Medicare special enrollment after losing Medicaid
If a person is no longer eligible for Medicaid, they may qualify for a Medicare special enrollment period (SEP) to ensure continuity of coverage.
Medicaid is a joint state and federal program that provides health insurance to individuals with lower incomes.
Medicare is federal health insurance program for individuals ages 65 years and over and people with disabilities and certain chronic health conditions.
SEPs are Medicare enrollment periods that occur following life events that affect health insurance coverage. Situations like moving to a new state, losing employer-sponsored health insurance, and losing Medicaid coverage can all trigger an SEP.
SEPs differ from traditional Medicare enrollment periods, which occur between set dates each year. When a person is eligible for Medicare, it is important that they maintain creditable health insurance.
If they lose coverage and do not enroll in Medicare, they may be subject to a late enrollment penalty. One of the benefits of an SEP is that it allows people to avoid incurring late enrollment penalties.
There are two types of Medicare SEP for people who have lost Medicaid coverage. They vary based on whether a person signed up for Medicare when they were able.
The opportunity for most people to enroll in Medicare is the initial enrollment period (IEP). This is a 7-month window around the time of a person’s 65th birthday.
If a person already has health insurance, either through an employer or a program like Medicaid, they may skip their IEP and go without Medicare. Some individuals on lower incomes put off enrolling in Part B due to the monthly premium cost.
In this situation, a person who loses their Medicaid coverage would qualify for a 6-month SEP. During this period, they may enroll in Medicare Part A, Part B, or both.
A person can enroll by completing a form called CMS-10797 and sending it via mail or fax to their local Social Security office.
Alternatively, they may contact the Social Security Administration at 800-772-1213 (TTY: 800-325-0778).
If a person has both Medicaid and Medicare coverage, they may qualify for a 3-month SEP if they lose their Medicaid coverage.
This SEP begins on either the date the person’s Medicaid coverage ended or the date they were notified — whichever is later.
A person can make changes to their existing coverage by contacting Medicare or the insurance provider selling their desired plan.
Medicare representatives are available by phone 24/7 at 800-633-4227 (TTY: 877-486-2048).
People can view the Medicare plans available in their area on Medicare.gov.
Some dually eligible individuals do not receive full Medicaid benefits but instead qualify for assistance with their out-of-pocket Medicare expenses through a Medicare savings program (MSP).
Medicare beneficiaries can apply for an MSP with their state and renew their coverage each year. If a person no longer meets the eligibility criteria, they will not be able to renew their MSP coverage.
In this case, they will not require an SEP, as they will already have Medicare coverage. Since Medicaid is managed by individual states, the rules can differ slightly. To learn more about MSPs, a person can visit their state’s Medicaid site.
If someone is no longer eligible for Medicaid, they may qualify for a Medicare special enrollment period (SEP).
The length of the enrollment period and the enrollment options will vary based on whether the person with Medicaid missed their Medicare initial enrollment period (IEP).
If so, they will get a 6-month SEP to enroll in Original Medicare. Otherwise, they will get a 3-month SEP to modify their existing Medicare coverage.