Medicare Eligibility

Election

Your decision to join or leave the Original Medicare Plan or a Medicare+Choice plan.

Election Periods

Time when an eligible person may choose to join or leave the Original Medicare Plan or a Medicare+Choice plan. There are four types of election periods in which you may join and leave Medicare health plans: Annual Election Period, Initial Coverage Election Period, Special Election Period, and Open Enrollment Period.

  • Annual Election Period: The Annual Election Period is the month of November each year. Medicare health plans enroll eligible beneficiaries into available health plans during the month of November each year. Starting in 2002, this is the only time in which all Medicare+Choice health plans will be open and accepting new members.
     
  • Initial Coverage Election Period: The three months immediately before you are entitled to Medicare Part A and enrolled in Part B. If you choose to join a Medicare health plan during your Initial Coverage Election Period, the plan must accept you. The only time a plan can deny your enrollment during this period is when it has reached its member limit. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP).
     
  • Special Election Period: You are given a Special Election Period to change Medicare+Choice plans or to return to Original Medicare in certain situations, which include: You make a permanent move outside the service area, the Medicare+Choice organization breaks its contract with you or does not renew its contract with CMS; or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP).
     
  • Open Enrollment Period: If the Medicare health plan is open and accepting new members, you may join or enroll in it. If a health plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.
  • Eligibility/Medicare Part A

You are eligible for premium-free (no cost) Medicare Part A (Hospital Insurance) if:

  • You are 65 or older and you are receiving, or are eligible for, retirement benefits from Social Security or the Railroad Retrirement Board, or
     
  • You are under 65 and you have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or
     
  • You or your spouse had Medicare-covered government employment, or
     
  • You are under 65 and have End-Stage Renal Disease (ESRD).
  • If you are not eligible for premium-free Medicare Part A, you can buy Part A by paying a monthly premium if:
  • You are age 65 or older, and
     
  • You are enrolled in Part B, and
     
  • You are a resident of the United States, and are either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the 5 years immediately before the month in which you apply.
  • Eligibility/Medicare Part B

You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A, but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the 5 years immediately before the month during which you enroll in Part B.

Emergency Care

Care given for a medical emergency when you believe that your health is in serious danger when every second counts.

Employer Group Health Plan (GHP)

A GHP is a health plan that:

  • Gives health coverage to employees, former employees, and their families, and
     
  • Is from an employer or employee organization.
  • End-Stage Renal Disease (ESRD)*

Kidney failure that is severe enough to need lifetime dialysis or a kidney transplant.

Enroll

To join a health plan.

Enrollment Period

A certain period of time when you can join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open, it must allow all eligible people with Medicare to join.

Enrollment/Part A

There are four periods during which you can enroll in premium Part A: Initial Enrollment Period (IEP), General Enrollment Period (GEP), Special Enrollment Period (SEP), and Transfer Enrollment Period (TEP).

  • Initial Enrollment Period: The IEP is the first chance you have to enroll in premium Part A. Your IEP starts 3 months before you first meet all the eligibility requirements for Medicare and continues for 7 months.
     
  • General Enrollment Period: January 1 through March 31 of each year. Your premium Part A coverage is effective July 1 after the GEP in which you enroll.
     
  • Special Enrollment Period: The SEP is for people who did not take premium Part A during their IEP because you or your spouse currently work and have group health plan coverage through your current employer or union. You can sign up for premium Part A at any time you are covered under the Group Health Plan based on current employment. If the employment or group health coverage ends, you have 8 months to sign up. The 8 months start the month after the employment ends or the group health coverage ends, whichever comes first.
     
  • Transfer Enrollment Period: The TEP is for people age 65 or older who have Part B only and are enrolled in a Medicare managed care plan. You can sign up for premium Part A during any month in which you are enrolled in a Medicare managed care plan. If you leave the plan or if the plan coverage ends, you have 8 months to sign up. The 8 months start the month after the month you leave the plan or the plan coverage ends. If you enroll in Part B or Part A (if you don't get it automatically without paying a premium) during the GEP, your coverage starts on July 1. (See Enrollment.)
  • Episode of Care

The health care services given during a certain period of time, usually during a hospital stay.

Evidence

Signs that something is true or not true. Doctors can use published studies as evidence that a treatment works or does not work.

Excess Charges*

The difference between a doctor's or other health care provider's actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount. (See Actual Charge; Approved Amount; Medigap Policy.)

Exclusions (Medicare)

Items or services that Medicare does not cover, such as most prescription drugs, long-term care, and custodial care in a nursing or private home.

Expedited Appeal

A Medicare+Choice organization's second look at whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.

Expedited Organization Determination

A fast decision from the Medicare+Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.

Explanation of Medicare Benefits (EOMB)

A notice that is sent to you after the doctor files a claim for Part B services under the Original Medicare Plan. This notice explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. This is being replaced by the Medicare Summary Notice (MSN), which sums up all the services (Part A and B) that were given over a certain period of time, generally monthly. (See Medicare Summary Notice; Medicare Benefits Notice.)

Jay J. Sangerman, PLLC
171 East 84th Street - Unit 21B
New York, New York 10028
Telephone (212) 922-0711
Facsimile (212) 439-0056

 

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