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A Crash Course on Medicare’s Eligibility Requirements

A Crash Course on Medicare’s Eligibility Requirements

Medicare is a complex health insurance program. This suite of courses from VTR Learning builds a solid foundation for professionals who deal with Medicare issues in the workplace.

This introductory course teaches learners the basics of Medicare Parts A, B and C, as well as other options such as Medigap coverage. It is pre-approved for SHRM, HRCI and NASBA credit. The course also includes supplemental fact sheets that are downloadable to most devices.

Medicare Basics

Medicare is health insurance for people age 65 or older. Some people who are younger can also qualify if they receive disability benefits from the Social Security Administration or Railroad Retirement Board and have been receiving them for 24 months, have End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant), or have Amyotrophic Lateral Sclerosis (ALS).

There are four parts of Medicare: Part A, Part B, Part C and Part D. These cover hospital care, doctor visits, prescriptions and more. Medicare Advantage plans offer additional coverage options, like vision and hearing aids. There are also special programs that help pay the cost of premiums and co-pays for those who need it. Not only that, it’s imperative that you know the existence of the CA Medigap birthday rule.

To qualify for Medicare, a person must be 65 or older and have paid into the system through payroll taxes for a certain amount of time. For most, this means paying into Medicare for at least 10 years. However, some people can also get Medicare if they:

Once someone meets the above criteria, they can sign up during their Initial Enrollment Period for Parts A and B. The IEP is the three months before, the month of and the three months after a person turns 65. People can also enroll during a Special Enrollment Period (SEP) for Parts B and C. If they were covered by a group health plan during that time, the SEP begins the month their employment ends or their current employer’s group health plan coverage ends, whichever comes first. They can also enroll during the Annual Election Period from October 15 to December 7 for coverage that starts on January 1 of the following year. This is a good opportunity to compare Medicare Advantage and Supplement plans that best fit their needs. eHealth provides comprehensive, accurate and up-to-date information about Medicare coverage. Our content is compliant with CMS regulations, ensuring you’re getting the right information to make the best Medicare decisions for your lifestyle and budget. Learn more about our Medicare Compliance Program. We’re here to help you navigate the complex world of Medicare.

Medicare Options & Coverage Rules

There are many different Medicare options, including Medicare Advantage plans (private insurance alternatives to Original Medicare), and Medigap supplemental insurance policies that pay for costs not covered by Medicare Parts A and B. Generally, you must be enrolled in both parts of Original Medicare to enroll in either of these options. You can enroll during your seven-month Initial Coverage Election Period, which starts three months before you turn 65, includes the month of your birthday and continues for three months afterward. You can also sign up during the General Enrollment Period, which occurs from January through March each year.

During this enrollment period, you can choose your Medicare Advantage or Medigap plan for the following year. If you don’t choose a plan during this time, you can still enroll in a new Medicare Advantage or Medigap plan during the Annual Enrollment Period, which happens each fall from October 15 to December 7.

You can also use an exception to the General Enrollment Period to get Medicare, if you have a special circumstance. This can include if you’re an active member of the military or Foreign Service employee, an individual with certain health conditions, or if your employer or union has group Medicare coverage. Individuals whose Medicaid eligibility terminated because of an incarceration may also enroll during this time. They can choose a coverage start date up to six months earlier than their release date from jail or prison and will be responsible for paying all prior premiums.

In addition to deciding what type of Medicare you want, you will need to decide how it interacts with any other health insurance that you have or will have. You can find a lot of information on this online, and it’s important to understand how your choices will affect each other.

Typically, you will need to have minimum essential health coverage in order to avoid penalty fees from the federal government for not having it. You can find more information on what counts as this coverage, as well as how it interacts with Medicare, on our Medicare & Other Coverage page.

Medicare: Appeals & Penalties

Depending on the situation, you may be able to appeal Medicare’s decision to deny coverage or add costs. There are five levels of Medicare appeals. It’s important to keep records and documentation as you move through the process, and to follow any instructions or deadlines that you receive.

There are several reasons that you might want to file an appeal, including:

You’re being discharged from a hospital sooner than you think is medically appropriate. You’re being denied a service you think you need, such as an MRI. You’re being charged a late enrollment penalty for Part D that you think is inaccurate. You have a Medicare Advantage plan and you think that your insurer is wrong about the cost of a service or item that you’ve received from another provider.

If you don’t agree with the decision at level 1 of the appeals process, you can move on to level 2. At this point, you’ll request a reconsideration hearing with an ALJ, or administrative law judge. You’ll submit new documentation to support your case and provide more information that you didn’t include in your original appeal.

In some cases, your doctor’s billing privileges may be revoked by CMS if they don’t meet certain requirements. If you have Medicare Advantage, your plan may be able to take on the responsibility for paying your claims, but if you have traditional Medicare, you can’t.

The next step in the appeals process is to request a review of the ALJ’s decision at level 3. At this stage, you can ask for a hearing with the Departmental Appeals Board (DAB). At this level, you can also seek judicial review, which means filing a civil lawsuit in federal court.

In some situations, you may be able to appeal a decision that’s been made by CMS or your Medicare Advantage plan. For example, you can use a Medicare appeals form to file an appeal if you’ve been charged a late enrollment penalty because you didn’t enroll in a Part D prescription drug plan during your initial enrollment period. This form is available here.

Medicare: Other Insurance and Assistance Programs

Medicare plays a vital role in the health and financial security of 60 million Americans. It pays for many basic health services, such as hospital stays, physician services and prescription drugs. However, it doesn’t cover everything. That’s why millions of people choose to enroll in private Medicare Advantage plans, also known as Part C, which offer an array of health plan options including HMOs and PPOs, or buy Medigap supplemental insurance policies.

The Centers for Medicare & Medicaid Services (CMS) administers Medicare, which is funded in part by Social Security and Medicare payroll taxes and part through premiums paid by those enrolled. Medicare is free for most people ages 65 and older, or under age 65 with certain disabilities or end-stage renal disease that requires dialysis or a kidney transplant. It’s a federal program, and the individual states provide assistance with the cost of the Medicare Part A premiums and co-payments for some beneficiaries.

People who are newly eligible for Medicare receive a General Enrollment Period between January 1 and March 31 of the year they turn 65. They can choose either Premium Part A or Medicare Advantage. If they choose Medicare Advantage, the plan they join must limit their out-of-pocket spending in certain ways, but they can still enroll in a stand-alone Part D plan.

In addition, some Medicare beneficiaries may qualify for help paying their premiums and out-of-pocket costs through the Medicaid program administered by each state. Some beneficiaries with limited income and resources can even get both Medicare and Medicaid benefits.

Unlike Original Medicare, which includes both parts A and B, some private Medicare Advantage plans are required to limit the amount of money beneficiaries pay out-of-pocket for medically necessary services, such as doctor visits or hospital stays. Medicare Advantage plans can also cover a wider variety of services, including dental and vision care.

In 2019, there are a growing number of proposals calling for “Medicare for All,” or universal health coverage that would replace private Medicare with a single government-funded program. While there are many variations on the proposal, all versions call for nearly all American citizens to have access to basic health coverage.