In a word, yes. Medicare is a very stable form of health insurance, meant for seniors to use until the end of their lives, or for people suffering from disabilities to use indefinitel – yet there are several circumstances, both within your control and outside of it, that can cause you to lose all or part of your Medicare coverage. The good news is that even if you lose your Medicare, there are many ways to get your Medicare benefits back (or to find good health insurance to replace it).
- You can lose Medicare coverage through your own actions: not paying for premiums, Medicare fraud, lying on an application, or moving outside of your coverage zone.
- You can also lose Medicare for reasons outside of your control, like recovery from disability or an insurance provider deciding to change or discontinue a plan.
- After losing Medicare coverage, you can re-apply sooner than the Open Enrollment period if you’ve experienced a Qualifying Life Event.
- If you can no longer qualify for Medicare, other healthcare options may be able to fill the gaps in your health care, such as Medicaid. CHIP, or private health insurance.
What is Original Medicare?
Original Medicare is a federally-administered health insurance program designed for some of the most vulnerable populations in the country. Original Medicare consists of Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Medicare Part A helps pay for events like hospital stays, care in skilled nursing facilities, hospice care, and some health care. Medicare Part B will help pay for things such as outpatient care, medical supplies like wheelchairs, preventative health services, and even some doctor’s services. Medicare can help offset the burden of large medical bills, but it can’t pay for everything. Generally, you will need to pay one-fifth of the cost of a service insured by Medicare.
How To Obtain Original Medicare
There are three main groups of people who are eligible for Original Medicare. The most common qualifier for Original Medicare depends on your ag – every citizen, permanent legal resident, or government worker aged 65 and older is eligible. Medical conditions such as End Stage Renal Disease (ESRD) and Lou Gehrig’s disease (ALS) also qualify you for Medicare. Finally, everyone eligible for Social Security Disability Insurance (SSDI) for at least 24 months is eligible for Medicare. Many people are automatically enrolled in Medicare after meeting these qualifications, although three enrollment periods are available for you to sign up.
After Obtaining Medicare, What Can Cause You to Lose it?
After you get Medicare, it’s still possible to lose your health coverage. Recovering from what qualified you for Medicare will result in a cessation of services. For people with End Stage Renal Disease, for example, Medicare coverage ends a year after you end dialysis treatments, or three years after a kidney transplant. If you recover from a disability that qualified you for Medicare, services may also end. Below, we’ll explain some circumstances that can result in a loss of Medicare coverage.
Failure to Pay for Premiums
Falling behind on payments is an easy way to lose Medicare coverage. Everyone on Original Medicare must pay a monthly premium for Part B, and if you haven’t paid Medicare taxes for 40 quarters or more, you will also pay premiums for Part A. Failure to make your premium payments for a month will result in a Second Notice, which will give you a deadline by which you must make your payment. Not doing so will result in a Delinquent Notice. Continuing not to pay your premiums on the 25th day of the month means your Medicare coverage can be discontinued. This includes your Medicare Advantage, Medicare Supplement, and Medicare Part D coverage, which you cannot receive without Original Medicare.
Medicare Fraud or “Disruptive Behavior”
Trying to defraud Medicare in any way will get your coverage taken away. For example, this means that if you let someone else use your Medicare card for care, or otherwise attempt through fraud to get Medicare benefits for someone who is ineligible, you can lose coverage. You may also lose coverage for “disruptive behavior,” which varies from plan to plan but will be defined by your insurance company. Generally, it means to substantially interfere with the ability of your plan to render services, and does not have to do with the use of medical services or whether or not you’re listening to your doctors’ advice.
Lying on Your Plan’s Application
Should you attempt to decrease the prices of your premiums by providing dishonest information on your Medicare application – such as claiming falsely you have a lower income, or that you’re a nonsmoker – you could lose your coverage when a provider investigates these claims.
Moving Outside of Your Coverage Zone
Some parts of Medicare coverage are region-dependent – particularly Medicare Advantage and Medicare Part D, which are sold by private insurance companies with provider networks. The good news is, if you lose any part of your Medicare coverage from moving to a new ZIP code, you qualify for a Special Enrollment Period that will allow you to sign up for a Medicare plan using your new residence.
When You No Longer Have Qualifying Disability
For people who qualified for Medicare based on disability and not age, recovery from the disability that qualified you for Medicare can result in a loss of coverage. However, returning to work doesn’t mean your Medicare coverage will end. In fact, so long as Medicare determines you have not recovered from your disability, you can continue to receive Original Medicare for 93 months with free premiums for Part A after your initial work trial period of nine months. Following that, you can continue to purchase Part A and Part B.
Your Plan Was Changed or Discontinued
Because Medicare Advantage and Medicare Part D are sold by private insurance companies, the coverages they offer aren’t set in stone. If the insurance company doesn’t get good returns from a plan, they may discontinue the plan, or alter their coverage. The insurance company itself could shut down, resulting in the loss of your Medicare plan. However, losing Medicare due to changes within the providing insurance company will qualify you for a Special Enrollment Period. This will allow you to change plans and regain coverage quickly.
You’ve Lost Original Medicare Coverage. What Next?
If you lose Medicare coverage, you may have options to re-enroll for Original Medicare. Besides the Initial Enrollment Period for seniors (extending three months before your 65th birthday and three months after), there is the Open Enrollment Period that lasts from January 1st to March 31st every year. Signing up during Open Enrollment will allow your coverage to begin July 1st of that year. Outside of these two times, you will need a Special Enrollment Period to sign up for Medicare coverage. You can only get a Special Enrollment Period if you have experienced what is called a Qualifying Life Event, or QLE. Some major QLEs are explained below.
Changes in Household
Changes to family structure can qualify you for a Special Enrollment Period for Medicare, but only if you act quickly. These events can include marriage, adoption/foster placement, having a baby, divorce or legal separation (if you lost health insurance), and the death of a family member on your Medicare plan, making you lose eligibility.
Changes in Residence
When you move, you can qualify for a Special Enrollment Period if you change zip codes, or have just moved to the United States from another country. Other people who qualify are people moving into or out of temporary housing, including students, seasonal workers, and people residing in shelters.
Loss of Health Insurance
If you or a member of your household lost health coverage after January 2020, or expects to lose health coverage in the next 60 days, you can qualify for a Special Enrollment Period.
An Employer Offer to Help With the Cost of Coverage
Employers can help you or a member of the household qualify for a Special Enrollment Period by offering Health Reimbursement Arrangements (HRAs) and Qualified Small Employer Health Reimbursement Arrangements (QSEHRAs). These arrangements allow your employer to contribute to paying the costs of health coverage.
More Qualifying Changes
There are some social circumstances that also qualify you for a Special Enrollment Period. These can include: gaining U.S. citizenship, leaving incarceration, gaining tribal status recognized by the federal government, and beginning or ending service in AmeriCorps, VISTA, or NCCC.
Alternative Health Insurance Options
Even if you lose Medicare Benefits, that doesn’t mean your health insurance situation is hopeless. There are several alternatives to Medicare that provide excellent health insurance. Some major groups are Medicaid, the Children’s Health Insurance Program, and private health insurance.
Medicaid is a joint program between state and federal governments, designed to provide health insurance coverage to low income families or individuals. Exact coverage varies by state, but common in plans is coverage for doctor’s appointments, hospitalization, custodial care, and long-term medical care, among other features. A household’s modified adjusted gross income (MAGI) is used to determine eligibility: if it is below 100% to 200% of the federal poverty level, you can receive Medicaid if you are also disabled, pregnant, a child, or above the age of 65. Those whose income falls below 138% of the federal poverty level may be eligible even as abled adults.
CHIP, or the Children’s Health Insurance Program, is state-run insurance designed to provide affordable health insurance to children (and in some states, pregnant women) whose household incomes are too high to qualify for Medicaid. While eligibility requirements vary from state to state, they are also based on household modified adjusted gross income. If you apply for Medicaid, you will also be notified whether you or your children qualify for CHIP. As with Medicaid, coverage types aren’t uniform across all states, but some coverages are common to all states, including vaccinations, routine check-ups, doctor’s appointments, hospitalization, outpatient care, dental and vision care, prescription medications, emergency services, and laboratory testing.
Private Health Insurance
Private health insurance encompasses all insurance that isn’t administered by the federal government (like Original Medicare) or state governments (like Medicate and CHIP). It is one of the most flexible and varied insurance types in terms of coverage benefits and eligibility requirements. Private insurance can include workplace health insurance (like group plans), health insurance purchased through the Marketplace, or even their local plans like Medicare Part D and Medicare Advantage. Health insurance plans that qualify under the Affordable Care Act must allow access to ten Essential Health Benefits. These are:
- Outpatient services
- Emergency services
- Prenatal and postnatal care
- Mental health treatment
- Prescription medications
- Rehabilitative and occupational therapy/devices
- Laboratory testing
- Preventative healthcare and chronic disease management
- Pediatric services (including vision and dental coverage)
Keep in mind that certain health care plans, like short term plans or catastrophic coverage, may not offer the benefits listed under the Affordable Care Act.