SPECIAL ENROLLMENTS PERIODS Flashcards

1
Q

YOU CHANGE WHERE YOU LIVE
I moved to a new address that isn’t in my plan’s service area.
What can I do?

A

Switch to a new Medicare Advantage Plan or Medicare drug plan.

Note: If you’re in a Medicare Advantage Plan and you move outside your plan’s service area, you can also choose to return to Original Medicare. If you don’t join a new Medicare Advantage Plan during the time explained below, you’ll be enrolled in Original Medicare when you’re disenrolled from your old Medicare Advantage Plan.

When?

If you tell your plan before you move, your chance to switch plans begins the month before the month you move and continues for 2 full months after you move.

If you tell your plan after you move, your chance to switch plans begins the month you tell your plan, plus 2 more full months.

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2
Q

YOU CHANGE WHERE YOU LIVE
I moved to a new address that’s still in my plan’s service area, but I have new plan options in my new location?
What can I do?

A

Switch to a new Medicare Advantage Plan or Medicare drug plan.

When?

If you tell your plan before you move, your chance to switch plans begins the month before the month you move and continues for 2 full months after you move.

If you tell your plan after you move, your chance to switch plans begins the month you tell your plan, plus 2 more full months.

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3
Q

YOU CHANGE WHERE YOU LIVE
I moved back to the U.S. after living outside the country. What can I do?

A

Join a Medicare Advantage Plan or Medicare drug plan.

When?

your chance to join lasts for 2 full months after the month you move back to the U.S.

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4
Q

YOU CHANGE WHERE YOU LIVE
I just moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital). What can I do?

A

–Join a Medicare Advantage Plan or Medicare drug plan.

–Switch from your current plan to another Medicare Advantage Plan or Medicare Prescription Drug Plan.

–Drop your Medicare Advantage plan and return to Original Medicare.

–Drop your Medicare prescription drug coverage.

When?

your chance to join, switch, or drop coverage lasts as long as you live in the institution and for 2 full months after the month you leave the institution.

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5
Q

YOU CHANGE WHERE YOU LIVE
I’m released from jail. what can I do?

A

Join a Medicare Advantage Plan or Medicare drug plan.

When?

If you kept paying for your Part A and Part B coverage while you were in jail, you have 2 full calendar months after you’re released from jail to join a plan. You have to sign up for Medicare before you can join a plan.

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6
Q

YOU LOSE YOUR CURRENT COVERAGE
I’m no longer eligible for Medicaid. What can I do?

A

–Join a Medicare Advantage Plan or Medicare drug plan.

–Switch from your current plan to another Medicare Advantage —–Plan or Medicare drug plan.
–Drop your Medicare Advantage Plan and return to Original Medicare.
–Drop your Medicare prescription drug coverage.

When?

your chance to change lasts for 3 full months from either the date you’re no longer eligible or notified, whichever is later.

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7
Q

YOU LOSE YOUR CURRENT COVERAGE
I left coverage from my employer or union (including COBRA coverage). What can I do?

A

–Join a Medicare Advantage Plan or Medicare drug plan.

When?

Your chance to join lasts for 2 full months after the month your coverage ends.

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8
Q

YOU LOSE YOUR CURRENT COVERAGE
I involuntarily lose other drug coverage that’s as good as Medicare drug coverage (creditable coverage), or my other coverage changes and is no longer credible. What can I do?

A

Join a Medicare Advantage Plan with drug coverage or a Medicare drug plan.

When?

Your chance to join lasts 2 full months after the month you lose your creditable coverage, or for 2 full months after you’re notified that your current coverage is no longer creditable, whichever is later.

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9
Q

YOU LOSE YOUR CURRENT COVERAGE
I had drug coverage through a Medicare Cost Plan and I let the plan. What can I do?

A

Join a Medicare drug plan.

When?

Your chance to join for 2 full months after you drop your Medicare Cost Plan.

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10
Q

YOU LOSE YOUR CURRENT COVERAGE
I dropped my coverage in a Program of All-inclusive Care for the Elderly (PACE) plan. What can I do?

A

Join a Medicare Advantage Plan or Medicare drug plan.

When?

Your chance to join lasts for 2 full months after the month you drop your Program of All-inclusive Care for the Elderly (PACE) (tooltip) plan.

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11
Q

YOU HAVE A CHANCE TO GET OTHER COVERAGE
I have a chance to enroll in other coverage offered by my employer or union. What can I do?

A

Drop your current Medicare Advantage Plan or Medicare drug plan to enroll in the private plan offered by your employer or union.

When?

Whenever your employer or union allows you to make changes in your plan.

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12
Q

YOU HAVE A CHANCE TO GET OTHER COVERAGE
I have or am enrolling in other drug coverage as good as Medicare drug coverage (like TRICARE OR VA coverage). What can I do?

A

Drop your current Medicare Advantage Plan with drug coverage or your Medicare drug plan.

When?

Anytime.

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13
Q

YOU HAVE A CHANCE TO GET OTHER COVERAGE
I enrolled in a Program of All-inclusive Care for the Elderly (PACE) plan. What can I do?

A

Drop your current Medicare Advantage or Medicare drug plan.

When?

Anytime.

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14
Q

YOUR PLAN CHANGES ITS CONTRACT WITH MEDICARE
Medicare takes an official action (called a “sanction”) because of a problem with the plan that affects me. What can I do?

A

Switch from your Medicare Advantage Plan or Medicare drug plan to another plan.

When?

Your chance to switch is determined by Medicare on a case-by-case basis.

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15
Q

YOUR PLAN CHANGES ITS CONTRACT WITH MEDICARE
Medicare ends (terminates) my plan’s contract. What can I do?

A

Switch from your Medicare Advantage Plan or Medicare drug plan to another plan.

When?

Your chance to switch starts 2 months before and ends 1 full month after the contract ends.

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16
Q

YOUR PLAN CHANGES ITS CONTRACT WITH MEDICARE
My Medicare Advantage Plan, Medicare Prescription Drug Plan, or Medicare Cost Plan’s contract with Medicare isn’t renewed. What can I do?

A

Join another Medicare Advantage Plan or Medicare drug plan.

When?

December 8 - the last day in February.

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17
Q

OTHER SPECIAL SITUATIONS
I’m eligible for both Medicare and Medicaid. What can I do?

A

Join, switch, or drop you Medicare Advantage Plan or Medicare drug coverage.

When?

One time during each of these periods:

  • January - March
  • April - June
  • July - September

If you make a change, it will take effect on the first day of the following month.

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18
Q

OTHER SPECIAL SITUATIONS
I qualify for Extra Help paying for Medicare prescription drug coverage. What can I do?

A

Join, switch, or drop Medicare drug coverage.

When?

Most people with Medicare can only make changes to their drug coverage at certain times of the year. If you have Medicaid or receive Extra Help, you may be able to make changes to your coverage one time during each of these periods:

  • January - March
  • April - June
  • July - September

If you make a change, it will begin the first day of the following month.

19
Q

OTHER SPECIAL SITUATIONS
I’m enrolled in a State Pharmaceutical Assistance Program (SPAP). What can I do?

A

Join either a Medicare drug plan or a Medicare Advantage Plan with drug coverage.

When?

Once during the calendar year.

20
Q

OTHER SPECIAL SITUATIONS
I’m enrolled in a State Pharmaceutical Assistance Program (SPAP) and I lost SPAP eligibility. What can I do?

A

Join either a Medicare drug plan or a Medicare Advantage Plan with drug coverage.

When?

Your chance to switch starts either the month you lose eligibility or the month you’re notified of the loss, whichever is earlier. It ends 2 months after either the month of the loss of eligibility or notification of the loss, whichever is later.

21
Q

OTHER SPECIAL SITUATIONS
I dropped a Medigap policy the first time I joined a Medicare Advantage Plan and I’m still in a “trial period” and eligible for guaranteed issue of a Medigap policy. What can I do?

A

Drop your Medicare Advantage Plan and enroll in Original Medicare. You’ll have special rights to buy a Medigap policy.

When?

Your chance to drop your Medicare Advantage Plan lasts for 12 months after you join the Medicare Advantage Plan for the first time.

22
Q

OTHER SPECIAL SITUATIONS
I have a severe or disabling condition, and there’s a Medicare chronic Care Special Needs Plan (SNP) available that serves people with my condition. What can I do?

A

Join a Medicare Chronic Care Special Needs Plan (SNP).

When?

You can join anytime, but once you join, your chance to make changes using this SEP ends.

23
Q

OTHER SPECIAL SITUATIONS
I’m enrolled in a Special Needs Plan (SNP) and no longer have a condition that qualifies as a special need that the plan serves. What can I do?

A

Switch from a Special Needs Plan (SNP) to a Medicare Advantage Plan or Medicare drug plan.

When?

You can choose a new plan starting from the time you lose your special needs status, up to 3 months after your SNP’s grace period ends.

24
Q

OTHER SPECIAL SITUATIONS
I joined a plan, or chose not to join a plan, due to an error by a federal employee. What can I do?

A

– Join a Medicare Advantage Plan with drug coverage or a Medicare drug plan.
– Switch from your current plan to another Medicare Advantage Plan with drug coverage or a Medicare Prescription Drug Plan.

– Drop you Medicare Advantage Plan with drug coverage and return to Original Medicare.

– Drop your Medicare prescription drug coverage.

When?

You chance to change coverage lasts for 2 full months after the month you get a notice of the error from Medicare.

25
Q

OTHER SPECIAL SITUATIONS
I wasn’t properly told that my other private drug coverage wasn’t as good as Medicare drug coverage (creditable coverage). What can I do?

A

Join a Medicare Advantage Plan with drug coverage or a Medicare Prescription Drug Plan.

When?

Your chance to join lasts for 2 full months after the month you get a notice of the error from Medicare or your plan.

26
Q

OTHER SPECIAL SITUATIONS
I wasn’t properly told that I was losing private drug coverage that was as good as Medicare drug coverage (creditable coverage). What can I do?

A

Join a Medicare Advantage Plan with drug coverage or a Medicare Prescription Drug Plan.

When?

Your chance to join lasts for 2 full months after the month you get a notice of the error from Medicare or your plan.

27
Q

Low-Income Subsidy (LIS) (aka “Extra Help”) – Federal and New York State Eligibility:

A

The Low-Income Subsidy (LIS), also known as “Extra Help,” is a federal program that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage1.

Federal Eligibility for LIS:

You must have Medicare Part A and/or Part B.
You must live within the U.S. (50 states or Washington D.C.)2.
If your monthly income is up to $1,843 in 2023 ($2,485 for couples) and your assets are below specified limits, you may be eligible for Extra Help.

If you are enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program (MSP), you automatically qualify for Extra Help regardless of whether you meet Extra Help’s eligibility requirements.
Effective January 1, 2024, eligibility of the full LIS group will expand to individuals with incomes up to 150 percent of the federal poverty level (FPL) and who meet the statutory resource requirements.

New York Eligibility for LIS:

The eligibility criteria are similar to the federal guidelines.
If your monthly income was up to $1,538 in 2018 ($2,078 for couples) and your assets were below specified limits, you may have been eligible for Extra Help.

Benefits of LIS:

–Pays for your Part D premium up to a state-specific benchmark amount.
–Lowers the cost of your prescription drugs.
–Gives you a Special Enrollment Period (SEP) once per calendar quarter during the first nine months of the year to enroll in a Part D plan or to switch between plans.
–Eliminates any Part D late enrollment penalty you may have incurred if you delayed Part D enrollment.

To apply for LIS, you can visit the Social Security Administration’s website. Please note that these are general guidelines and individual circumstances can vary.

28
Q

Low-Income Subsidy (LIS) (aka “Extra Help”) – Federal Eligibility:

A

Federal Eligibility for LIS:

You must have Medicare Part A and/or Part B.
You must live within the U.S. (50 states or Washington D.C.)2.
If your monthly income is up to $1,843 in 2023 ($2,485 for couples) and your assets are below specified limits, you may be eligible for Extra Help.

If you are enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program (MSP), you automatically qualify for Extra Help regardless of whether you meet Extra Help’s eligibility requirements.
Effective January 1, 2024, eligibility of the full LIS group will expand to individuals with incomes up to 150 percent of the federal poverty level (FPL) and who meet the statutory resource requirements.

29
Q

Low-Income Subsidy (LIS) (aka “Extra Help”) – New York State Eligibility:

A

New York Eligibility for LIS:

The eligibility criteria are similar to the federal guidelines.
If your monthly income was up to $1,538 in 2018 ($2,078 for couples) and your assets were below specified limits, you may have been eligible for Extra Help.

Benefits of LIS:

–Pays for your Part D premium up to a state-specific benchmark
amount.
–Lowers the cost of your prescription drugs.
–Gives you a Special Enrollment Period (SEP) once per calendar
quarter during the first nine months of the year to enroll in a
Part D plan or to switch between plans.
–Eliminates any Part D late enrollment penalty you may have
incurred if you delayed Part D enrollment.

30
Q

What are the two concepts of Medicare Savings Programs (MSPs)

A
  1. Medicare Savings Programs (MSPs): These are programs that help cover Medicare premiums and other cost-sharing expenses for people with low income1. MSPs can help pay your Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums. If you qualify, MSPs might also pay your Part A and Part B deductibles, coinsurance, and copayments. There are four types of MSPs:

-Qualified Medicare Beneficiary (QMB) Program
-Specified Low-Income Medicare Beneficiary (SLMB) Program
-Qualifying Individual (QI) Program
-Qualified Disabled and Working Individuals (QDWI) Program
Each program has different benefits and eligibility requirements.

  1. Medicare Secondary Payer (MSP): This term is used when the Medicare program does not have primary payment responsibility, i.e., when another entity has the responsibility for paying before Medicare. The MSP provisions have protected Medicare Trust Funds by ensuring that Medicare does not pay for items and services that certain health insurance or coverage is primarily responsible for paying.

Please note that eligibility for both MSPs and the MSP program can vary based on factors like income, resources, and state regulations

31
Q

1 of 4 types of Medicare Saving Program is the Qualified Medicare Beneficiary Program (QMB). What is the QMB program?

A

The Qualified Medicare Beneficiary (QMB) Program is one of the four Medicare Savings Programs that allows you to get help from your state to pay your Medicare premiums. This Program helps pay for:

-Part A premiums
-Part B premiums
-Deductibles
-Coinsurance
-Copayments
In order to qualify for QMB benefits, you must meet certain income and resource requirements. As of the information available, the income requirements are:

Individual monthly income limit: $1,060
Married couple monthly income limit: $1,430
Individual resource limit: $7,730
Married couple resource limit: $11,600

Please note that these limits change from year to year, so it’s recommended to check the Medicare Savings Programs page for the most up-to-date income requirements1. To apply for the QMB Program, you can call your state Medicare Program.

It’s important to note that federal law forbids Medicare providers and suppliers, including pharmacies, from billing people in the QMB program for Medicare cost-sharing. Medicare beneficiaries enrolled in the QMB program have no legal obligation to pay Medicare Part A or Part B deductibles, coinsurance, or copays for any Medicare-covered items and services.

For more information, you can visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).

32
Q

What is the Special Low-Income Medicare Beneficiary (SLMB) Program?

A

The Specified Low-Income Medicare Beneficiary (SLMB) Program is one of the four Medicare Savings Programs that allows you to get help from your state to pay your Medicare premiums. This Program helps pay for Part B premiums only.

In order to qualify for SLMB benefits, you must meet certain income and resource requirements1. As of the information available, the income requirements are:

Individual monthly income limit: $1,269
Married couple monthly income limit: $1,711
Individual resource limit: $7,730
Married couple resource limit: $11,600
Please note that these limits change from year to year, so it’s recommended to check the Medicare Savings Programs page for the most up-to-date income requirements. To apply for the SLMB Program, you can call your state Medicaid Program.

If you qualify for the SLMB Program, you’ll also get Extra Help paying for your prescription drugs. You’ll pay no more than $10.35 in 2023 for each drug your Medicare drug plan covers.

For more information, you can visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).

33
Q

What is the Qualifying Individual (QI) Program?

A

The Qualifying Individual (QI) Program is one of the four Medicare Savings Programs that allows you to get help from your state to pay your Medicare premiums. This Program helps pay for Part B premiums only.

In order to qualify for QI benefits, you must meet certain income and resource requirements. As of the information available, the income requirements are:

-Individual monthly income limit: $1,426
-Married couple monthly income limit: $1,923
-Individual resource limit: $7,730
-Married couple resource limit: $11,600

Please note that these limits change from year to year, so it’s recommended to check the Medicare Savings Programs page for the most up-to-date income requirements. To apply for the QI Program, you can call your state Medicaid Program. You must apply every year for QI benefits. QI applications are granted on a first-come, first-served basis, with priority given to people who received QI benefits the previous year.

For more information, you can visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).

34
Q

What is the Qualified Disabled and Working Individuals (QDWI) Program?

A

The Qualified Disabled and Working Individuals (QDWI) Program is one of the four Medicare Savings Programs that allows you to get help from your state to pay your Medicare premiums. This Program helps pay for Part A premiums only.

In order to qualify for QDWI benefits, you must meet certain income and resource requirements. As of the information available, the income requirements are:

Individual monthly income limit: $4,249
Married couple monthly income limit: $5,722
Individual resource limit: $4,000
Married couple resource limit: $6,000

Please note that these limits change from year to year, so it’s recommended to check the Medicare Savings Programs page for the most up-to-date income requirements. To apply for the QDWI Program, you can call your state Medicaid Program.

Eligibility for the QDWI Program also includes the following criteria:

-You must be under age 65.
-You must be disabled and no longer entitled to free Medicare Hospital Insurance Part A solely because you successfully returned to work.
-You must continue to have a disabling impairment.
-You must sign up for Premium Hospital Insurance (Part A).
-You must have limited income.
-You must have resources worth less than $4,000 for an individual and $6,000 for a couple, not counting the home where you live, usually one car, and certain insurance.
-You must not already be eligible for Medicaid.

For more information, you can visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).

35
Q

What is SNP?

A

In the context of Medicare Insurance Programs, SNP stands for Special Needs Plan. A Special Needs Plan is a type of Medicare Advantage plan that provides coverage for certain specialized groups of people. It is designed to provide targeted care and limit enrollment to special needs individuals.

SNPs provide benefits and services to people with specific diseases, certain health care needs, or who also have Medicaid. They include care coordination services and tailor their benefits, provider choices, and list of covered drugs (formularies) to best meet the specific needs of the groups they serve. SNPs are either HMO or PPO plan types, and cover the same Medicare Part A and Part B benefits that all Medicare Advantage Plans cover. However, SNPs might also cover extra services for the special groups they serve.

There are three different types of SNPs:

  1. Dual Eligible SNP (D-SNP): For individuals who have both Medicare and Medicaid.
  2. Chronic Condition SNP (C-SNP): For individuals with specific chronic conditions.
  3. Institutional SNP (I-SNP): For individuals who live in an institution (like a nursing home) or who require nursing care at home.

You can join an SNP if you meet these requirements:

You have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).

You live in the plan’s service area.
You meet the eligibility requirements for one of the 3 types of SNPs.

All SNPs must provide Medicare drug coverage (Part D)1. Each year, different types of SNPs may be available in different parts of the country.

For more information, you can visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).

36
Q

Talk about the Dual Eligible SNP (D-SNP):

A

The Dual Eligible Special Needs Plan (D-SNP) is a type of Medicare Advantage plan designed for individuals who are eligible for both Medicare and Medicaid. These individuals are often referred to as “dual eligible” individuals.

To qualify for a D-SNP, individuals must meet the following requirements:

-Be eligible for both Medicare and Medicaid.
-Reside within the service area of the D-SNP plan.
-Meet the plan’s specific eligibility criteria, which may vary by insurance provider.
-Be U.S. citizens or lawful residents.
-Be eligible for Medicare Parts A and B while also meeting the income requirements for their state’s Medicaid program.
The Medicaid eligibility includes those who are eligible for:

Full Medicaid coverage
Qualified Medicare Beneficiary (QMB) or QMB Plus
Each state will determine if you qualify for a dual health plan. If you don’t meet all the requirements, you may still be partially eligible for a D-SNP.

For more information, you can visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227)

37
Q

What Makes a person eligible for Medicare?

A

To be considered eligible for both Medicare and Medicaid (dual eligible), individuals must meet certain criteria:

Medicare Eligibility:

Individuals aged 65 or older.
Certain individuals under 65 with disabilities and entitled to Social Security disability or Railroad Retirement Board (RRB) benefits for 24 months (the 24-month waiting period is waived for people with amyotrophic lateral sclerosis [ALS], also known as Lou Gehrig’s disease).
Individuals of any age with End-Stage Renal Disease (ESRD).
Medicare consists of four parts:

Part A – Hospital Insurance (inpatient hospital care, inpatient care in a Skilled Nursing Facility, hospice care, and some home health services).

Part B – Medical Insurance (physician services, outpatient care, durable medical equipment, home health services, and many preventive services).

Part C – Medicare Advantage (MA) (Medicare-approved private insurance companies cover all Part A and Part B services and may cover prescription drug coverage and other supplemental benefits).

Part D – Prescription Drug Benefit (Medicare-approved private companies cover outpatient prescription drug coverage).

38
Q

What Makes a person eligible for Medicaid?

A

Medicaid Eligibility:

Medicaid is a joint federal and state program that provides health insurance for certain individuals with low income.
Each state administers its own program, following broad national federal guidelines, statutes, regulations, and policies.
Each state establishes its own eligibility standards, decides the type, amount, duration, and scope of services, sets payment rates.

39
Q

What makes a person eligible for Medicaid in New York?

A

To be eligible for Medicaid in New York, individuals must meet certain criteria:

-Be a resident of the state of New York.
-Be a U.S. national, citizen, permanent resident, or legal alien.
-Be in need of health care/insurance assistance, whose financial situation would be characterized as low income or very low income.
-Be one of the following: Pregnant, or.
-Eligible populations include children, pregnant women, single individuals, families, and individuals certified blind or certified disabled.
-Any person between the ages of 21 and 65 will only be eligible for Medicaid if they are disabled (or expected to be disabled for at least a year), certified blind, below the public assistance income and resource levels, or already receiving Supplemental Security Income.
In addition, there are specific income and asset limits for eligibility. For instance, a single individual applying for Nursing Home Medicaid in 2023 in New York must meet the following criteria:

-Have income under $1,677 / month
-Have assets under $30,180
-Require the level of care provided in a nursing home facility.

Please note that these limits change from year to year, so it’s recommended to check the New York State Department of Health website for the most up-to-date income requirements.

For more information, you can visit the New York State Department of Health website or call the NYS Medicaid Helpline Toll Free: (800) 541-2831

40
Q

What is the Initial Enrollment Period (IEP)?

A

This is the initial period when you first become eligible for Medicare. It starts three months before your 65th birthday month and ends three months after. During this period, you can enroll in Medicare Part A and/or Part B.

41
Q

What is the General Enrollment Period (GEP)?

A

General Enrollment Period (GEP): If you missed your IEP, you can enroll in Medicare during the General Enrollment Period, which runs from January 1 to March 31 each year. Coverage begins on July 1 of the same year. Late enrollment penalties may apply if you didn’t enroll during your IEP.

42
Q

What is the Annual Enrollment Period (AEP) ?

A

Also known as the Medicare Open Enrollment Period, the AEP occurs every year from October 15 to December 7. During this period, you can make changes to your Medicare Advantage or Part D prescription drug plans. Changes made during this period take effect on January 1 of the following year.

43
Q

What is Medicare Advantage Open Enrollment Period (MA OEP)?

A

This enrollment period allows individuals who are already enrolled in a Medicare Advantage plan to make one change. It runs from January 1 to March 31. You can switch to a different Medicare Advantage plan or drop your Medicare Advantage plan and return to Original Medicare. You cannot use this period to switch from Original Medicare to a Medicare Advantage plan.

44
Q
A