04.40 Medicare

*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***

Medicare

Medicare is a federal health insurance program for people age 65 or older, disabled and under age 65, or any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). The Social Security Administration (SSA) and Railroad Retirement Board (RRB) determine entitlement to Medicare, depending on the benefits the client is receiving. The Centers for Medicare and Medicaid Services (CMS) administers Medicare.

Clients can be on all, some, or one of the parts at a given time. All parts have premiums, co-insurance, co-payments, and deductibles, which are subject to annual increases on January 1 of each year.

Medicare issues beneficiaries a red, white, and blue card. Medicare beneficiaries use the card to get services in Original Medicare (fee-for-service). Beneficiaries who join a Medicare health plan will get a card from their plan in addition to their Medicare ID card.

l People who qualify for monthly RSDI benefits at age 65 or older, or people who qualify for railroad retirement benefits.

l People age 65 or older who do not qualify for monthly RSDI or railroad retirement benefits, but who reside in the United States, whether or not they are U.S. citizens. If a noncitizen, the person must be lawfully admitted to the United States for permanent residence (LPR), and residing continuously in the United States five years or more at the time of application.

l People under age 65 with disabilities, after they have qualified for Social Security disability for 24 months. This includes disabled people age 18 and over who receive benefits because they became disabled before reaching age 22.

l Disabled widows and widowers, and disabled divorced widows and widowers after the 24 month qualifying period. (For disabled widows and widowers, previous months of eligibility for Supplemental Security Income (SSI) based on disability may count toward the 24 month qualifying period.)

Exceptions: Disabled persons with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s Disease, do not have a 24 month waiting period for Medicare.

l People with End-Stage Renal Disease (ESRD) defined as permanent kidney failure requiring dialysis or a kidney transplant.

Note: Medicare for people with ESRD is unique because filing for benefits can take place after the death of the ESRD individual.

l People under 65 who receive survivors' benefits or early retirement benefits only.

l Disabled people under age 65 who do not have sufficient work credits to get social security disability. This includes SSI only recipients who are under 65 years old. (Their receipt of only SSI benefits indicates insufficient work credits to qualify for disability benefits and Medicare.)

Note: A disabled spouse under age 65 who does not have enough work credits or a disabled child may qualify for disability benefits and Medicare if they are dependents of a person who has enough work credits to qualify. Work credits are deemed to spouses and children.

For people who qualify for Medicare at age 65, benefits usually begin on the first day of the month in which the person’s 65th birthday occurs. There is an exception to this rule for people who were born on the first day of a month. Their Medicare coverage begins the first day of the month prior to their birthday month.

Jack and Emma are both entitled to Medicare at age 65. Jack’s 65th birthday is on July 6. His Medicare coverage begins July 1.

Emma’s 65th birthday is on November 1. Her Medicare coverage begins October 1.

The initial enrollment period (IEP) for new Medicare beneficiaries is seven months long. It begins three months before the person is entitled to Medicare and ends three months after the month the person is entitled to Medicare. This enrollment period applies to Parts A, B, C and D.

There is a general enrollment period (GEP) from January 1 through March 31 each year. During the GEP, people who failed to enroll in Medicare during their IEP can enroll and people who cancelled Medicare can reenroll. Coverage for people who sign up during the general enrollment period begins July 1 of that year.

For people who enrolled in Medicare Part C products and Medicare Part D plans, an annual election period (AEP) is available each year from October 15 through December 7. During this period, Medicare beneficiaries may enroll in Part D plans, change their plans for Medicare Part C or Part D, or may go back and forth between Medicare Part C products and Original Medicare. Plan enrollment takes effect on January 1.

Starting in 2011 for Medicare Part C, there is a disenrollment period from January 1 through February 14 each year. During this time, beneficiaries enrolled in a Medicare Advantage plan can leave the Part C plan and return to Original Medicare with a Stand Alone Prescription Drug Plan. Beneficiaries cannot change to another Medicare Advantage plan, nor can beneficiaries in Original Medicare enroll in a Medicare Advantage plan. Disenrollment from the Medicare Advantage plan takes effect the following month. Enrollment in a Stand Alone Prescription Drug Plan takes effect the first of the month after the plan receives the person’s enrollment form.

Special Enrollment Periods (SEP) allow people to enroll in Medicare Part D or Medicare Advantage Plans (Part C) or make changes to their plan participation outside of the standard enrollment periods in certain circumstances. Beneficiaries are granted SEPs when:

n They become dually eligible for Medicare and federally funded Medical Assistance (MA) or a Medicare Savings Program.

n They apply and are approved by the Social Security Administration for Extra Help paying Medicare Part D costs.

n They have a change in residence and move outside of their current plan’s service area.

n They have another change that is determined by the Centers for Medicare and Medicaid Services (CMS) to warrant a SEP.

People may choose how their Medicare services are provided. Once enrolled in Part A and/or Part B a person can choose to:

l Stay with Original Medicare for Parts A and B and enroll in a stand-alone Part D prescription drug plan.

l Enroll in a Medicare Advantage Health Plan (Part C) that covers Parts A, B and D.

n The Part C plan must provide all basic Medicare services but may add other services, may charge an additional premium and may alter the beneficiary cost-sharing from traditional fee-for-service Medicare.

l Enroll in a Medicare Advantage Health Plan (Part C) that covers Parts A and B; and enroll in a stand-alone Part D prescription drug plan.

l Remain covered under an employer-provided health insurance plan with creditable drug coverage. The beneficiary should contact SSA to enroll in Part A and to decline Parts B and D since most people are automatically enrolled in Parts A and B. Once employer coverage ends, beneficiaries have a special enrollment period in which to enroll in Parts B and D without a penalty.

To receive a payment under Original Medicare, doctors, other health care providers, and suppliers of health care equipment and supplies must meet certain conditions of participation and must sign a participation agreement that says they accept assignment.

l Providers who accept assignment agree to only charge the beneficiary the Medicare deductible or coinsurance amount, and to wait for Medicare to pay its share.

l Providers who do not accept assignment may charge the beneficiary up to 15% over the Medicare-approved cost for a service and may require the beneficiary to pay the entire charge at the time of service. The beneficiary must then submit a claim to get reimbursed from Medicare.

A person enrolled in Original Medicare Parts A and B may purchase a policy in the private insurance market that covers the person’s Medicare cost-sharing. This policy is known as a Medigap (Medicare Supplement Insurance) policy. It will cover the ”gap” expenses not covered by Medicare such as the co-insurance and deductibles. Medigap policies cannot be sold to people enrolled in Medicare Advantage Plans and cannot be used to pay Medicare Advantage Plan cost-sharing.

l Medigap policies only pay the cost-sharing on Medicare-covered services, not Medicare premiums.

l Beneficiaries have six months from the date of their Medicare enrollment to select a plan. After the six months, plans can deny coverage due to health status.

Note: Medicare enrollees who purchased a Medigap policy with creditable drug coverage prior to January 1, 2006, can keep this coverage and not enroll in Part D. Medigap policies cannot offer drug coverage after this date.

People who need more information about Medicare should call the toll free numbers below or visit the websites listed:

n Designated by the Centers for Medicare and Medicaid Services (CMS) to be the State Health Insurance Assistance Program (SHIP) for Minnesota. Free phone and in-person assistance is available in all 87 counties.

Chapter 04 - Social Security Administration (SSA) Benefits	Effective: February 1, 2011
04.40 - Medicare	Archived: June 1, 2016 (Previous Versions)