By Brian Craig, J.D.
CMS will send a notice to certain consumers who pay a premium for Medicare Part A that exchange coverage may duplicate benefits they already receive through Medicare.
In order to provide guidance to consumers enrolled in both Medicare Part A and an exchange plan, CMS will send a notice to consumers who pay a premium for Medicare Part A that Exchange coverage may duplicate benefits they already receive through Medicare. The notice will also inform consumers that they may benefit from ending their exchange coverage and that they may have to repay for financial assistance already paid to the health plan on the consumer’s behalf for exchange coverage. In the frequently asked questions (FAQ) document, CMS is providing guidance on the Medicare Periodic Data Matching (PDM) and notices that will be sent to consumers.
Medicare PDM includes the process by which health insurance exchanges periodically examine available data sources to identify consumers enrolled in exchange health plans with financial help at the same time they are enrolled in Medicare Part A (Hospital Insurance) or Medicare Part C (Medicare Advantage) that is considered qualifying coverage. Financial help includes advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSR), which help pay for Exchange plan premiums and covered services.
Consumers who have to pay a premium for Medicare Part A, should compare their exchange plan costs with their Medicare benefits and total premiums. Consumers can choose to end Medicare coverage and remain enrolled in an exchange plan, with or without financial assistance through APTC/CSR. In those cases, they are not eligible for APTC/CSR for exchange coverage after they became eligible for Medicare and must end their financial assistance through the exchange. Impacted consumers will have 30 days from the date the notice is sent to respond to the notice. For consumers who do not respond to the notice, the exchange will end APTC/CSR or exchange plan coverage, depending on what the consumer elected when applying, after the 30-day window elapses.
Repayment for financial assistance. When consumers are enrolled in both Medicare (Part A or Part C) and an exchange health plan, they do not qualify for financial assistance to help reduce their monthly payment. These consumers have to pay the full cost of the exchange health plan premium and covered services for exchange coverage after they became eligible for Medicare. The household’s tax filer may have to repay all or some of the APTC paid to the health plan on the consumer’s behalf for Exchange coverage after they became eligible for Medicare.
Enrollment in Part B. Consumers may be able to avoid financial penalties if they want to enroll in Medicare Part B. For a limited time, the Medicare PDM notice informs consumers of the potential for "equitable relief" which may be available for certain consumers dually enrolled before September 30, 2019. This relief may provide eligible consumers with an opportunity to enroll in Medicare Part B without a late enrollment penalty. In addition, consumers can request a penalty reduction if they enrolled in Medicare Part B with a penalty while eligible for this relief. This relief will be considered on a case-by-case basis for current or previously dually enrolled beneficiaries. To be eligible for the relief, the consumer must provide evidence of dual enrollment, be enrolled in premium-free Medicare Part A, and meet other requirements.
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