(Medicare General Information, Eligibility, and Entitlement)

Eligible individuals may enroll:   If notified of Medicare entitlement during the IEP - The month after the end of the IEP, or   If notified of Medicare entitlement after the IEP - The month of notification of Medicare entitlement.   Coverage begins:  If notified of Medicare entitlement during the IEP:   The month of enrollment, or   The first month after the end of the IEP   If notified of Medicare entitlement after the IEP:   The month of enrollment, or   The month SMI terminated based on the refusal.   If entitlement is based on ESRD, coverage begins:   The month of HI entitlement, or   The month of enrollment, or   The month after the end of the IEP.  40.3.6 - SEP for Beneficiaries for Whom Medicare is Now the Primary Payer (D -SEP)  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals entit led to Medicare Part A based on disability, but who did not enroll in Part B because Medicare was the secondary payer for covered services, may enroll using this 7-month SEP.   Eligible individuals may enroll with the later of:   The month in which the employer notifies the beneficiary that Medicare is the primary payer, or   The month Medicare becomes the primary payer.    Coverage begins either:   The first day of the month of filing for Part B, or   During any month of the 7- month D -SEP, or   Retroactive to the mo nth Medicare becomes the primary payer provided the beneficiary makes arrangements to pay the past due premiums; either by a lump sum payment or by monthly installments.   40.3.7  SEP for Exceptional Conditions  (Rev. 12046, Issued:05 -18-23, Effective:01- 01-23, Implementation:06- 21-23)  Effective January 1, 2023, the following SEPs for exceptional conditions are available for Premium Part A and Part B, respectively.   40.3.7.1 - SEP for Individuals Impacted by an Emergency or Disaster  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals who do not enroll in Part B or Premium Part A when first eligible due to having an emergency or disaster as declared by a federal, state, or local government entity may enroll during this SEP.  Eligible Individuals may enroll as early as:   The month of the emergency or disaster, or   Up to six months after the emergency or disaster has ended.   NOTE: they may also be able to use this SEP if the disaster or emergency  takes place where their authorized representative, legal guardian, or person who makes health care decisions on their behalf resides.  The SEP begins the date an emergency or disaster is declared, or the start date identified in the emergency declaration,  whichever is earlier. The SEP ends six months after the end of the date which is the later of:    The end date identified in the disaster or emergency declaration, or   The end date of any extensions or the date when the declaration has been determined to hav e ended or has been revoked, or   The date of the declaration, if such date is after the end of the disaster.  Coverage begins the first day of the month following enrollment.  40.3.7.2  SEP for Individuals Affected by a Health Plan or Employer Misrepresent ation  (Rev.  12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals who do not enroll in Part B or Premium Part A when first eligible due to misrepresentation or reliance on incorrect information provided by their employer or GHP, agents or brokers of health plans, or any person authorized to act on behalf of such entity may enroll during this SEP.  An eligible person must demonstrate (by documentation or written attestation) both of the following:    They did not enroll in Part  B or Premium Part A during another enrollment period in which they were eligible based on information received from an employer or GHP, agents or brokers of health plans, or any person authorized to act on such organizations behalf.   An employer, GHP, agent or broker of a health plan, or their representative materially misrepresented information or provided incorrect information relating to enrollment in Part B or Premium Part A.   The SEP begins the day an individual notifies the Social Security Administ ration and ends six months later.   Coverage begins the first day of the month following enrollment.  40.3.7.3 - SEP for Formerly Incarcerated Individuals  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals who do not e nroll in Part B or Premium Part A when first eligible because  they were incarcerated may enroll during the SEP.  An eligible person can sign up anytime within the 12 months after their release from incarceration.  The SEP begins the day an individual is r eleased from the custody of penal authorities.  However, individuals have the option to select a retroactive effective date (not to begin  prior to their release date and not to exceed 6 months). If individuals choose this retroactive option, they will be responsible for paying Medicare premiums back to the date of coverage.   Coverage begins the first day of the month following enrollment or up to six months retroactive.   40.3.7.4 - SEP for Termination of Medicaid Coverage  (Rev.  12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals whose Medicaid eligibility terminated may enroll during this SEP.   A person may be eligible based on this condition if they have:    Lost Medicaid entirely,   Missed a Medicare enrollment period, and   Their Medicaid coverage was terminated on or after January 1, 2023.   The SEP begins when an individual is notified of an upcom ing termination of Medicaid  eligibility and ends six months after the Medicaid termination. Medicare benefits start the  month after Medicare enrollment unless the individual elects a start date back to the first  day of the month the individual lost Medicaid and agrees to pay all prior premiums.   Note: Individuals who are still eligible for Medicaid, including a Medicare Savings  Program, and have not received notice of an upcoming Medicaid termination are not  eligible for this SEP.     40.3.7.5 - SEP fo r Other Exceptional Conditions  (Rev. 12046, Issued:05- 18-23, Effective:01-01-23, Implementation:06-21-23)  Individuals who do not enroll in Part B or Premium Part A when first eligible because conditions beyond their control caused them to miss an enrollment period may enroll during the SEP. This SEP is available for individuals whose unique conditions do not qualify for other SEPs.  An eligible person must demonstrate (by documentation or written attestation) that conditions outside of their control that occurred on or after January 1, 2023, caused them to miss an enrollment period.  An individuals request for this SEP will only be granted in conditions that are truly exceptional in nature, and will not be used to grant individuals enrollment due to forgetfulness, lack of knowledge, or failure to make premium payments.  SSA will determine when this SEP begins on a case-by-case basis, but the SEP will end no less than 6 months after it begins.  Coverage begins the first day of the month following enrollment.   40.4 - Nature and Purpose of State Buy -in (Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)  Under the State Buy -in program, states, the District of Columbia, and the U.S. territories may enter into buy- in agreements with CMS to enroll certain individuals who are dually eligible for Medicare and Medicaid into Medicare Part B and pay the premiums on their behalf.   Most states have expanded their buy- in agreements to also include payments of Part A premiums for individuals who must pay a premium to enroll in Medicare Part A and who are eligible for the Qualified Medicare Beneficiary (QMB) eligibility group. State buy -in agreements maximize the number of full- benefit Medicaid recipients enrolled in Medicare, which ensures  that Medicare pays primary to Medicaid. State buy-in agreements also facilitate enrollment in Medicare for low income individuals who are not eligible for full-benefit Medicaid coverage by paying Medicare premiums and cost sharing. Please see the Manual for State Payment of Medicare Premiums, chapter 1, section 1.2 for additional state buy-i n information.    40.5 - End of Coverage  (Rev. 1, 09-11-02)  An individual may notify CMS in writing, at any time, that he or she no longer wishes to participate in the supplementary medical insurance plan.  Termination of coverage takes effect at the close of the calendar month following the calendar month in which the request for termination was filed.  Enrollment under medical insurance is terminated because of nonpayment of premiums.  Termination is effective with the end of the grace period provided for payment of premiums.  ( See chapter 2, 40.7.4 of this manual.)  For individuals under age 65, enrollment is terminated because HI entitlement ended.  SMI terminates at the same time as HI.   If not terminated sooner, coverage ends with the beneficiary's death.  40.6 - Termination and Reenrollment  (Rev. 1, 09-11-02)  An individual whose enrollment has terminated may reenroll only in a general enrollment period or a special enrollment period if the requirements are met.   40.7  Premiums  (Rev. 1, 09-11-02)  A premium is due for each month of entitlement under SMI.  The SMI premium covers about one-fourth of the cost of the Part B program.  40.7.1 - Amount of Premiums  (Rev. 1, 09-11-02)  In the third quarter of each calendar year, the Secretary of the Department of Health and Human Services announces the base premium for SMI coverage that is payable as of the following January 1.  The SMI premium is the same for all enrollees even though the cost to the program is greater for ESRD enrollees and the disabled than it is for the aged.  The SMI premium is refigured each year and is based on the lower of one- half of SMI program costs per aged enrollee or the general percentage by which social security benefits were increased during the calendar year in which the announcement occurs.  (During the 5-year period, January 1984 through December 1988, the formula for computing the SMI premium has been modified to provide that the Part B premium reflects exactly one -fourth of the cost of the Part B program.  Beginning with the premium announced for the period beginning January 1989, however, the method of computing the SMI premium reverts back to the pre-January 1984 rules.)  40.7.2 - Increase in Base Premium Amount  (Rev. 1, 09- 11-02)  The base premium that is announced by the Secretary is paid by most enrollees.  However, it is increased for those who enroll late or reenroll after a prior termination of entitlement.  The amount of the increase is 10 percent of the ba se rate for each full 12 -month period during which the individual could have been but was not enrolled in the program.  However, months in which an individual has GHP coverage based on current employment status are not counted as months in which the indivi dual "could have been, but was not enrolled."  This exception does not apply to individuals who are entitled to Medicare on the basis of ESRD.   40.7.3 - Collection of Premiums  (Rev. 1, 09- 11-02)  SMI premiums are collected from benefits payable (in order of priority) by the Railroad Retirement Board, SSA, or Office of Personnel Management (Civil Service) unless the individual is covered under a State buy- in agreement.  If the individual is entitled to such benefits but the payments are in suspense, e.g., du e to work deductions, he or she is billed for the amounts due.  Uninsured beneficiaries are also billed directly for the premiums due.  Premium bills are sent every 3 months unless the individual specifically requests a monthly bill or is also entitled to Premium -  HI (in which case a monthly combined SMI -Premium- HI bill is sent).   40.7.4 - Grace Period for Payment  (Rev. 1, 09- 11-02)  A grace period has been provided for payment of premiums by those who are billed directly.  The period extends for 90 days after the month in which the bill is mailed.  If the premiums are not received in that prescribed time, entitlement terminates at the end of the grace period.  This 90 -day grace period for paying overdue SMI premiums and continuing SMI coverage may be  extended by CMS for good cause for up to an additional 90 days.  Good cause, for example, is found if the enrollee was mentally or physically incapable of paying his or her premiums timely, or had some reasonable basis to believe that payment had been mad e, or the failure to pay was due to administrative error.