AHIP Medicare - Module - 1, Original Medicare_ Eligibility, Enrollment, Entitlement, and Premiums

– 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.

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).

2. 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.

– 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.

– 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.

– 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.

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).

– 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

–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.

1. Emergency/Disaster SEP: For those affected by government-declared emergencies; enroll up to 6 months after the emergency ends.

2. Health Plan/Employer Error SEP: For individuals misled by employers or plans; enroll within 6 months of reporting the issue to Social Security.

3. Formerly Incarcerated SEP: Allows enrollment within 12 months of release; choose retroactive (up to 6 months) or future coverage.

4. Medicaid Termination SEP: For those losing Medicaid; enroll within 6 months, with optional retroactive coverage to the Medicaid end date.

5. Exceptional Conditions SEP: CMS may approve case-by-case SEPs (6 months) for circumstances beyond the person’s control.

6. Applies to Medicare Part B and premium Part A only.

7. Retroactive coverage requires payment of back premiums.

8. Aims to reduce penalties and coverage gaps.

9. Increases flexibility for unexpected life events.

10. Effective for enrollments beginning January 1, 2023, onward.

– 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).

Individual must:
- be entitled to Part A and enrolled in Part B; and
- reside in the MA plan’s service area.

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

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.

Individual must:
- be eligible for both Medicare and Medicaid;
- meet eligibility requirements specific to the state; and
- reside in the plan’s service area.

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.

Individuals eligible based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant, unless the individual is eligible for Medicare on another basis, such as age or disability. However, beginning in 2023, such individuals may remain enrolled in Part B only but solely for coverage of immunosuppressive drugs if they have no other health care coverage that would cover the drugs.

Most individuals are entitled to Part A without paying a premium.

– For individuals age 65 or older to be entitled to premium-free Part A, the individual or their spouse must have worked and paid Medicare taxes for at least 10 years; or
_ All individuals eligible for Medicare due to a disability, End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS) are eligible for premium-free Part A.

For those individuals who do not automatically qualify for premium-free Part A coverage, the monthly Part A premium in 2023 is:
- $506, for individuals or their spouses who paid Medicare taxes for less than 30 quarters.
- $278, for individuals or their spouses who paid Medicare taxes for 30-39 quarters.

– Individuals who are not eligible for premium-free Part A and those who don’t buy Part A when they are first eligible may pay a late penalty of up to 10% unless they enroll during a special enrollment period. (They will have to pay the higher premium for twice the number of years they could have had Part A but did not sign up.)

Beneficiaries enrolled in Part B must pay a monthly premium.

– In 2023, the standard monthly premium for Part B is $164.90. Most people pay the standard monthly premium. However, some people pay more based on their income (as reported to the IRS two years prior in 2021).

Individuals with incomes in 2021 over $97,000 or filing jointly with incomes over $194,000, pay more in 2023, up to $560.50 a month, based on the income-related monthly adjustment amount (IRMAA).

– Part B premiums may be deducted from Social Security checks, Railroad Retirement checks, or Office of Personnel Management (civil service annuity) checks If an individual does not get these checks, they will get a premium bill from Medicare every 3 months.

– Employer may pay monthly Part B premiums on behalf of retirees.

– For individuals who do not enroll in Part B when first eligible, the Part B premium is increased 10% for each full 12-month period the beneficiary could have had Part B but did not enroll. This is known as a “late enrollment penalty.”

Exception from Penalty: Individuals who have group health plan coverage based on their current employment or the employment of a spouse are not subject to the premium increase penalty if they enroll in Part B anytime while covered under the group health plan or during the special enrollment period that occurs during the 8-month period immediately following the last month they have group coverage. In addition, individuals enrolling during any other SEP are not subject to the penalty.