Module - 1, Original Medicare_ Eligibility, Enrollment, Entitlement, and Premiums Flashcards
Original Medicare covers only Part A and Part B benefits:
– Part A benefits include inpatient hospital, skilled nursing facility, hospice, and home health services.
– Part B benefits include outpatient and professional services such as those provided by a doctor (or non-physician professional such as a nurse practitioner or physician assistant), clinical lab services, durable medical equipment, preventative services, and other outpatient medical services.
Eligibility For Part A and Part B:
to be eligible for Medicare Part A and Part B, an individual must:
1. Be age 65 or older, or be under age 65 with certain disabilities or health conditions, including:
– All who get disability benefits from Social Security or certain disability benefits from the Railroad Retirement Board for 24 months.
– individuals with Amyotrophic Lateral Sclerosis (ALS), often referred to as Lou Gehrig’s Disease, or have an end-stage renal disease (ESRD).
- Be a U.S. resident; and
– be either a U.S. citizen, or
– be an alien who has been lawfully admitted for permanent residence and has been residing in the United States for 5 continuous years before the month of applying for Medicare.
Medicare Enrollment - Parts A and B
Some people are automatically enrolled in Parts A and B:
– Subject to the Part B exception below for Puerto Rico:
- Individuals who are already getting benefits from Social Security or the Railroad Retirement Board (RRB) will automatically be enrolled in Part A and Part B starting the first day of the month they turn 65. (If their birthday is on the first day of the month, Part A and Part B will start the first day of the prior month.) These individuals are also allowed to refuse Part B coverage. (See Medicare Part B for the potential consequences of refusing Part B).
– Individuals with disabilities who are under age 65 are automatically enrolled in Parts A and B the month after they have received Social Security or Railroad Retirement disability benefits for 24 months. However, they have an opportunity to refuse Part B coverage.
– Individuals with ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease) get Part A and Part B automatically the month their Social Security disability benefits begin.
- Individuals living in Puerto Rico are not automatically enrolled in Part B. They must sign up for it.
Medicare Enrollment - Initial Enrollment Period:
– Individuals who are close to 65 but are not getting benefits from Social Security or the Railroad Retirement Board (RRB) may sign up for Parts A and B during their Initial Enrollment Period, which begins 3 months before their 65th birthday, including the month they turn 65 and ends 3 months after. (see Medicare Part B for the potential consequences of failing to sign up for Part B when first eligible).
– If an individual enrolls during any of the first three months of their Initial Enrollment Period (IEP), their coverage will start the first month of eligibility (e.g., age 65).
– If an individual enrolls during their IEP in the month they become eligible, coverage will start the month after they enroll. Premium free-Part A coverage will be retroactive to the month they turned 65.
– If an individual enrolls during any of the last three months of their IEP, their coverage will start the month after they enroll. Premium free-Part A coverage will be retroactive to the month they turned 65.
Medicare Enrollment - End -Stage Renal Disease (ESRD):
– Individuals with end-stage renal disease (ESRD) may sign up for Medicare at any time. However, the date on which their Medicare coverage begins is usually on the fourth month after dialysis treatments begins but may be earlier if certain conditions are met.
Medicare Enrollment - Premium-free Part A:
Individuals eligible for Premium-free Part A can also sign up for Part A any time after they turn 65. Their Part A coverage starts 6 months back from when they signed up but cannot start earlier than the month they turned 65. If they have not signed up by the time they apply for Social Security, they will automatically be signed up (and coverage will be retroactive for 6 months).
Medicare Enrollment - General Enrollment Period:
– Individuals who do not enroll in Part B (or Part A if they have to buy it) when they are first eligible, can enroll during a General Enrollment Period (GEP) each year from January 1 to March 31.
- Coverage begins the first day of the month following the month in which the beneficiary enrolls
Medicare Enrollment - Special Enrollment Period:
–Individuals who have group health plan coverage based on their current employment or the employment of a spouse may enroll in Part A (if they have to buy it) and/or Part B anytime while covered under the group health plan or during a Special Enrollment Period that occurs during the 8-month period immediately following the last month they have group coverage.
– Individuals who are eligible for premium-free Part A may sign up at any time.
Medicare Enrollment - New Special Enrollment Periods for 2023 and Beyond:
The new SEPs for enrollment in Part B and Part A if an individual is not eligible for premium-free Part A, apply to:
– Individuals impacted by an emergency or disaster - allows eligible individuals or their authorized representative who missed an enrollment opportunity because they were impacted by a disaster or other emergency as declared by a Federal, state, or local government entity to enroll the individual up to six months after the end of the emergency declaration.
– Individuals impacted by a health plan or employer –applies where an eligible individual can demonstrate that their employer or health plan (including brokers or agents of plans) materially misrepresented information related to enrolling in Medicare premium Part A timely. The individual may enroll up to six months after the individual notifies Social Security of the error.
– Formerly incarcerated individuals – allows eligible individuals to enroll following their release from correctional facilities up to 12 months post-release. Such individuals may choose between retroactive coverage back to their release date (not to exceed 6 months) or coverage beginning the month after the month of enrollment. If an individual selects retroactive coverage, they must pay the premiums for the retroactive covered time period.
– Individuals whose Medicaid coverage is terminated – allows eligible individuals who have missed a Medicare enrollment period to enroll in Medicare after termination of Medicaid eligibility for up to 6 months. Such individuals may choose between retroactive coverage back to the date of termination from Medicaid (but not earlier than January 1, 2023) or coverage beginning the month after the month of enrollment. If an individual selects retroactive coverage, they must pay the premiums for the retroactive covered time period.
– Individuals with other exceptional conditions – allows CMS, on a case-by-case basis, to grant a 6-month SEP to an individual when circumstances beyond the individual’s control prevented them from enrolling during the IEP, GEP, or other SEPs.
Medicare Part A Entitlement and Part B Enrollment:
– An individual is entitled to Part A if they are eligible for premium-free Part A or if the individual has enrolled in Part A and continues to pay the premium (or have the premium paid on their behalf).
– For an individual to enroll in Part B and remain enrolled in Part B, the individual must pay the Part B premium (or have the premium paid on their behalf).
OTher Ways to get Medicare - Part C:
Individual must:
- be entitled to Part A and enrolled in Part B; and
- reside in the MA plan’s service area.
Other Ways to get Medicare - Part D:
Individual must:
- be entitled to Part A and/or Part B enrolled in Part B; and
- reside in the plan’s Part D service area
Other Ways to get Medicare - Cost Plans:
Individual must:
- Be entitled to Part A and/or enrolled in Part B (If they are not entitled to Part A, they will not have coverage of Part A benefits under the Cost Plan); and
- reside in Part D Plan’s service area.
Other Ways to get Medicare - Medicare-Medicaid Plans:
Individual must:
- be eligible for both Medicare and Medicaid;
- meet eligibility requirements specific to the state; and
- reside in the plan’s service area.
Other ways to get Medicare - PACE Plans:
Individual must:
- Be age 55 or older;
- be certified as eligible for nursing home care by their state;
- be able to live safely in a community setting at the time of
enrollment;
- reside in the PACE organization’s service area;
- meet any additional program-specific eligibility conditions imposed under plan’s PACE Program agreement.
