Medicare's Special Enrollment Period Helps People Losing Medicaid Access Health Insurance
As the unwinding of COVID-era Medicaid continuous coverage protections comes to a close, we want to remind readers about the availability of a Medicare Special Enrollment Period (SEP) for individuals who lose Medicaid and did not enroll in Medicare when they were first eligible. This SEP allows people to enroll in Medicare upon the loss of Medicaid coverage, even if it is outside of the annual Medicare enrollment period, as long as they otherwise qualify.
Many people who became eligible for Medicare between March 2020 and March 2023 did not enroll in Medicare when they were first eligible because they had Medicaid at the time. Recall that people who were on Medicaid at the start of the pandemic in March 2020 could not lose their coverage prior to March 2023 when the COVID-era continuous coverage protections ended. Beginning in April 2023, the state began reviewing eligibility for everyone on Medicaid, and people can now be terminated from Medicaid if they don't meet the eligibility rules.
Under the SEP, people who lose Medicaid coverage have six months from the date their Medicaid ends to enroll in Medicare without any late enrollment penalty. Those enrolling through this SEP have the option to choose when their Medicare coverage begins: either on the first day of the month following the month of enrollment, or retroactively back to the month they lost Medicaid. People who want retroactive coverage will be required to pay the monthly premiums for the prior months.
To invoke this SEP, individuals must complete form CMS-10797 and mail or fax it to their local Social Security office along with a copy of their Medicaid termination notice. It is important to keep proof of mailing or faxing and keep a copy of what is sent. If someone no longer has their Medicaid termination notice or any other documents showing the date their coverage ended, the Social Security office can contact Pennsylvania’s Department of Human Services to confirm when the person lost Medicaid coverage.
When using this SEP, individuals have a choice of when their Medicare coverage begins: either the first day of the month following the month of enrollment, or retroactive back to the month they lost Medicaid. People who want retroactive coverage must pay the premiums for the prior months of coverage.
Here is an example that illustrates how this SEP works: Sonia did not enroll in Medicare Part B when she was first eligible because she had Medicaid coverage at the time. In May, her Medicaid eligibility was reviewed, and the County Assistance Office determined that she was no longer eligible. She received a Medicaid termination notice letting her know that her coverage would end May 31st. In July, Sonia learns about the Medicare Part B SEP. She quickly fills out form CMS-10797 to enroll in Medicare Part B without penalty and attaches a copy of her Medicaid termination notice. Sonia must choose whether she wants her Medicare coverage to start August 1st, the first day of the month after enrollment, or June 1st, when her Medicaid ended. If she chooses June 1st, she will have to pay the Part B premium for June and July, in addition to paying the premiums for all future months.
This new SEP is permanent and not limited to the unwinding of the COVID-era eligibility protections. In the future, if someone delays enrolling in Medicare because they have Medicaid, they will be able to use this SEP to enroll in Medicare once they no longer qualify for Medicaid.
People who need help using this SEP to enroll in Medicare should call PA MEDI at 1-800-783-7067. People who already have Medicare can also contact PA MEDI for counseling about Medicare plan options after losing Medicaid. Individuals with questions about Medicaid eligibility or a Medicaid termination notice should contact PHLP’s Helpline at 1-800-274-3258
