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It’s becoming more common for individuals to not collect Social Security benefits prior to turning 65, as they continue to work and have group health plan coverage through that employer. However, some individuals plan their retirement around the same time they are becoming eligible for Medicare. The purpose of this tip sheet is to provide information on the order for the Medicare Part A and Part B Initial Enrollment Period and the Special Enrollment Period for the Working Aged so that you can better informand counsel those who are enrolling in Medicare.

In the case where an individual qualifies for more than one enrollment period, the order for Medicare

enrollment periods is: 1. Initial Enrollment Period (IEP) 2. Special Enrollment Period (SEP) 3. General Enrollment Period (GEP)

Both the Special Enrollment Period and the General Enrollment Period are only available following the end of an individual’s IEP. Section1837(i)(1) of the Social Security Act outlines that an individual is eligible for the SEP for the Working Aged if he or she is covered under a group health plan based on their (or their spouse’s) current employment AND they didn’t enroll during their IEP. This means that the individual must be out of their IEP before they can use the SEP to enroll. If an individual tries to use the SEP and enroll during the last 3 months of his/her IEP, the enrollment will be processed as an IEP enrollment and the individual will have a delay in the start of the Part B coverage. The effective dates for IEP enrollments are outlined in law.

This chart explains the enrollment dates and coverage effective dates for the IEP and SEP for the aged. Note: Coverage always starts on the 1st of the month

erTipSheet:UnderstandingtheOrderofMedicarePartAandPartBEnrollmentPeriods

*The SEP can only be used once the individual’s IEP is over.

Understanding the Order of Medicare Part A and Part B Enrollment Periods March 2013

National Training Program

Partner Tip Sheet: Understanding the Order of Medicare Part A and Part B Enrollment Periods

Partner Tip Sheet: Understanding the Order of Medicare Part A and Part B Enrollment Periods March 2013

 

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The effective dates for a SEP enrollment vary based on when the enrollment request is made. If an individual enrolls in Part B while still enrolled in a group health plan or during the first full month when not enrolled in a group health plan based on their (or their spouse’s) current employment status, coverage begins with either:

• the month the individual enrolls in Part B, or • at the individual's option, with the first day of any of the following three months.

If the individual enrolls in Part B during any of the remaining 7 months of the SEP, coverage begins with the first day of the month after the month of enrollment.

In addition, an individual who enrolls in an SEP month that occurs in January, February, or March may elect to have the enrollment processed as either a GEP or as an SEP. If the individual elects to have the enrollment processed as a GEP, coverage will be effective July 1 of that year.

IEP/SEP Scenario: Mr. Smith turns 65 in November, 2012. He has GHP coverage through his current employment and decides to retire starting January 1, 2013. He plans to enroll in Part B using the SEP in December so that his coverage will be effective January 1. Can he do this?

Answer: No, Mr. Smith’s IEP is from August 1, 2012 through February 28, 2013. Therefore, if Mr. Smith submits his enrollment in December, it must be processed using his IEP, because his IEP isn’t over. Mr.Smith’s enrollment for Part B in December will be effective February 1, 2013.

When counseling individuals, you can look at the Part B enrollment effective dates for the IEP and the SEP, assuming the individual is eligible for the SEP, to help them determine when to enroll in Medicare.

CAUTION: It’s important to consider that SSA makes the final determination of eligibility for the SEP based on information provided by the employer regarding the end date of group health plan coverage and the end date of the employment. If the individual isn’t eligible for the SEP and doesn’t file during the IEP, the individual will have to wait until the GEP to enroll. The coverage won’t start until July of that year and the individual may be subject to a Part B late enrollment penalty for as long as they have Part B coverage.

Remember, the SEP for the Working Aged is only available if the individual has or recently had group health plan coverage based on current employment of themselves or their spouse. The SEP is available while the individual has group health plan coverage based on current employment or the 8 months following the end of the group health plan coverage or the employment, whichever occurs first. COBRA and retirement coverage don’t count as current employment. In addition, following the Defense of Marriage Act (DOMA), a spouse is defined as a marriage between a man and a woman, even if your State permits same-sex marriages. Individuals in same-sex marriages aren’t considered spouses for the purposes of this SEP. For more information about enrolling in Medicare, please see the following links: www.medicare.gov www.medicare.gov/sign-up-change-plans/index.html www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-and-how-to-get-parts-a-and-b.html 

 

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Medicare A & B – 2016 1

Case Study — George Bell

George Bell is a 64 year old man who will soon be reaching his 65th birthday. George is so busy with a full-time career that his plans for retirement are far in the future. George will continue employment with a major corporation beyond his 65th birthday. What should he do about Medicare enrollment and his current group health insurance? Case Study — Frank

Frank is 70 years old. He retired at 65 from the GMYM Savings and Loan. Since he was receiving retiree insurance, he did not sign up for Medicare Part B. He has recently received notification from the bank that the retiree insurance will be changing and some of the benefits will be eliminated. Frank has decided that he now wants to sign up for Medicare Part B. When Frank went to the local Social Security office on April 12, he was told that he would be penalized for not signing up for Part B when he was initially eligible. Is this true? What would Frank’s penalty be?

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Medicare A & B – 2016 2

Case Study — Ruth Rose

Ruth Rose comes to see you at the SHINE office. She says that she will be 65 in 5 months. She will continue to work and is covered by her employer group plan. She does not want to sign up for Medicare. However, her friend Rhoda told her that if he does not sign up now, she will not be able to get Medicare later. What information would you give her? Case Study— Agnus

Agnus is 64 years old and has been divorced for 15 years. Agnus married soon after high school and was a full-time homemaker. Until 5 years ago, Agnus had never worked outside the home. For the past 5 years she has worked for the Red Dye Company. She will be retiring in 4 months when she turns 65. The benefits administrator of the Red Dye Company told Agnus that she will not be eligible for Social Security or Medicare since she has not worked for a full 10 years. Is this true? What would you tell Agnus?

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Medicare A & B – 2016 3

Case Study — Justin Time

Justin Time will turn 65 and be retiring in 4 months. After talking with the benefits manager at his employer, he is very confused about Medicare and what it does and does not pay for. Since he will be getting retiree insurance from his employer, he is not sure if he really needs Medicare at all. What information would you give him?

*Complete a Client Contact form on Justin

Case Study - Mrs. Carroll

Mrs. Carroll called the SHINE office for help on June 1st for help with a problem. Mr. Carroll, much to his wife’s dismay, refused to sign up for Medicare Part B when he was initially eligible. He is very proud of the fact that he has only spent $1,000 for medical care in the last 3 years. As he repeatedly told his wife, that is cheaper than paying the Part B premium for the last 3 years. Mr. Carroll now needs to have surgery. His wife is beginning to realize some of the problems involved as a result of an uninformed decision he made three years ago. List the problems he will now face.

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Medicare A & B – 2016 4

Case Study - Ms. Washington

Ms. Washington lives in Massachusetts. She goes to see Dr. Franklin in her town who does not accept assignment. Ms. Washington is required to pay the entire bill of $150. When she receives the Medicare Summary Notice (MSN), she notices that the Medicare approved amount is $100. She wants to know what the exact amount is that Medicare will pay and the amount that is her responsibility? She explains that she has already met her Part B annual deductible. What would Ms. Washington owe if she lived in Florida? Case Study — Hal

Hal will celebrate his 65th birthday in a couple of months. He just received his Medicare Initial Enrollment Package from the Social Security Administration. While he has a general understanding of Medicare Part A, Hal doesn’t feel well informed about Medicare Part B. What information would you provide Hal?

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Medicare A & B – 2016 5

Case Study - Bill Fold

Bill Fold comes to meet with you at the SHINE office. He will be turning 65 and retiring in 3 months and wants to know about Medicare. He tells you that he will be receiving retiree health insurance from his employer and would like to know if he really needs Medicare. He says that he is healthy and takes no medication. What questions would you ask and what information would you give?

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Case Study — - Mr. Sal Lowe- Sal calls you to find out why a bill is not being paid by Medicare. He tells you that he became violently ill while traveling on a cruise ship to Greece and was treated by the ship’s doctor. He is surprised that the bill is not being paid since had a similar circumstance a few years earlier while on a cruise to Alaska. He explains that on the Alaska trip he had dinner on shore and became ill soon after returning to the ship. He was seen and treated by the ship’s doctor and the bill was paid. He doesn’t understand why Medicare is not covering this time. How would you help him?

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Medicare A & B – 2016 6

Medicare True/False/Multiple Choice Quiz 1. Raymond’s doctor just visited him in the hospital and told him he needs to

stay for a few more days. He is concerned about the costs of his hospital stay. He understands that after he pays his deductible, Medicare Part A will cover the expenses associated with his hospital stay, but that he is responsible for the costs of his television and telephone service.

True ___ False ___ 2. Kirby is scheduled to have surgery in two months and will be hospitalized for

a few days. He has Medicare A & B only. Kirby will have the Part A deductible to pay but all other costs will be covered.

True ___ False ___ 3. Mario is 65 years old and receives Social Security benefits. He is covered by the group health insurance policy provided by his wife’s employer. He wants to wait to enroll in Medicare Part B after his wife retires in 2 years. Delaying enrollment will result in an additional 10% penalty added to the monthly premium for each year he could have been enrolled in Part B but was not. True ___ False ___

Medicare A & B – 2016 7

4. Marta enrolled in Medicare A and B in 2003. She just had her annual checkup with her doctor. Medicare Part B will not cover which item listed below? a. Flu shot b. Routine Physical c. Diabetes test d. All of the above will be covered

Medicare Part A Quiz

1. What are the requirements for Medicare eligibility for age 65 and over? 2. What is the definition of a benefit period?

3. Name four services covered under Medicare Part A. 1.__________________________ 2.__________________________ 3.__________________________ 4.__________________________ 4. What is the current Part A deductible?___________ 5. Which of the following services is not covered by Medicare Part A during a hospital stay?

a. Intensive Care b. Operating Room c. Physician services d. Drugs provided during a covered stay in a hospital or SNF 6. How many days will Medicare provide full coverage in a skilled nursing facility? 7. Medicare requires that the following 4 conditions be met before payment is made for skilled nursing facility care: 1._______________________________________________________

Medicare A & B – 2016 8

2._______________________________________________________ 3._______________________________________________________ 4._______________________________________________________ 8. What is the monthly Part A premium for a voluntary enrollee who has 37 work credits?

Medicare Part B Quiz

1. What are the major areas of coverage under Part B? 2. What is the current monthly premium for Medicare Part B? 3. A beneficiary who lost her Medicare card should call CMS to order a new card. True____ False ____ 4. A non-participating physician may accept assignment on a case-by-case basis.

True____ False ____ 5. When physicians accept assignment, they accept Medicare’s payment of 80%

of the Medicare approved charges as payment in full for the service. True____ False ____

6. If you are unhappy with your looks, Medicare will pay for a face lift.

Medicare A & B – 2016 9

True____ False ____ 7. Medicare does cover an annual physical. True____ False ____

Medicare A/B Quiz

1. Describe Medicare’s Enrollment Periods. 2. What is the Part B penalty and how can an individual avoid this? 3. Mr. Hoover comes to ask about his mother’s hospitalization. His mother has been hospitalized for 62 days. His mother has no insurance other than Medicare. a. After Medicare pays, what part of the bill is her responsibility? b. If she is discharged, but is readmitted 10 days later and stays for 10 days, what additional amount of money will she owe? c. If she stays an additional 40 days instead of 10 days, what additional amount of money will she owe? 4. List gaps in Medicare Part B coverage.

Medicare A & B – 2016 10

5. Mr. Smith comes to see you at the Council on Aging (COA) office. He will be retiring soon and living on a limited income. His understanding is that he can get by with just Medicare A+B coverage. What would you tell him about having Medicare A+B coverage only.