CMS Proposed Rule to Medicare Coverage Waiting Periods

The Centers for Medicare & Medicaid Services recently proposed a rule change that would affect the current Medicare coverage waiting periods. Currently, the rules are pretty reasonable, but these new changes could be a quality improvement for Medicare beneficiaries that fall into certain categories.

Eligibility for the Medicare Program

To be eligible for the Medicare program you must either be 65 years old or older. The exceptions to getting Medicare under 65 are if you are disabled for more than two years, or have certain medical conditions.

Medicare health insurance is a federal government health care program put in place to help cover our retired Americans.

Many receive Medicare A at no cost due to paying their Medicare tax for at least 10 years, or 40 quarters. if you didn’t work, but have a spouse that did meet the requirements you’ll qualify for premium-free Part A also.

Medicare Part B has a standard premium that most Medicare beneficiaries will be required to pay a part B premium.

Current Medicare Medicare Coverage Waiting Periods

When you become eligible for Medicare, you begin your Initial Enrollment Period. This enrollment period continues for 3 months after your month of eligibility, usually the month of your 65th birthday.

With the current rules, if you enroll in Medicare before the end of your birth month your Medicare will begin the month after without any delays.

But if you miss that window and don’t enroll until the month after you will have a month with no coverage before it begins. If you want until the second or third month after your month of legibility, your coverage will not start for two months.

For most Americans, this isn’t an issue. Most will begin their enrollment into Medicare 3 months prior to their 65th birthday ensuring the coverage will begin on the first day of their birthday month.

There are currently two other enrollment periods with regard to traditional Medicare. General Enrollment Period and the Special Enrollment Period.

The General Enrollment Period starts on January 1st and continues to March 31st Annually. When Medicare beneficiaries enroll using the GEP their coverage will start on July 1st.

The Special Enrollment period allows Medicare beneficiaries eight months to start Medicare after leaving a group health plan or creditable employer coverage. This start date is usually the month after you apply for Medicare.

Changes to Medicare Coverage Waiting Periods

These proposed changes would help Medicare enrolls by adjusting when the dates of coverage would begin in certain situations.

Initial Enrollment Period

Medicare beneficiaries using their Initial Enrollment Period would no longer have to wait for coverage to start if they enroll within the three months after their birth month. Instead, the Medicare coverage will begin the immediate month after.

General Enrollment Period

If approved implementing these rule changes would allow enrollees to start their health coverage the month after they enroll during the GEP.

For example, since the GEP runs from January 1st to March 31st, and with the new changes, you wouldn’t have to wait until July for coverage to begin.

Instead, the coverage would start at the beginning of the next month. if you enrolled in January, coverage would start on February 1st and so on.

Special Enrollment Periods

The proposal also aims to add 5 additional Special Enrollment Periods. This would be the first time there have ever been changes or additions to SEPs.

SEP for Individuals Impacted by an Emergency or Disaster

This SEP would be for beneficiaries that are not able to enroll in Medicare Part A, Part B, or both if they reside or resided in an area where the Federal, state, or local government declared a new emergency or disaster. You must show that you live or lived in the area affected when the declaration was enacted.

SEP for Health Plan or Employer Misrepresentation or Providing Incorrect Information

If you’re provided incorrect information by a health plan, or employer you would qualify for a SEP that begins the day you notify the Social Security Administration and would continue for two months.

SEP for individuals serving as volunteers outside the United States at the time they first become eligible for Medicare

For people that are serving outside of the United States and covered through health insurance coverage while serving with the non-profit for at least a 12-month period.

SEP for Formerly Incarcerated Individuals

Recently incarcerated beneficiaries would gain a SEP that allows them to enroll from the day they are released and continues for six months.

SEP to Coordinate with Termination of Medicaid Coverage

This SEP would start when you receive notice that you’re losing Medicaid eligibility. The SEP would continue for 6 months after the termination of eligibility from Medicaid programs. There are many low-income beneficiaries that will benefit from this SEP.

SEP for Other Exceptional Conditions

For this SEP to apply the beneficiary must be able to prove two conditions. First, an individual must show that reasons outside of their control caused them to miss an enrollment period. Second, the condition must be considered exceptional. The time limit of this SEP would be on a case by cases basis.

FAQs

How long do new beneficiaries currently wait to gain Medicare coverage after enrolling?

It depends on when they Enroll. If they enroll prior to the month of their 65th birthday it will start on the first of that month. When you wait until after the birthday month, they will have to wait an additional month for coverage to begin. If they enroll the second or third month after, they will have a two-month wait before coverage begins.

How long would beneficiaries have to wait to gain Medicare coverage if these new rules took effect?

What are special enrollment periods? (SEPs)

A special enrollment period is a one-time exception to allow you to enroll in Medicare outside of a normal enrollment period. Currently, there is only one SEP that occurs once you leave group or employer coverage. The new proposal would add five more.

What is the Medicare lock-in period?

The Medicare lock-in period refers to Medicare Advantage plans and Medicare Part D prescription drug coverage. The lock-in period runs from April 1st to October 14th.

What is initial enrollment for Part C and D?

The initial Enrollment starts three months before your Medicare eligibility dates and continues three months after. During this time you can enroll in the Medicare Part C or Part D drug plan of your choice.

How long should we wait after Medicare is active?

You should make a decision on additional coverage right away.

How long until Medicare is approved?

Medicare typically takes two to four weeks to approve your application.

What is CMS’s proposed rule?

The proposed rule will make starting your Medicare quicker and allow more people to enroll outside of the Initial Enrollment Period and General Enrollment period.

When does the CMS rule go into effect?

If approved the new rules would go into effect on January 1st, 2023.

Get Help Understanding Medicare Coverage Waiting Periods

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We can help with education, advice, comparing plan options, and even checking your drugs and doctor to ensure you have the plan that’s best for you.

With a quick phone call, we can guide you through any part of the process. Call us today or fill out our online request form. We’re happy to help.

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