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From the Initial Enrollment Period to the Annual Enrollment Period, you are advised on when you should sign up for Medicare. However, it is not always clear when those Medicare benefits actually begin. If you are not careful, there can be gaps in coverage that leave you without access to the care you need.
The Initial Enrollment Period (IEP) starts three months before the month you turn 65 and ends three months after you the month you turn 65 . This gives you seven months to sign up for Medicare without facing late penalties. That does not mean that your Medicare benefits will start at the same time as someone else.
When you sign up in the first three months of your IEP, Medicare coverage starts the month you turn 65. When you sign up in your birth month, benefits start the next month. However, you have to wait two months for coverage when you sign up one month after your birthday. You could be without coverage for three months if you wait to sign up two or three months after you turn 65. For most people, this applies only to Part B since Part A premiums are free for people who worked 40 quarters (10 years) in Medicare-taxed employment.
Even when you follow the rules and enroll during the IEP, you could face a significant gap in coverage. Thankfully, the Centers for Medicare and Medicaid Services has proposed a policy change to address this. This is based on the BENES Act that passed in late 2020. Starting on January 1, 2023, anyone signing up for Medicare in the last three months of their IEP will receive benefits the month after they enroll.
When you miss the IEP (based on age or disability), you have to wait until the General Enrollment Period (January 1 – March 31) to apply for Medicare. This could leave you waiting several months just for the opportunity to sign up. When you finally do enroll, benefits do not start until July 1 of that year. This could leave you without coverage for a minimum of three months but up to a year or longer in some cases.
Rather than punishing you twice for missing the IEP deadline, CMS is proposing that benefits start the month after you sign up. Like the IEP effective date changes, this stems from the BENES Act and will take effect starting on January 1, 2023.
Not everyone on Medicare is 65 or older. According to CMS, as many as 12.5% of Americans qualify for Medicare based on a disability or qualifying medical condition.
To qualify for Medicare, someone must first receive Social Security Disability Insurance (SSDI) or Railroad Retirement Board (RRB) disability benefits. The application process for these benefits can take time and there is a five-month waiting period from the time an application is approved to the time benefits are paid out. For most disabilities, Medicare coverage does not start until the 25th month of benefits.
Most people on Social Security Disability Insurance get Medicare coverage on their 25th month of SSDI benefits. However, because amyotrophic lateral sclerosis (ALS) is a rapidly progressive disease, Medicare benefits start the first month you receive SSDI benefits.
Also, people with ALS do not have a five-month waiting period for SSDI like other people with disabilities do.
People with end-stage renal disease (ESRD) need dialysis or a kidney transplant. Their Medicare benefits start on their fourth month of dialysis if they receive the treatment at a clinic, hospital, or medical office but could start on their first month of dialysis if they receive their treatments at home.
Alternatively, benefits can start right away when someone is admitted to a hospital for a kidney transplant and that transplant takes place within two months. If it takes longer than two months to get the transplant, Medicare coverage starts two months before the transplant is actually completed.
What makes ESRD coverage different from other types of Medicare coverage is that ESRD coverage has an end date. Benefits stop 12 months after dialysis treatments are discontinued or 36 months after a successful kidney transplant. The problem with the latter is that people need to take life-long immunosuppressive drugs to prevent their body from rejecting the transplant. Losing Medicare coverage could affect their ability to afford these necessary medications.
With this in mind, CMS is now proposing a new rule that will allow people with kidney transplants to hold onto some of their Part B benefits. Again, this proposal is based on legislation from the 2020 BENES Act. It is referred to as the Part B-ID benefit, the ID referring to immunosuppressive drugs.
Starting in October 2022 (with benefits starting January 1, 2023), people with kidney transplants who do not have other health coverage can sign up to cover those drug treatments. Part B-ID does not include other Part B benefits and as a result, the monthly premiums would be lower. That said, they could still qualify for a Medicare Savings Program to help keep costs down.
Not everyone signs up for Medicare during the IEP based on age. If you are still working and have a health plan through your employer (or your spouse does), you can wait to sign up but only if your employer has the equivalent of at least 20 full-time employees. When you (or your spouse) leave your job or the health plan, whichever happens first, you have eight months to sign up for Medicare. Your benefits start the month after you sign up. It’s important to understand how delays in signing up for Part B could affect your coverage.
If the COVID pandemic taught us anything, it’s that not everything is within our control. CMS understands that. That is why they are proposing a new set of Special Enrollment Periods to give you more options. If implemented, these new enrollment periods would decrease the number of people who face late penalties and would decrease gaps in care by allowing people to sign up right away, rather than waiting for the General Enrollment Period.
The proposal – also based on legislation from the BENES Act – takes a number of situations into consideration that could cause you to miss your IEP. They include emergencies and natural disasters (including pandemics), loss of Medicaid coverage, misleading information from your employer or health plan, and release from prison. It also allows Medicare to look into circumstances on a case-by-case basis.
Tanya Feke M.D. is a licensed, board-certified family physician. As a practicing primary care physician and an urgent care physician for nearly ten years, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization review and medical necessity compliance. She currently works as a physician advisor at R1 RCM, Inc., where she performs case reviews for hospitals nationwide.
Dr. Feke is an expert in the field, having Medicare experience on the frontlines with both patients and hospital systems. To educate the public about ongoing issues with the program, she authoredMedicare Essentials: A Physician Insider Reveals the Fine Print. She has been frequently referenced as a Medicare expert in the media and is a contributor to multiple online publications. As founder of Diagnosis Life, LLC, she also posts regular content about health and wellness to her site at diagnosislife.com.