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Medicare Case Studies

Updated over 2 weeks ago

Review these case studies to determine what to do in these unique situations.

Level: Easy

Turning 65 Medigap Enrollment

About Paul

  • Paul will be turning 65 next month. He’s very active and enjoys running and swimming. He’s kept himself in great shape, but knows that could easily change as he ages. Paul wants to get a Medicare Supplement to cover expensed Original Medicare will not.

  • He does not take any medications so does not think a drug plan is a good idea. He’s not on a specific budget and would like the ‘best’ plan available to him. He’s heard a lot about a plan that covers all costs including his Part A and Part B deductibles, and prefers that one.

Key Questions

  • Can Paul enroll in a Medigap Plan without enrolling in a prescription drug plan?

  • Will Paul be able to enroll in the plan that pays for his deductibles?

Answers

  • Yes, Paul can enroll in a Medigap Plan without enrolling in a prescription drug plan, but he may be subject to a late enrollment penalty if he does not have other creditable prescription drug coverage.

  • No, Paul does not meet the criteria to enroll in Plan C or Plan F. However, he can enroll in Plan G, which covers the Part A deductible but not Part B.

Switching from Original Medicare to a Medicare Advantage Plan

About Johnathan

  • Johnathan stays close to home and does not travel much. He sees his trusted Primary Care Physician several times a year, as well as specialists referred by his PCP. He takes several medications monthly and receives partial LIS (Extra Help). He wears glasses, has dentures, and is often taken to and from appointments by family or friends.

  • He hopes to find an advertised plan that will help cover the costs of his medications while adding supplemental benefits he's currently not receiving with Original Medicare.

Key Questions

  • Can Johnathan switch from Original Medicare to an MAPD?

  • Will Johnathan have to find a new Primary Care Physician?

  • Can he get a plan that includes rides to his doctor's visits or is that only provided through Medicaid and other state programs?

Answers

  • Yes, Johnathan can switch from Original Medicare to a Medicare Advantage plan during AEP (October 15 - December 7), or if he meets eligibility for a Special Election Period (SEP).

  • No, Johnathan may not have to find a new provider. You should use your Provider Search tool in the Spark Engagement Platform to find a plan his provider accepts.

  • Yes, he may be able to get a plan that includes transportation to and from doctor's visits and other plan-approved places.

Level: Medium

Delaying Part B Enrollment

About Arturo

  • Arturo turned 65 three years ago and decided not to enroll in Medicare Part B during his Initial Enrollment Period (IEP) because he was covered by his employer’s group health insurance.

  • He is 68 now and is retiring from his job at the end of the month. As a result, he is losing his coverage through his employer and wants to enroll in Part B. He had read that enrolling late in Part B will result in coverage gaps and penalties.

Key questions

  • Can Arturo enroll in Part B?

  • Will he have to pay a late enrollment penalty?

  • Will he face gaps in coverage?

Answers

  • Yes, Arturo can enroll in Part B. He will not have to pay a late enrollment penalty or face gaps in coverage.

  • Arturo has a Special Enrollment Period (SEP). SEPs are periods of time outside of normal enrollment periods that are triggered by specific circumstances. In Arturo’s case, he is eligible for a Part B SEP.

  • The Part B SEP is the time during which you can enroll in Medicare Part B without penalty or waiting for the General Enrollment Period (GEP). The Part B SEP starts when you have coverage from your current work (job-based insurance) and you are in your first month of eligibility for Part B. It ends eight months after you lose coverage from your current employment, because the employment or insurance ends. In order to qualify for the Part B SEP, two criteria must be met:

    • You must have insurance from your current work (from your job or your spouse’s job) or have had such insurance within the past eight months.

    • You must have been continuously (no gap longer than eight months) covered by job-based insurance or Medicare Part B since becoming eligible for Medicare, including the first month you became eligible for Medicare.

Using LIS for prescriptions

About Francine

  • Francine just turned 65 and aged into Medicare.

  • She takes several medications costing thousands of dollars monthly. She was enrolled in Medicare Parts A and B and was auto-enrolled in a prescription drug plan because she applied for and was granted Extra Help.

  • She’d like to start taking her Social Security benefit in order to afford a Med Supp, which she could use; however, this could cause her to lose her Extra Help eligibility.

Key Questions

  • What should you recommend she do?

  • Does Francine qualify for Medicaid?

Answers

  • If Francine qualifies for Medicaid, she may also be eligible for a Dual Eligible Special Needs Plan.

  • You could help her set up and prepare for an appointment with a Medicaid caseworker.

  • You could also check if she’s eligible for a State Pharmaceutical Assistance Program or any drug manufacturer rebates.

  • Make sure she understands the value of buying generic vs. brand-name prescriptions and using in-network or mail-order pharmacies that could lower costs substantially.

Switching from an MAPD to a Medicare Supplement plan before a surgery

About Cynthia

  • Cynthia needs hip surgery. She’s currently enrolled in a Medicare Advantage Prescription Drug plan (MAPD) and wants to switch to a Medicare Supplement (Medigap).

Key Questions

  • When’s the best time to write her into a plan?

  • Will she be able to enroll into a Medigap plan?

Answers

  • If Cynthia was told by her doctor that hip surgery would be required, she may not be able to pass medical underwriting until AFTER her surgery.

  • However, before jumping to that conclusion, check if she has a Guaranteed Issue Right (GI).

  • If there are no GI Rights available to Cynthia, the next best option would be to look at an MAPD with a low Maximum Out-of-pocket (MOOP).

Level: Hard

Qualifying for premium-free Part A

About Henrietta

  • Henrietta is turning 65 in a few months and wants to enroll in Medicare because she has no other insurance.

  • She has never worked in the U.S. and is worried about the costs. She knows that people who have fewer than 10 years of work history in the U.S. may owe a premium for Part A.

  • Her husband Edward is 58 and has worked in the U.S. for over 25 years.

Key Questions

  • Is Henrietta eligible to enroll in Medicare when she turns 65? Will she qualify for premium-free Part A?

  • What if Henrietta cannot afford the Part A premium?

Answers

  • Yes, Henrietta is eligible to enroll in Medicare when she turns 65. She can enroll starting three months before she turns 65, the beginning of her Initial Enrollment Period (IEP).

  • Although work history does not affect someone’s eligibility for Medicare, it does affect how much someone pays for the Part A premium. Based on her own work history, Henrietta does not qualify for premium-free Part A. However, she can use Edward’s work history to qualify for premium-free Part A once he is eligible for Social Security benefits. Edward will be eligible for Social Security benefits when he turns 62 or becomes eligible to receive Social Security Disability Insurance (SSDI). Until then, Henrietta will owe a premium for Part A. Note that Edward does not have to be collecting Social Security benefits in order for Henrietta to use his work history—he just has to be eligible for them.

  • To avoid possible late enrollment penalties and gaps in coverage, Henrietta should enroll in premium Part A and Part B during her IEP.

  • If Henrietta cannot afford the Part A premium, she may decide to enroll in Part B and wait to enroll in Part A until Edward is eligible for Social Security benefits. Before delaying premium Part A enrollment, Henrietta should carefully consider three things:

    1. Her need for Part A-covered services. Without Part A, Henrietta will not have coverage for services like inpatient hospital care or skilled nursing facility care. She will have to pay out of pocket for the cost of those services.

    2. Possible gap in coverage. If Henrietta wants or needs to enroll in premium Part A before she qualifies for premium-free Part A, she may have to use the General Enrollment Period (GEP) to enroll. The GEP runs January 1 through March 31 of each year, and coverage does not start until July 1 of that same year.

    3. Premium Part A late enrollment penalty. If Henrietta delays enrollment in premium Part A, she may have a late enrollment penalty if she decides to enroll later. The Part A penalty is 10% of the Part A premium after the first 12-month period that Henrietta did not enroll in premium Part A. It lasts for twice the number of years that Henrietta was eligible for premium Part A but did not sign up. Henrietta will not have a penalty when she becomes eligible for premium-free Part A.

    4. Note if Henrietta and Edward have limited income and assets, Henrietta may qualify for assistance to pay the Part A and/or B premiums through the Medicare Savings Program (MSPs).

From ACA to Medicare

About Joseph

  • Joseph is currently on a Marketplace plan and will be turning 65 in two months, making him eligible for Medicare.

Key Questions

  • Does becoming eligible for Medicare prevent him from keeping his Marketplace plan?

  • What should Joseph do to avoid paying costs incurred after this change?

Answers

  • Becoming eligible for Medicare does not prevent him from keeping his Marketplace plan but he will no longer be eligible for financial assistance through the Marketplace. Joseph will have to pay full-price for his Marketplace plan once he is enrolled in Medicare Part A.

  • Joseph should return to the Marketplace to update his information once he is enrolled in Medicare Part A.

  • Reporting this change will end his financial assistance and help prevent having to repay Advance Premium Tax Credit (APTC).

  • To avoid gaps in coverage, Joseph should not terminate his Marketplace plan before his Medicare coverage begins. Once Medicare coverage starts, he can then terminate his Marketplace plan.

  • If Joseph decides to enroll in Medicare, he may be able to enroll in a MAPD or Medigap policy, which may be appropriate if he thinks that Medicare Part A and B coverage is not adequate for his needs.

  • If Joseph decides to stay enrolled in an individual Marketplace plan and does not sign up for Medicare when he is first eligible, he may have to pay a late enrollment fee every month if he later decides to enroll in Medicare. You should review his Medicare Coverage Options with him.

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