they can enroll in an MAPD or PDP for three months before, the month of, and three months
after they turn 65 using IEP. When enrolling before Medicare is in effect, their effective date will be the same as their A & B effective date. When enrolling after Medicare is in effect,
their effective date will be the first day of the month following enrollment.

If they enroll in an MA-only during that time, they can use ICEP. If a beneficiary delays their Part B, they can enroll in a MAPD or MA-only using ICEP. If a beneficiary is enrolling in a PDP past their IEP, they will need to use another election period.

Question 8

Medicare Advantage (MA) and Prescription Drug Plan (PDP):

Answer 8

Medicare Advantage (MA) and Prescription Drug Plan (PDP) Enrollment: Beneficiaries are required to have a valid election or enrollment period, which is separate and distinct from their Med Supp open enrollment.

let’s consider an example:

Suppose a beneficiary, let’s call her Jane, is turning 65 on June 1, 2024, and she enrolls in Medicare Parts A & B to be effective on her birthday.

Three Months Before Turning 65: Jane’s Initial Enrollment Period (IEP) for a Medicare Advantage (MA) or Prescription Drug Plan (PDP) begins three months before her 65th birthday. So, it starts on March 1, 2024. If Jane enrolls in an MA or PDP plan during this time, her plan’s effective date will be the same as her Medicare Parts A & B effective date, which is June 1, 2024.

The Month of Turning 65: Jane’s IEP continues through the month of her 65th birthday, which is June 2024. If she enrolls in an MA or PDP plan during June, her plan’s effective date will be July 1, 2024, because it’s the first day of the month following her enrollment.

Three Months After Turning 65: Jane’s IEP continues for three months after her 65th birthday, ending on September 30, 2024. If she enrolls in an MA or PDP plan during this time, her plan’s effective date will be the first day of the month following her enrollment.

Now, suppose Jane decides to enroll in an MA-only plan during her IEP. She can use her Initial Coverage Election Period (ICEP) to do so. The ICEP is the same duration as the IEP.

If Jane delays her Part B enrollment and decides to enroll in an MA or MA-only plan later, she can use her ICEP at that time. The ICEP in this case would start the month Jane enrolls in Part B and continue for three months.

Question 9

Initial Enrollment Period (IEP):

Answer 9

Initial Enrollment Period (IEP): For beneficiaries new to Medicare with the same Parts A & B effective date, they can enroll in an MA or PDP plan three months before, the month of, and three months after they turn 65 using the IEP. If they enroll before Medicare is in effect, their effective date will be the same as their Parts A & B effective date. If they enroll after Medicare is in effect, their effective date will be the first day of the month following enrollment.

Example:
Suppose a beneficiary, let’s call him John, is turning 65 on May 1, 2024, and he enrolls in Medicare Parts A & B to be effective on his birthday.

Three Months Before Turning 65: John’s Initial Enrollment Period (IEP) for a Medicare Advantage (MA) or Prescription Drug Plan (PDP) begins three months before his 65th birthday. So, it starts on February 1, 2024. If John enrolls in an MA or PDP plan during this time, his plan’s effective date will be the same as his Medicare Parts A & B effective date, which is May 1, 2024.

The Month of Turning 65: John’s IEP continues through the month of his 65th birthday, which is May 2024. If he enrolls in an MA or PDP plan during May, his plan’s effective date will be June 1, 2024, because it’s the first day of the month following his enrollment.

Three Months After Turning 65: John’s IEP continues for three months after his 65th birthday, ending on August 31, 2024. If he enrolls in an MA or PDP plan during this time, his plan’s effective date will be the first day of the month following his enrollment.

Question 10

Initial Coverage Election Period (ICEP):

Answer 10

Initial Coverage Election Period (ICEP): If beneficiaries enroll in an MA-only plan during the IEP, they can use the ICEP. If a beneficiary delays their Part B, they can enroll in an MA or MA-only plan using the ICEP.

let’s consider an example:

Suppose a beneficiary, let’s call him Bob, is turning 65 on July 1, 2024, and he enrolls in Medicare Part A to be effective on his birthday, but he decides to delay his Part B enrollment because he’s still working and has coverage through his employer.

Initial Enrollment Period (IEP): Bob’s IEP for a Medicare Advantage (MA) plan begins three months before his 65th birthday. So, it starts on April 1, 2024. However, because Bob has decided to delay his Part B enrollment, he doesn’t enroll in an MA plan during this time.

Bob Retires: Now, let’s say Bob retires and decides to enroll in Medicare Part B, effective January 1, 2025.

Initial Coverage Election Period (ICEP): At this point, Bob’s ICEP begins. The ICEP starts the month Bob enrolls in Part B and continues for three months. So, Bob’s ICEP starts on January 1, 2025, and ends on April 30, 2025. During this time, Bob can enroll in an MA or MA-only plan.

Let’s say Bob decides to enroll in an MA-only plan on February 15, 2025. Because he’s enrolling during his ICEP, his MA plan’s effective date will be March 1, 2025, which is the first day of the month following his enrollment.

Question 11

Enrollment in a PDP Past the IEP:

Answer 11

Enrollment in a PDP Past the IEP: If a beneficiary is enrolling in a PDP past their IEP, they will need to use another election period.

let’s consider an example:

Suppose a beneficiary, let’s call her Alice, is turning 65 on August 1, 2024, and she enrolls in Medicare Parts A & B to be effective on her birthday.

Initial Enrollment Period (IEP): Alice’s IEP for a Prescription Drug Plan (PDP) begins three months before her 65th birthday. So, it starts on May 1, 2024, and ends on November 30, 2024. However, Alice decides not to enroll in a PDP during her IEP.

Enrollment in a PDP Past the IEP: Now, let’s say Alice decides she wants to enroll in a PDP on December 15, 2024, which is past her IEP. At this point, she will need to use another election period.

One such period is the Annual Election Period (AEP), which runs from October 15 to December 7 each year. During the AEP, Alice can change her Medicare health or prescription drug coverage for the following year. However, since Alice is trying to enroll on December 15, which is after the AEP, she cannot use this period.

Another period is the Special Election Period (SEP). SEPs can occur at any time during the year and are triggered by specific circumstances, such as moving out of the plan’s service area, losing other creditable prescription drug coverage, or living in an institution like a nursing home. If Alice has a qualifying event, she could use an SEP to enroll in a PDP.

If Alice doesn’t have a qualifying event for an SEP and missed the AEP, she would have to wait until the next AEP to enroll in a PDP, unless she qualifies for an exception.

Question 12

AEP: Annual Enrollment Period (October 15 - December 7):

Answer 12

From October 15 to December 7, any Medicare beneficiary can join, change, or drop a Medicare Advantage or PDP plan. The last election made during that period will go into effect on January 1 of the following year.

Annual Enrollment Period:

• Applies to current Medicare beneficiaries
• Those eligible can join, change, or drop a Medicare Advantage or PDP plan, making an unlimited number of elections.
• The last election made during the Annual Enrollment Period will go into effect on January 1.

Question 13

OEP: Open Enrollment Period (January 1 - March 31):

Answer 13

From January 1 to March 31, Medicare beneficiaries enrolled in a Medicare Advantage plan (MA/MAPD/SNP) can make one change to a different Medicare Advantage plan or disenroll and return to Original Medicare by enrolling in a PDP. The coverage effective date during OEP will be the first day of the month following the date of their application. The beneficiary cannot change from Original Medicare to Medicare Advantage coverage, nor can they change from one PDP to another PDP using the OEP election.

Open Enrollment Period:

• Applies to those currently enrolled in an MA, MAPD, or SNP.
• Enrollees can make 1 change to a different Medicare Advantage plan, or
• they may disenroll from an MA/MAPD, return to Original Medicare, and add a PDP.
• Changing from one PDP to another is not allowed

Question 14

SEP’s: Special Elections Periods:

Answer 14

Clients may also enroll and make changes to their coverage outside of the standard enrollment periods if they qualify for a Special Election Period. Coverage obtained during an SEP is effective the first day of the month following the date of the application.

Question 15

Low-Income:

Answer 15

Medicare beneficiaries maintaining their Dual-Eligible or LIS status can add, change, or drop an MA or PDP plan once per calendar quarter for the first three calendar quarters. If a beneficiary gains, loses, or experiences a change in their Dual-Eligible or LIS status, they can make one election during the three months after their change or after they are notified of the change, whichever is later. The coverage effective date for this SEP will be the first day of the month following the date of their application.

Question 16

Moving:

Answer 16

Medicare beneficiaries who move out of their current plan’s service area, move within their current plan’s service area with new options available to them, or are released from incarceration are granted a special election period. Beneficiaries can make one election from the day they notify the plan in advance of the move to the end of the 2nd full month after the move. Or if they notify their plan after the move, from the day they notify the plan to the end of the 2nd full month after they notify the plan. The coverage effective date for this SEP will be the first day of the month following the date of their application.

Question 17

FEMA:

Answer 17

From the start of a FEMA-declared emergency or major disaster incident period and for four full calendar months after, Medicare beneficiaries who had a valid election period but did not use it can make one change. The coverage effective date for this SEP will be the first day of the month following the date of their application.

Question 18

5 Star:

Answer 18

From December 8 to November 30 of the following year, Medicare beneficiaries living in the service area of a 5-star rated plan can make one election to enroll in that plan. the coverage effective date for this SEP will be the first day of the month following the date of their application.

Question 19

Changes for 2024:

Answer 19

Starting January 1, 2024, if you sign up for Part A and/or Part B because of an exceptional situation, you’ll have 2 months to join a Medicare Advantage Plan (with or without drug coverage) or a Medicare drug plan (Part D). Your coverage will start the first day of the month after the plan gets your request to join.

Question 20

In the context of Medicare enrollment periods, what is ICEP and what is it used for?

Answer 20

Initial Coverage Election Period:

The Initial Coverage Election Period (ICEP) is a Medicare enrollment period. It is the first opportunity for people newly eligible for Medicare to enroll in a Medicare Advantage (Part C) plan.

Medicare Advantage plans are sold by private insurance companies and replace your Original Medicare coverage (Part A and Part B). These plans provide at least the same healthcare coverage as Original Medicare, and often offer additional benefits, such as prescription drug coverage and wellness benefits.

The ICEP usually happens at the same time as your Initial Enrollment Period (IEP) if you enroll in both Part A and Part B when you turn 65. The IEP lasts for seven months, beginning three months before your 65th birthday. If you enroll in Medicare parts A and B during the IEP, then your ICEP runs simultaneously.

However, some people choose not to enroll in Medicare Part B during their IEP, often because they have health coverage from their own or their spouses’ group health plan through their employer. If you enroll in Part B at a later date rather than during the IEP, your ICEP begins three months before your Part B coverage is due to start. It runs until the last day of the month before your Part B coverage begins.

Meet John, who turns 65 on July 1, 2024. He is eligible for Medicare, but he’s still working and has excellent health coverage through his employer. Because of this, John decides not to enroll in Medicare Part B during his Initial Enrollment Period (IEP), which runs from April 1, 2024, to October 31, 2024.

Fast forward to 2025, John decides to retire on September 30. His employer health coverage will end then, so he decides to enroll in Medicare Part B. He contacts Social Security in June to arrange for his Part B coverage to start on October 1, 2025.

Example:
In this case, John’s Initial Coverage Election Period (ICEP) for a Medicare Advantage plan would start three months before his Part B coverage begins, i.e., on July 1, 2025. It would run until the last day of the month before his Part B coverage begins, i.e., September 30, 2025. During this time, John can enroll in a Medicare Advantage plan of his choice. If he misses this window, he would have to wait for the next Annual Election Period (AEP) or a Special Election Period (SEP) if he qualifies for one.

Question 21

How does being eligible for social security disability or being on social security disability create a special enrollment period for Medicare or Medicare Advantage?

Answer 21

If you become eligible for Medicare because of a disability and have been receiving Social Security Disability Insurance (SSDI) or railroad disability annuity checks for 24 months, you should automatically be enrolled in both Medicare Parts A and B at the start of your 25th month.

This automatic enrollment triggers a Special Enrollment Period (SEP) during which you can enroll in a Medicare Advantage Plan. The SEP allows you to make changes to your Medicare Advantage and Medicare drug coverage when certain events happen in your life, like if you move or you lose other coverage.

For example, if you’re under 65 and have a disability, you’re eligible for Medicare. If you’ve been receiving SSDI checks for 24 months, you’re automatically enrolled in Medicare Parts A and B at the start of your 25th month. This is your SEP to enroll in a Medicare Advantage Plan.

Please note that the specifics of your SEP will depend on your individual circumstances, so it’s always a good idea to check with Medicare or a trusted advisor to understand your options.

Question 22

How does someone with a chronic disease trigger a SEP?

Answer 22

If you have a chronic condition, you may be eligible for a Chronic Condition Special Needs Plan (C-SNP). This type of Medicare Advantage plan is designed to serve individuals with specific severe or disabling chronic conditions123.

Enrollment in a C-SNP can occur during Medicare’s Annual Enrollment Period, which runs from October 15 through December 7 every year13. However, if you develop a qualifying chronic condition, you can enroll in a C-SNP at any time. This is considered a Special Election Period (SEP)2.

For example, if you are diagnosed with a chronic condition such as heart failure or diabetes, this diagnosis could trigger an SEP, allowing you to enroll in a C-SNP outside of the usual enrollment periods2.

Please note that the specifics of your SEP will depend on your individual circumstances, so it’s always a good idea to check with Medicare or a trusted advisor to understand your options45

Question 23

What triggers a dual SEP?

Answer 23

A Dual Special Enrollment Period (SEP) is triggered when you are passively enrolled into a Part D plan or a Dual-eligible Special Needs Plan (D-SNP).

Dual-eligible Special Needs Plans are specifically designed for people who have both Medicare and Medicaid. These plans provide all of your Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and prescription drug coverage (Part D).

If you are passively enrolled into a Part D plan or a D-SNP, you can use this SEP to switch to another Medicare Advantage Plan or to Original Medicare1. This SEP is available once per calendar quarter for the first nine months of the year.

Question 24

How does one become passively enrolled in Part D?

Answer 24

Passive enrollment into Medicare Part D typically occurs for certain low-income beneficiaries. Each year, the Centers for Medicare & Medicaid Services (CMS) reassigns these beneficiaries who were previously automatically enrolled by CMS into a new Medicare prescription drug plan (PDP) to ensure they continue to pay “zero” monthly premiums for their prescription drug coverage in the following plan year.

Additionally, CMS reassigns certain low-income beneficiaries to a PDP to prevent drug coverage disruptions. This includes beneficiaries enrolled in a terminating Medicare Advantage (MA) plan, Medicare-Medicaid Plan (MMP), or PDP; or an MA plan that is reducing its service area at the end of the year.

The annual reassignment process occurs in mid-October each year. At this time, CMS sends a file to states identifying who has been reassigned in their state. CMS also notifies beneficiaries of the plan to which they are being reassigned and their other plan options.

For example, states may conduct an annual passive enrollment process for individuals newly eligible or re-eligible for MMP enrollment. This includes those who were involuntarily disenrolled from an MMP during the current calendar year, e.g., due to short-term loss of Medicaid; those who were reassigned by CMS to a PDP effective January of the current calendar year and have not otherwise opted out of passive enrollment; or new dually eligible individuals auto-enrolled by CMS to a PDP effective any month in the current calendar year.

Question 25

How is it determined that one is eligible for both Medicaid and Medicare?

Answer 25

Eligibility for both Medicare and Medicaid, also known as “dual eligibility,” is determined by meeting certain criteria for each program:

Medicare Eligibility:

Medicare is a federal health insurance program. Individuals generally need to be 65 or older or have a qualifying disability to be eligible for Medicare124.
You must be enrolled in Medicare Part A (hospital insurance), and/or Medicare Part B (medical insurance). Alternatively, you may opt for Medicare Part C (Medicare Advantage), which is managed by Medicare-approved private insurance companies and provides Medicare Part A, Part B, and often Part D (prescription drug coverage).
Medicaid Eligibility:

Medicaid is a state and federal medical assistance program for financially needy persons of any age.
Each state has different qualifications and requirements for enrollment in Medicaid. Your income and resources may not exceed state-specific thresholds to be eligible for Medicaid coverage.
Medicaid coverage typically comes at no cost to the beneficiary.

To be considered dually eligible, you must meet the federal qualifications for Medicare eligibility and the state-specific qualifications for Medicaid eligibility. If you qualify for both Medicare and Medicaid, most – if not all – of your healthcare costs will be covered.

Please note that the specifics of dual eligibility will depend on your individual circumstances, so it’s always a good idea to check with Medicare or a trusted advisor to understand your options12.

Question 26

How do I check the state-specific threshold and qualifications to be eligible for Medicaid?

Answer 26

1. Visit the official Medicaid website. This site provides general information about Medicaid eligibility and links to each state’s Medicaid website.
2. Alternatively, you can visit the Medicaid Planning Assistance website or the Medicaid Eligibility Income Chart which provides state-specific Medicaid eligibility requirements.
3. Click on your state’s name to see the specific eligibility requirements for your state.
4. You can also take a Medicaid eligibility test on these websites to determine if you meet the requirements.
5. If you need further assistance, consider contacting your state’s Medicaid agency.

Question 27

As a Medicare agent, once I figure out that a beneficiary’s income is within the medicaid threshold of their state, shoulld I right an LIS application for them?

Answer 27

As a Medicare agent, if you determine that a beneficiary’s income is within the Medicaid threshold of their state, they may automatically qualify for the Low-Income Subsidy (LIS), also known as Extra Help.

The Centers for Medicare & Medicaid Services (CMS) works with partners to find and enroll people who may qualify for the LIS. If your clients qualify for the LIS Medicare Extra Help Program, they’ll likely also qualify for Medicaid3. Low-income clients who qualify for both Medicare and Medicaid are called “dual eligible,” and they can enroll in Medicare Advantage plans called Dual Special Needs Plans (DSNP).

However, there are instances where beneficiaries may need to apply for LIS. For example, each September, CMS mails a notice on gray paper to people who’ll no longer automatically get the LIS. This notice is a LIS application, and it includes a postage-paid pre-addressed envelope. These people may still qualify for the LIS, but they will need to send in a new application.

So, if your client is not automatically enrolled in LIS but you believe they may qualify, you could assist them in filling out an LIS application. However, it’s always a good idea to check with CMS or a trusted advisor to understand the specifics of your client’s situation.

Question 28

As a Medicare Agent, what can I enroll a beneficiary in if they are already on Medicaid?

Answer 28

1. Medicare Advantage Dual-Eligible Special Needs Plan (D-SNP): If the beneficiary is eligible for both Medicare and Medicaid (dual-eligible), they may qualify for a D-SNP1. These plans are designed to provide all of the beneficiary’s Medicare Part A and Part B benefits, prescription drug coverage (Part D), and additional benefits tailored to their needs. However, these plans aren’t available in all locations, so it’s important to compare local plan options.
2. Medicare Savings Programs (MSPs): Beneficiaries with low incomes can get help paying their Medicare Part A and Part B premiums and cost-sharing expenses from Medicaid through MSPs. MSPs also provide assistance paying for Medicare premiums.
3. Part D Low-Income Subsidy (LIS) Program: Also known as Extra Help, this program helps beneficiaries with their Part D premiums and cost sharing. If a beneficiary qualifies for full Medicaid coverage, they’ll automatically get Extra Help with their drug costs.

Please note that the specifics of these programs will depend on the beneficiary’s individual circumstances, so it’s always a good idea to check with Medicare or a trusted advisor to understand their option.