Losing Health Coverage? You Could Qualify for a Medicare Special Enrollment Period.
Key Takeaways
- If you’re eligible for Medicare, you may qualify for a Special Enrollment Period when you lose existing healthcare coverage in several different ways.
- If you lost employer-based insurance because you left a job or are no longer covered by a spouse’s insurance, you can sign up for Original Medicare and have the option to switch to Medicare Advantage.
- If you’ve become ineligible for Medicaid, you can join a Medicare Advantage prescription drug plan, add Part D coverage, or change plans.
- If your drug coverage is no longer creditable, you can join a Medicare Part D prescription drug plan or a Medicare Advantage plan with prescription coverage.
Losing your health insurance is stressful, confusing, and can have serious consequences. Studies show that that people without health insurance are less likely to access vital preventive care or even treatments for severe health problems like chronic diseases.
Fortunately, older adults, as well as younger people with certain disabilities, have a range of Medicare coverage options. You likely qualify for Original Medicare, which is health insurance administered by the U.S. federal government, if you’re a permanent citizen or resident who fulfills any of the following criteria:
- You’re over 65 years old.
- You’ve received Social Security disability benefits for at least two years.
- You have amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s Disease.
- You have end-stage renal disease (ESRD).
Many people enroll in Original Medicare during their Initial Enrollment Period, which usually lasts for seven months around their 65th birthday. However, you have other chances to change your coverage every year. There’s the Annual Enrollment Period from October 15 to December 7, plus Special Enrollment Periods based on events in your life like losing your insurance.
Here are some common ways of losing health insurance that could qualify you for a Special Enrollment Period.
You’re No Longer Insured Through an Employer
If you reached your Medicare Initial Enrollment Period while you were still on private health insurance through your own employer or your spouse’s, you may have decided to put off signing up for Medicare at that time … or at least part of Medicare.
People with other insurance often sign up for Medicare Part A (used for hospital stays and other inpatient care) as soon as they turn 65 because it can help with costs and most enrollees pay no monthly premium. Still, they might wait to join Medicare Part B (for doctor’s visits and other outpatient services), which does charge a monthly premium.
You may lose your employer-based insurance because you leave your job or are no longer covered through a spouse’s insurance. In either case, there are a few possibilities to consider:
- When either your health coverage or employment ends, whichever comes first, you have an eight-month window to sign up for Medicare Parts A and/or B. If you wait longer, you could be charged late-enrollment penalties.
- For two full months after the month when your coverage ends, you have the option to add a Medicare Part D prescription drug plan. Part D plans are offered by private insurance carriers to help with the costs of medications. Coverage details and costs vary based on the plan you sign up for. You may be charged a late-enrollment penalty when you start a Medicare Part D plan if you’ve gone 63 days or more in a row without drug coverage that the Centers for Medicare and Medicaid Services (CMS) consider “creditable,” which means it’s equivalent to what you’d receive from a Medicare Part D plan.
- If you’ve enrolled in both Medicare Parts A and B, you also have the option to join a Medicare Advantage plan for two full months after your employer-based insurance ends. Also known as Medicare Part C, Medicare Advantage plans from private insurance carriers can substitute for Original Medicare coverage. These plans establish an out-of-pocket maximum for your annual healthcare spending, and most include Part D prescription drug coverage. They may include a variety of other supplemental benefits like dental, hearing, and vision.If you miss this Special Enrollment Period, you still have a chance every year to switch from Original Medicare to a Medicare Advantage plan. The Annual Enrollment Period lasts from October 15 to December 7.
You’ve Become Ineligible for Medicaid
Medicaid is a health insurance program that’s separate from Medicare, designed to provide health coverage for adults with low incomes and limited financial resources. Each state administers its own Medicaid program, setting rules for enrollment and benefits.
People who meet the requirements for both Medicare and Medicaid are dual eligible. Dual-eligible beneficiaries can receive their primary coverage through Original Medicare with a Medicare Part D prescription drug plan from a private insurer, and secondary coverage from Medicaid for added assistance with their healthcare costs. Many enroll in Dual Eligible Special Needs Plans (D-SNPs), which are Medicare Advantage plans with supplementary benefits specifically created for people with lower incomes.
During the COVID-19 pandemic, the federal government required continuous coverage for everyone who was already on Medicaid. However, once the health emergency ended, states could once again require Medicaid beneficiaries to re-enroll and remove beneficiaries who either no longer qualified or failed to complete the necessary paperwork. According to the health policy nonprofit KFF, more than 18 million people were disenrolled between the official end of the pandemic and March 12, 2024.
If you’re one of the millions who lost your Medicaid coverage, but you’re still eligible for Medicare, then you qualify for a Special Enrollment Period. Starting the day after your Medicaid coverage ends, you can sign up for Medicare Part A and/or B for the next six months without paying a late-enrollment penalty.
In addition, for three full months after you’re notified that you’re no longer eligible for Medicaid or three months after you lose eligibility, whichever is later, you can:
- Join a Medicare Advantage plan with prescription drug coverage.
- Add a Medicare Part D prescription drug plan to your Original Medicare without paying a late-enrollment penalty.
- Switch from the Medicare Advantage or Medicare Part D plan that you’re currently on to a different one.
- Leave the Medicare Advantage plan you’re currently on and go back to Original Medicare.
- Leave your Part D prescription drug plan.
Ready for a new Medicare Advantage plan?
Your Employer or Union Health Plan Stated That Your Drug Coverage Is No Longer Creditable
Even if CMS has considered the drug coverage you receive through employer-based or union insurance creditable in the past, that may change; plans sometimes reduce their drug benefits. That situation could make it harder to access medications. If you go without creditable coverage for at least 63 days in a row, you’ll also likely have to pay a late-enrollment penalty when you sign up for a Medicare Part D plan.
In September every year, you should receive a “Notice of Creditable Coverage” from your health plan that states whether your drug coverage is still creditable.
If not, you’ll be eligible for a Special Enrollment Period that lasts two full months after the month when you lose your previous drug coverage or two full months after you receive the notice, whichever’s later. During this time, you can join a Part D plan or a Medicare Advantage plan that includes drug coverage.
Losing your health insurance can be a nerve-wracking experience. However, if you qualify for Medicare, you may have a variety of options to fit your medical and financial situation. By exploring your choices with guidance from a licensed insurance agent, you can make certain that you have the coverage that’s right for you.