This searchable page features questions commonly asked during ACE TA Center webinars on Medicare. FAQs and answers are arranged into six categories:
- Medicare Costs and Coverage
- Eligibility and Enrollment
- Transitioning from Marketplace or Employer Insurance, Deferring Enrollment, and Penalties
- Social Security - Work Credits and Disability
- Financial Assistance
- Medicare-Medicaid Dual Eligibility
Frequently Asked Questions
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Medicare Costs and Coverage
It depends. Each client should be assessed individually, as the answer depends on the client’s unique life circumstances, the assistance that RWHAP and ADAP provides in the client’s state, Medicare Advantage and Medigap plan availability, and the eligibility criteria for financial assistance programs such as Medicare Savings Programs in the area.
Medicare-eligible clients should first compare the pros and cons (including costs, coverage, and provider networks) of Original Medicare vs. Medicare Advantage plans in the area. If the client opts for Original Medicare, they should consider adding on a Medigap policy and Medicare Part D prescription drug coverage.
After enrolling in Medicare coverage (Original Medicare or Medicare Advantage), the client should review the eligibility criteria for additional financial assistance programs, including but not limited to:
- State Medicaid programs
- Program of All-Inclusive Care for the Elderly (PACE)
- State-administered Medicare Savings Programs
- The federal Extra Help program (i.e. the Part D Low Income Subsidy)
- State-administered State Pharmaceutical Assistance Programs (SPAPs)
- Locally available Pharmaceutical Assistance Programs (PAPs) to reduce the cost of specific brand-name medications
Case managers should also stay up-to-date on the RWHAP and ADAP policies in their jurisdiction, including allowable costs and payor of last resort requirements.
While all Medicare Part D plans must cover all HIV antiretroviral therapy (ART) medications, different Medicare Part D plans have different cost-sharing requirements for ARTs. Clients should look at each plan in their area to see which one makes the most sense for their needs. CMS has a Medicare Plan Finder Tool that clients and case managers can use to compare options. Clients can enter all their medications and see which are covered and which have copays. Remember, RWHAP clients’ copays for HIV medications can be covered by ADAP.
Yes. ADAP assistance to help clients pay for Medicare Part D copays and coinsurance counts towards Medicare true out-of-pocket (TrOOP) costs. This will help clients get through the “donut hole” phase of their Medicare Part D prescription drug coverage.
Yes, however, the cost-sharing requirements are different. When a Medicare enrollee is in the Medicare Part D prescription drug coverage “donut hole,” they are required to pay up to 25 percent of the costs of their prescription drugs (both brand name drugs and generics). These costs will count towards their out-of-pocket maximum. When they reach their out-of-pocket maximum, they will exit the “donut hole” and transition to the catastrophic coverage phase of Medicare Part D coverage. Find more information about costs in the coverage gap on the CMS website.
No. Medicare Part D is prescription drug coverage only. Medicare Advantage plans, also known as Medicare Part C, are Medicare plans that bundle (group together) Medicare Part A, Part B, and usually Part D coverage. If a client is enrolled in a Medicare Advantage plan that includes prescription drug coverage (Part D), they will not have to enroll in a separate Medicare Part D plan. If a client is enrolled in a Medicare Advantage plan that does not include prescription drug coverage, they can choose to enroll in a separate Medicare Part D plan for prescription drug coverage.
Medicare Advantage plans, also known as Medicare Part C, are Medicare plans that bundle (group together) Medicare Part A, Part B, and usually Part D coverage. Medicare Advantage plans are managed by a private insurance carrier (e.g. Aetna or Blue Cross Blue Shield), instead of CMS.
Medigap policies, also known as Medicare supplemental insurance plans, are optional add-ons for clients who have Original Medicare. Medigap policies help to cover some or all of the gaps in Medicare Parts A and B coverage but do not include prescription drug coverage.
Clients with Medicare Advantage plans cannot purchase Medigap policies.
Eligibility and Enrollment
Clients who lose Medicare Part D coverage because of nonpayment of premiums are able to re-enroll in the same plan or a new plan as long as they repay owed premiums and enroll during an Open Enrollment period. The client will also incur a late enrollment penalty for months without creditable coverage.
Yes. Individuals who qualify for the Extra Help program can join, switch, or drop their Medicare drug plans once per quarter for the first three quarters of the year (January - March, April - June, or July - September). Any changes made will be effective the first day of the following month.
All Medicare enrollees can make changes to their Medicare health or drug coverage during the Medicare Open Enrollment period, which takes place from October 15 - December 7 every year. Any changes made during this period will take effect on January 1 the following year.
Medicare enrollment is not mandatory. Individuals who qualify for Medicare can choose not to enroll in coverage. However, keep in mind that if an individual chooses to enroll after initial eligibility, they may have incurred late enrollment penalties. The amount of these penalties increases the longer enrollment is delayed. For this reason, it is strongly recommended that individuals enroll in Medicare when they first become eligible.
Depending on a person’s age and the kind of health coverage they have, there may be certain times of year that they can sign up for a Medigap plan. A person can also sign up for Medigap when they first enroll in a Medicare Part B plan. If you think Medigap is a good option for your client, review this resource: When Can I Buy Medigap.
Medicare enrollment assistance can be found through the State Health Insurance Assistance Program (SHIP). SHIPs are available in all 50 states, Washington D.C, Puerto Rico, Guam, and the U.S. Virgin Islands.
Supplemental Medigap plans are sold by private insurance companies. Medicare.gov has a tool to help you find one in your area, but you must purchase Medigap plans directly from the insurer. In most states, you’ll find that Medigap policies are named by letters (ex: Medigap Plan F or Medigap Plan G). If you live in Massachusetts, Minnesota, or Wisconsin, Medigap plans have different names that are not letter-based.
Typically, no. Individuals who are eligible for Medicare (and who may already be enrolled in Medicare Parts A and B) are not automatically enrolled into a Medicare Advantage plan. If the client prefers Medicare Advantage, they must elect to enroll during the Medicare Advantage Open Enrollment Period.
In some states, some individuals who are dually eligible for both Medicare and Medicaid can be automatically enrolled into a specific type of Medicare Advantage plan called a Dual Eligible Special Needs Plan (D-SNP), but that is not the general policy for the majority of Medicare-only enrollees.
Depending on what type of Medicare coverage your client is already enrolled in and what changes they want to make to their coverage, there are multiple times throughout the year that this is possible. Generally, a person can join, switch, or drop coverage without penalties or gaps in coverage if they do so during specific Open Enrollment periods or Special Enrollment Periods.
- From January 1 - March 31, a person can switch from one Medicare Advantage plan to another Medicare Advantage plan, or switch from Medicare Advantage to Original Medicare (Parts A and B) and join a Part D plan.
- From October 15 - December 7, a person can switch from Original Medicare to Medicare Advantage or vice versa, join a Medicare drug plan if they didn’t have one already, switch from one Medicare drug plan to another, or drop Medicare drug coverage completely, among other things.
The client can also call 1-800-MEDICARE or their Medicare Advantage plan to request disenrollment outside of the Open Enrollment period. Before moving from Medicare Advantage to Original Medicare, it is a good idea for clients to check with all of their health care providers to make sure that switching to Original Medicare won’t cause any disruptions in care.
Calendar months. The Medicare Initial Enrollment Period (IEP) is a seven (7) month period centered around an individual’s 65th birthday month. It includes the individual’s birthday month, the three (3) calendar months prior to the birthday month, and the three (3) calendar months after the birthday month. For this reason, the IEP is sometimes referred to as the “3-1-3” period. For example, if your birthday is on May 15, your Initial Enrollment Period would begin on February 1 and end on August 31. This includes the three (3) calendar months prior to your birthday (February, March, and April), your birthday month (May), and the three (3) calendar months after your birthday (June, July, and August).
Note: If your birthday is on the 1st of the month, your seven-month Initial Enrollment Period is distributed differently. It will include the four (4) calendar months before your birthday, your birthday month, and the two (2) calendar months after your birthday. Instead of a “3-1-3” distribution, it becomes a “4-1-2” distribution. For example, if your birthday is on May 1, your Initial Enrollment Period would begin on January 1 and end on July 31. This includes the four (4) calendar months prior to your birthday (January, February, March, and April), your birthday month (May), and the two (2) calendar months after your birthday (June and July).
No, but a person must be a US citizen or a legal resident for at least five years to qualify for Medicare, and they must meet one of the following criteria:
- Age 65 or older
- Under age 65 with a qualifying disability
- Have End Stage Renal Disease
Transitioning from Marketplace or Employer Insurance, Deferring Enrollment, and Penalties
If the client became eligible for Medicare Parts A and B before age 65, any late enrollment penalties they may have incurred (as a result of deferring Part B coverage) will automatically reset to $0 when they turn 65 and become eligible to enroll in Medicare again during their Initial Enrollment Period.
If the client became eligible for Medicare Parts A and B at age 65, they will likely face a Medicare Part B penalty if they choose Marketplace coverage instead of enrolling in Medicare when they first become eligible during their Initial Enrollment Period. They will be ineligible for Marketplace subsidies, such as Advance Premium Tax Credits (APTCs) and Cost Sharing Reductions (CSRs), which will increase their monthly premium amounts.
Yes, this is likely. Clients who lose their Medicare Part B coverage while incarcerated and re-enroll in Medicare after their release (but outside of their Initial Enrollment Period) will be charged a late enrollment penalty and will have to wait until a General Enrollment Period to enroll. However, some states allow incarcerated individuals to enroll in Medicare Savings Programs to help pay for Part B costs upon re-enrolling.
The Medicare Part B and Part D late enrollment penalties are lifetime penalties.
The Medicare Part B penalty is an additional 10% per 12-month period that an individual was eligible for Part B coverage but did not enroll, on top of the monthly Part B premium. This additional penalty amount must be paid monthly for as long as the individual has Medicare Part B coverage.
For example, if an individual was eligible for Medicare Part B but chose not to enroll in coverage for 2.5 years (30 months), they will have to pay an additional 20% (10% x 2, 12-month periods) on top of their monthly Part B premium for as long as they have Part B.
The Medicare Part D penalty is 1% of the national base beneficiary premium (a benchmark amount that changes annually) multiplied by the number of full, uncovered months that an individual was eligible for Medicare Part D but did not enroll or did not have creditable prescription drug coverage. This additional penalty (rounded to the nearest $0.10) must be paid monthly for as long as the individual has Medicare Part D coverage.
For example, if an individual was eligible for Medicare Part D but chose not to enroll or did not have other creditable prescription drug coverage for 17 months, they will have to pay 17% (1% x 17 full, uncovered months) of the national base beneficiary premium. In 2022, this number was $33.37, so the penalty is $5.70 (17% x $33.37, rounded to the nearest $0.10) on top of their monthly Part D premium for as long as they have Part D.
Yes. Having a late enrollment penalty for Medicare does not impact eligibility for Medicaid or the Medicare Savings Program.
Yes. Individuals who qualified for Medicare prior to age 65 (due to disability or having End Stage Renal Disease) will have all of their late enrollment penalties reset to $0 when they turn 65.
It depends. If a client cancels their Medicare Part D coverage, they will not be charged a penalty for re-enrolling at a later point - as long as they had creditable prescription drug coverage for the entire time they did not have Part D. If a client cancels their Medicare Part D coverage and did not have creditable prescription drug coverage, then they will be charged a penalty based on how many months they did not have creditable coverage.
Yes, but only if the employer has 20 or more employees. If your employer has fewer than 20 employees and therefore is not required to provide minimum essential coverage, then Medicare will likely not let you defer Medicare Part B enrollment without a penalty. If you are unsure, contact your employer’s Human Resources department as well as the Social Security Administration to see if you will face any penalties for staying on your specific employer-sponsored insurance plan.
If an individual is working past the age of 65, they can elect not to enroll in Medicare without incurring a penalty as long as their employer-sponsored insurance is considered minimum essential coverage. Once they retire and their employer insurance ends, they will have an eight-month Medicare Special Enrollment Period (SEP) in which to enroll in Medicare coverage with no penalties.
It is also possible for a person who is still working to defer Medicare Part B enrollment but sign up for premium-free Medicare Part A.
Yes. Federal rules allow for individuals who have enrolled in Medicare (either through an Initial Enrollment Period, Special Enrollment Period, or General Enrollment Period) and who are eligible for premium-free Part A* to stay enrolled in Marketplace coverage and continue to receive Marketplace subsidies until their Medicare coverage begins.
Once Medicare coverage begins:
- Individuals should contact the Marketplace immediately to terminate their coverage
- Individuals who remain enrolled in Marketplace coverage will no longer receive Marketplace subsidies and will be responsible for the full cost of coverage
- Individuals who continued to benefit from Marketplace subsidies after their Medicare coverage began will be asked to pay back those subsidies
*Note: Individuals who do not qualify for premium-free Medicare Part A are allowed to keep their Marketplace coverage and continue qualifying for Marketplace subsidies.
Generally no, unless the individual meets the criteria for the CMS equitable relief policy, which is specific to Medicare Part B late enrollment penalties.
To qualify for equitable relief, individuals must:
- Have attempted to actively enroll in Medicare Part B, and
- Provide documentation that “error, misrepresentation, or inaction of a federal worker or an agent of the federal government (such as an employee of the Social Security Administration, CMS, or a Medicare administrative contractor) resulted in late Part B enrollment.”
Certain time-limited equitable relief policies may also be available.
- CMS may provide a Medicare Special Enrollment Period (SEP) for individuals affected by a weather-related emergency or major disaster to enroll in Medicare Part B without incurring a late enrollment penalty.
- Currently, equitable relief is available to individuals who were unable to contact the Social Security Administration after January 1, 2022 to enroll in Medicare Part B during their Initial Enrollment Period or Special Enrollment Period. This time-limited policy is available through December 30, 2022.
In all other cases, individuals who did not actively attempt to enroll in Medicare and who chose to keep their Marketplace coverage instead will likely incur Medicare late enrollment penalties if they choose to enroll in Medicare coverage at a later point.
Yes. For detailed information on how to smoothly transition from Marketplace to Medicare and avoid gaps and overlaps in coverage, view this HealthCare.gov guide on Changing from Marketplace Health Insurance to Medicare and this ACE TA Center tool on Transitioning from Marketplace to Medicare Coverage for RWHAP Clients.
Yes, coverage options offered through the Marketplaces are considered “minimum essential coverage”, meaning that they meet the Affordable Care Act’s standards of affordability and comprehensiveness.
Individuals currently enrolled in Marketplace plans are not required to switch to Medicare when they become eligible, but they may face significant late penalties if they choose to enroll in Medicare later. For this reason, it is strongly recommended that Marketplace enrollees enroll in Medicare when they first become eligible.
Social Security - Work Credits and Disability
Generally, if a client qualified for Medicare via the SSDI disability pathway and subsequently loses their SSDI benefits, they will also lose Medicare coverage unless they also qualify on the basis of age (65 or older) or if they have End Stage Renal Disease (ESRD).
However, there are also a number of programs that support people receiving SSDI to engage in trial work periods while maintaining eligibility for SSDI benefits and Medicare. Even after a trial work period ends and a person loses their SSDI benefits, they may still be able to maintain Medicare coverage for a certain period of time.
There are many health conditions and impairments that the Social Security Administration (SSA) recognizes as qualifying disabilities (called listings). These include: musculoskeletal disorders, respiratory disorders, neurological disorders, mental disorders, immune system disorders, and more.
Individuals under age 65 can qualify for Medicare if they have a qualifying disability (as determined by the SSA) and have been receiving Social Security Disability Insurance (SSDI) benefits for at least 24 consecutive or non-consecutive months. Individuals with End Stage Renal Disease (ESRD) can qualify for Medicare at any age, without first having to receive SSDI benefits for 24 month.
Note: According to the SSA, a diagnosis of HIV alone is not considered a qualifying disability for the purposes of SSDI eligibility. Individuals with HIV can qualify for SSDI if they have either a serious HIV-related condition, a qualifying CD4 count, repeated hospitalizations, or repeated manifestations of HIV.
- Duke Law School: Fact Sheet on SSA HIV Disability Listings
- Social Security Administration: Disability Evaluation Under Social Security (Blue Book)
- Social Security Administration: HIV Listing #14.11
No, however individuals who have received 24 months of SSDI benefits will be automatically enrolled in Medicare Parts A and B when they begin receiving their 25th month of SSDI benefits. After auto-enrollment occurs, individuals can choose to keep or decline their coverage.
For Medicare Part A, individuals can:
- Keep their premium-free Medicare Part A coverage
- Decline their Medicare Part A coverage, withdraw their original Social Security application, and pay back all Social Security cash benefits
For Medicare Part B, individuals can:
- Keep their Medicare Part B coverage and pay a premium
- Decline Medicare Part B coverage and avoid a late enrollment penalty later if they have qualifying coverage
- Decline Medicare Part B coverage and pay a late enrollment penalty later if they do not have qualifying coverage
In such cases, it is advantageous for clients to enroll in one or more Medicare Parts (especially premium-free Part A) if the client needs or wants assistance with Medicare cost-sharing (through Medicare Savings Programs), prescription drug cost-sharing (through the Extra Help program), and behavioral health and/or long-term care costs.
Individuals receiving Social Security retirement benefits before age 65 (as early as age 62) will be automatically enrolled in Medicare when they turn 65.
Individuals under age 65 who are receiving Social Security Disability Insurance (SSDI) benefits will be automatically enrolled in Medicare when they receive their 25th month of SSDI benefits.
Individuals receiving Supplemental Security Income (SSI) benefits are not automatically eligible for Medicare coverage. If an individual receiving SSI also qualifies for Medicare due to:
- Age (65 or older): they may enroll in Medicare during their Initial Enrollment Period.
- Disability (receiving SSDI benefits for at least 24 months): they will be automatically enrolled in Medicare when they receive their 25th month of SSDI benefits.
- End Stage Renal Disease: they may enroll in Medicare immediately and may also be eligible for 12 months of retroactive Medicare coverage
Yes, individuals can continue to earn work credits past age 65 if they do not have enough (40 credits) to qualify for premium-free Medicare Part A. They may choose to enroll in Medicare Part A at age 65 but pay a premium for Part A coverage until they have earned 40 credits. Medicare Part A premium amounts vary depending on how many credits the individual has earned.
No. The 40 work credits required to qualify for premium-free Medicare Part A do not have to be earned consecutively. Individuals can earn a maximum of 4 credits per year (one credit every three months) while working full time, so 40 credits is roughly equivalent to 10 years of full time work.
You can help your client create an account (or log in to an existing account) at https://www.ssa.gov/myaccount/ to check how many work credits they have accumulated in their lifetime, as well as what benefits they are eligible for.
It is very challenging for third party payors, such as RWHAP and ADAP, to pay for clients’ Medicare premiums after the premium amount has been automatically deducted from the client’s Social Security payment. As a result, for the vast majority of clients, this is not a cost that RWHAP and ADAP can pay due to the inability to coordinate with the Social Security Administration, even though it is an allowable cost that RWHAPs can pay for. This is a known issue that many RWHAPs across the country struggle with.
Many RWHAP clients who qualify for Medicare may also qualify for a Medicare Savings Program (MSP) on the basis of income. If you believe that your client meets the criteria for a MSP in your state, then you should help them apply for that program.
Medicare Savings Programs (MSPs) are state-administered programs that help certain low-income individuals pay for some or all of their Medicare costs. There are four types of MSPs, each of which have different income and asset eligibility criteria. States may offer one to four types of MSPs and may determine the specific income and asset limits for eligible residents. Contact your state Medicaid program, which administers MSPs, to see what MSP options are available in your state. If you believe that your client meets the criteria for an MSP in your state, then you should help them apply for that program. Many RWHAP clients who qualify for Medicare may qualify for an MSP on the basis of income. Some people who qualify for an MSP automatically qualify to get Extra Help to pay for their Medicare prescription drug coverage as well.
Yes, but keep in mind that HRSA HAB requires RWHAP recipients to “vigorously pursue” insurance for clients, including Medicare prescription drug coverage. RWHAP, including ADAP, is always available as a safety net, particularly for individuals who may have missed an open enrollment period. However, RWHAP, including ADAP, will only cover a person’s HIV care and provide medication coverage for a person’s HIV medications. RWHAP, including ADAP, is not comprehensive health coverage.
RWHAP funds may be used to pay for Medicare premiums and cost-sharing associated with Medicare Parts B, C, and D coverage, when doing so is determined to be cost-effective in the aggregate and includes coverage for both outpatient/ambulatory health services and prescription drug coverage that includes at least one drug in each class of core antiretroviral therapeutics. Review HRSA HAB Policy Clarification Notice (PCN) #18-01 for more details about Medicare costs payable by the RWHAP, and check with your local RWHAP as policies may differ by state or jurisdiction.
Medicare-Medicaid Dual Eligibility
Generally, yes. Dually eligible people get their prescription drug coverage through Medicare, either through a standalone Medicare Part D plan (added on to Original Medicare) or through a Medicare Advantage plan. All Medicare prescription drug plans must cover HIV medications, including antiretroviral treatments (ART). Some state Medicaid programs also provide coverage for outpatient prescription drugs.
If the client is interested in whether a specific medication is covered, especially non-HIV medications, they should contact their Medicare and Medicaid plan administrators and ask if it is covered by the plan’s formulary.
No. If an individual has Medicare coverage through a Medicare Advantage plan and Medicaid coverage through a Medicaid managed care plan, it is possible but not required for the Medicare Advantage plan and the Medicaid managed care plan to be administered by the same insurance company. There may be potential benefits to such an arrangement, such as having to contact only one insurance company instead of two. However, they will still have to navigate two separate sets of coverage and benefits, as well as billing requirements.
Note: This type of arrangement is not the same as enrolling in a single integrated care plan that is administered by one insurer, which provides a higher level of care coordination.
It depends. A person who is dually eligible and does not have access to an integrated care plan may benefit from enrolling in a Medicare Advantage plan (as well as their state Medicaid program) instead of Original Medicare if they:
- Anticipate needing extra benefits such as vision, dental, and hearing services that Original Medicare does not offer
- Have existing providers who are part of the Medicare Advantage plan’s network
- Do not anticipate needing health care when traveling outside of the country
Note: There are special types of Medicare Advantage plans, called Dual Eligible Special Needs Plans (D-SNPs), that are available only to dually eligible people. D-SNPs tailor their benefits, provider networks, and drug formularies to meet the unique needs of dually eligible people. D-SNP enrollees are not required to also enroll in their state Medicaid program, as Medicaid benefits are already included in the plan.