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Eligibility and Enrollment

In This Article:

• Part B General Enrollment Period and Part D
• Patient Assistance Program Tip Sheet

Part B General Enrollment Period and Part D

Who might not have Part B coverage?
Some people who are eligible for Medicare Part B don’t have it because they declined that coverage when they first became eligible for Medicare. They break down into two groups.

• People With Health Insurance Though Active Employment

  Medicare-eligible people who are currently employed and covered by employer group health insurance, along with their spouses and other Medicare-eligible dependents, can delay Part B enrollment until their retirement without facing higher premiums.

  What happens if these people want to sign up for Part B later on? They have a Special Enrollment Period (SEP) to enroll in Part B when they – or their spouses – retire or lose their health insurance. That SEP lasts for eight months after their employer group health insurance ends.

• Any Other Medicare Eligible Person Who Declines Part B

  For anyone not covered by employment-related health insurance who declined Part B when they were initially eligible to enroll, there are severe penalties. These include not only a lack of coverage for all of the diagnostic, treatment, and preventive services covered by Part B, but also a 10 percent premium penalty for each full year that they were not enrolled in Part B.

  So if you were eligible for Medicare at age 65 but didn’t sign up until you were 72, you would pay a 70% premium penalty (7 years x 10% per year). If you signed up in 2009, your monthly premium would be $163.88 -- $96.40 (the current Part B monthly premium) + $67.48 (70% of $96.40).

• But Can These Beneficiaries Still Get Part B Later On?

  Every year, there is a General Enrollment Period from January through March 31st during which people who don’t have Part B and are not covered by employer group health insurance can sign up for Part B. So anyone who doesn’t have Part B and isn’t covered by an employer health plan should think carefully about signing up before March 31st to limit his or her future premium penalty and to get Part B coverage.

  Part B goes into effect on July 1st for anyone who signs up during the General Enrollment Period. After March 31, 2009, most people without Part B would have to wait for the 2010 General Enrollment Period.

• So How Does This Relate to Part D?

  There is a related Part D Special Enrollment Period, lasting from April through June of each year, that allows people who enrolled in Part B during the General Enrollment Period to make one election to join a Part D plan. For more details on this Part D Special Enrollment Period, see the article in the About the Part D Benefit library about Special Enrollment Periods.
  
  

• What Happens to People Who Cannot Afford Part B Premiums?

  The Medicare Savings Programs pay Part B premiums for beneficiaries whose finances are limited, (income of up to 135 percent of the Federal Poverty Level, or $1,218 and resources of $4000 or less if single and $1,639 in income and resources of $6,000 if married). There is also a $20 income disregard for unearned income such as Social Security. See more information about these very important programs that help low-income beneficiaries to get and use Medicare.

  BenefitsCheckUp provides an easy way to find and submit Medicare Savings Program applications for every state in the U.S.

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Patient Assistance Program Tip Sheet

Helpful Hints*:

• Find out whether a PAP is offered by the manufacturers of specific medications.
• Search manufacturers’ requirements regarding PAPs.
• For many applications for PAPs, visit BenefitsCheckUp and click on “Apply for Benefits.”
• By answering a few questions, you can screen your clients for extra help, State Pharmacy Assistance Programs, and PAPs. Visit BenefitsCheckUp and click on “Find More Benefits Programs” and then “Prescription Drug Assistance” to get started.
• Through a toll-free number (1-888-4PPA-NOW) and Web site (www.pparx.org), the Partnership for Prescription Assistance provides a single point of access to more than 475 public and private patient assistance programs that could offer help on more than 2,500 prescription medicines.
• As some PAPs require a Low Income Subsidy (LIS) denial letter before helping Medicare beneficiaries, consider advising Part D enrollees who might need PAP assistance to apply for LIS. While getting an LIS denial letter may create work and may delay the process, patients may qualify for LIS and in any event it might be the best strategy in the long run.
• It might take some time for a PAP application to be processed and medicine to be sent out. Many PAP programs have medicines sent to the patient's home or the physician's office, or the medicine may be available at the pharmacy.– Each PAP is different.
• Remember that applications generally need prescriber information and a signature.
• When PAP eligibility is denied, the applicant may be able to submit an appeal. While there is no single standard appeals process, the American Society of Health Systems Pharmacists advises that:
  • Companies may accept an appeal letter or a letter of medical necessity from the physician that accompanies the application explaining the extenuating circumstances of the financial hardship that purchasing their needed medication would cause. These are considered on a case by case basis.
  • See some steps you can take in connection with an appeal.

*The links provided will take you to sites maintained by third parties who are solely responsible for their web site’s contents. My Medicare Matters provides these sites as a service and makes no representations regarding the sites. My Medicare Matters is not responsible for the Privacy Policy of any third party web sites. We encourage you to read the privacy policy of every web site you visit.

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