Why this 68-year-old cancer patient can’t enroll in Medicare Part B – .

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Why this 68-year-old cancer patient can’t enroll in Medicare Part B – .


Scarlet Poulet (right), pictured with wife Nadine Kujawa, before Poulet was diagnosed with cancer in 2019.
Courtesy: Scarlet Chicken
Medicare rules for enrollment put Scarlet Poulet, 68, in an unenviable position.
The New Orleans resident, who is recovering from cancer, has been enrolled in Medicare Part A (hospital coverage) since 2018, when she reached the eligibility age of 65. Yet due to the way Medicare interacts with insurance through an employer – coverage it lost in August – Chicken is no longer allowed to enroll in Part B (outpatient care) before January.

That’s when a three-month enrollment window opens for recipients who didn’t enroll when they were supposed to. Even then, however, Part B coverage of Chicken wouldn’t begin until July due to Medicare rules – and she could face lifetime late enrollment penalties.

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“The rules around Medicare eligibility, especially when it comes to employer-sponsored coverage, are unnecessarily complicated, with fairly unfair results in some situations, like this,” said David Lipschutz, associate director and Senior Counsel for the Center for Medicare Advocacy. .

For most of the 63.3 million Medicare beneficiaries, long delays before coverage begins or late enrollment penalties are not typical. However, for people who have insurance elsewhere when they turn 65, mistakes in adhering to membership rules can be problematic at best and costly at worst.

A bill that authorized Congress last year, called the BENES Act, fixes the kind of seven-month lag that Poulet faces between Part B registration and its start date, but it doesn’t take effect. until 2023. At this point, coverage will begin the following month. one person signs up.

However, the legislation does not specifically address the issue that led to Poulet’s predicament.

What went wrong

In Poulet’s case, signing up for Part A only made sense at the time – she was covered by his wife Nadine Kujawa’s occupational health plan. And, the rules allow beneficiaries to delay Part B without penalty if they have coverage elsewhere that Medicare considers acceptable.
The problem arose when Kujawa quit her job to care for Chicken – who was diagnosed with rare head and neck cancer in 2019 – and the couple remained on Kujawa’s insurance as permitted. Consolidated Omnibus Budget Reconciliation Act, or COBRA.

This law allows workers to stick to their health plan for up to 18 months (sometimes more) when they leave a company, although they must cover the full cost of the premiums instead of the participation of the employer.

Unfortunately, under Medicare rules everything changes once insurance is not tied to active employment. It’s confusing and trips up a lot of people.

David Lipschutz

Associate Director and Senior Policy Counsel for the Center for Medicare Advocacy

While the work-based plan was suitable in place of Medicare Part B for Chicken while his wife was working, Kujawa’s termination automatically made coverage unacceptable.

“Unfortunately, under Medicare rules, everything changes once insurance isn’t tied to active employment,” Lipschutz said. “It’s confusing and trips up a lot of people. “

Unbeknownst to Chicken, at this point, she had an eight-month window to enroll in Part B under Medicare rules to avoid late enrollment penalties.

In 2019, about 764,000 people paid the late registration penalty for Part B, according to a congressional study. The penalty is 10% for every 12 months that an individual should have been enrolled in Part B but was not.

Ignoring the rules, Poulet remained covered by COBRA until three months ago. She was not entitled to a special registration period for Medicare.

Without ambulatory care insurance, Chicken’s last cancer-related appointment cost $ 5,563 out of pocket. And that was after asking for financial relief from the original price of $ 7,974.

Poulet said his next step would be to seek “fair relief”. Essentially, this involves asking the Social Security Administration to allow them to enroll in Part B immediately and eliminate late enrollment penalties, although the request usually must involve proof that a government official has provided. inaccurate information which led to the error.

There is no guarantee that advocacy will work or how long a decision would take. Other federal rules prohibit Poulet from obtaining a health plan on the public market. She is also not eligible for Medicaid, which limits the income and savings a person can have.

“I lost my insurance, I have cancer, the pandemic is getting worse and I am supposed to wait [July] to register? Chicken said. “It’s like they’re saying you didn’t sign up for Part B, so we’re going to graze you and shoot you.” “

The BENES Act – the law coming into force in 2023 that corrects certain delays in Medicare coverage – also authorizes the government to allow special Part B enrollment periods for “exceptional circumstances.” (This already exists for Part D prescription drug coverage and Part C benefit plans)

The problem isn’t that COBRA coverage is available, it’s that there is no support for these transitions.

Casey Schwarz

Senior Education and Federal Policy Advisor at the Medicare Rights Center

What exactly will qualify at this point is uncertain. In other words, there is no way to know if the definition would include errors related to employer-based coverage, including COBRA.

Advocates say that when people find themselves in Chicken’s situation – unable to register and / or face penalties – it is usually because they think they are doing the right thing and no one is telling them. contrary.

“It’s especially difficult in situations where people have paid premiums for other insurance, particularly under COBRA,” said Casey Schwarz, senior education and federal policy attorney at the Medicare Rights Center. .

“They say ‘clearly I wasn’t trying to play anything because I was paying more for the bonuses than I should have for Part B,” said Schwarz.

Chicken and Kujawa’s premiums under COBRA were $ 1,686 per month, compared to Medicare Part B’s standard premium of $ 148.50 per month ($ 170.10 next year).

A provision that has not been incorporated into the BENES Act but is supported by advocates would require the government to notify people approaching Medicare eligibility of the enrollment rules.

“The problem isn’t that COBRA coverage is available, it’s that there is no support for these transitions,” Schwarz said.

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