“What time is it?” The answer to this common question usually depends on where you are at the time, right? Usually, it does. When it comes to knowing when to make the right choices for the right circumstances and for the best consequential outcomes, it is a good thing to have an idea of time. What I am writing to you today about has to do with time-frames in the US Government’s Retirement Healthcare program we refer to as Medicare. This article will not answer the question as to whether or not Medicare really cares; rather, the forgoing information is written in order for Retirees or those on Medicare Disability to have a better idea of when the right time (according to Medicare) is to make wise healthcare decisions. We Geriatric Care Managers are in the daily grind of helping our communities (or online, anywhere) make well informed decisions. Medicare can seem so complicated and yet, with a keen focus on one’s own healthcare needs narrated by even a shy reliance on a bureaucratic healthcare system, we move bravely forward as we age. And we do need care. In the US, it’s MediCARE for most of us as we get older. Let’s do a quick and rather broad overview of the Medicare system as we digress into Medicare’s time frames for when to do what…
First, there is Medicare Part A, also referred to as hospital insurance. I always think of it this way; I go to the hospital first, and then I see my doctor afterwards. Part B then, is for outpatient care-after a hospital stay. INPATIENT vs OUTPATIENT STAYS in the hospital:
Inpatient care is when you go to the hospital-or need acute care.
By the way, if you do have to be hospitalized it is always good to know whether or not you are “in” or “out” patient. Why is this important? According to most insurance plans, outpatient hospital admission is just that, outpatient, and you will be billed as such. Outpatient stays are typically 23 hrs. I used to be a hospital case manager and would refer outpatient stays as a “23 hours obs” categorically, meaning patients in a particular unit/department of the hospital were admitted for 23 hours to determine the intensity or severity of the illness or impairment for the admission. There are guidelines to help the medical staff determine in and out stays such as the Milliman Criteria or InterQual Criteria that a hospital staff uses to help determine “in” or “out” stay status. I mention this so the general public understands that it’s not the hospital staff alone making such calls. There is always a bigger narrative- we are an insurance driven healthcare system I do believe. Such criterion will help the hospitalist (doctor assigned to hospital patients) and the medical staff to determine underlining causes or need for further stay. It’s the intensity and severity of illness that counts.
Part A Medicare covers hospital stays and is termed “Hospital Insurance” for disabled and retirees, while Part B is termed “Medical Insurance.” It’s good to know that both Part A and Part B will cover Home Health or Hospice Care, as well as Skilled Nursing Facility Care at time of post hospital discharge. Patients have the right to get what care they want. I have seen many patients refuse post hospital discharge care planning, desiring only to simply return home without any sub-acute care. Hopefully, they will see their PCP (Primary Care Physician) though.
Needless to say, there is much too large a gap in care when someone “transitions” from acute to sub-acute or even home care. I will need to write another post on post discharge care-planning, as presently I am tempted to do so, but for the sake of time and topic, let’s move on to what is Medicare Plan C?
Medicare Plan C is an alternative to the Traditional Medicare’s Plans A, B, and D (Drug Plans). Plan C is an option that was created to allow a Private Insurance Company to manage your Medicare benefit if you so choose. Many Private Insurance Companies will sell all sorts of bells and whistles such as free hearing, dental and eye care coverage that Traditional Medicare does not. However these plans are very attractive for those economically driven. Plan C is referred to as “Medicare Advantage Plans.”
According to the “Medicare & You 2025” publication; “Medicare Advantage is a Medicare approved plan from a private company that offers an alternative to original [or “Traditional”] Medicare for your health and drug coverage.” The important issue I like to remind others of is that an Medicare Advantage Plan works like private insurance plans, because that is exactly what they are. Private Insurance Companies may create their own preferences as to which providers you may choose. Plan C is where the US Government has partnered with Private Insurance Companies to help manage the Medicare healthcare system. You can spend hours looking up more details online about this very fact. If you are really interested in how the US Government and Private Insurances work together, or with how it all began…
Original Medicare had its “Traditional” roots in the 1960’s while Part C “Advantage Plan” erupted in the 90’s as the country’s aging population grew and is continuing to do so. According to the US Census Bureau, nearly 20% of Americans are on Medicare. Today Medicare is working to ensure aging and disabled persons have healthcare coverage options. Now let’s cascade into the Medicare time frames I think you should know and make note of…
Medicare Times that the industry refers to as Enrollment Periods…
IEP (Initial Enrollment Period)
IEP begins 3 months before you turn 65 yrs old and ends 6 months after turning 65 yrs of age. You can sign up for Original Medicare (also referred to as Traditional- that is Part A, B and D). As mentioned before, Part D is Drug Plans. You may also opt for Plan C during IEP if you decide you want to go with a Private Insurance Company that offers Advantage Plans. Many people decide to stay with the insurance carrier they have had prior to turning 65 yrs of age. I advise visiting the CMS website to find out how well these Private Insurance Companies are rated before deciding to go with a particular group or carrier. That very fact leads us to the next Enrollment Period breakdown.
If you joined a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare Part A & Part B
5-star Special Enrollment Period or 5-star “SEP”
Did you know that insurance carriers can earn five stars with Medicare and that when a carrier has five stars, there is this special enrollment period where you can do just that. Taken from CMS website (https://www.cms.gov/files/document/2015-5-star-plan-ratings-overview-job-aidpdf):
“For plans covering health services, the overall score
for quality of those services covers 36 different topics
in five categories:
Health plan telephone customer service
Includes how well the plan handles calls from
members.
Staying healthy
Includes how often members got various screen-
ing tests, vaccines, and other check-ups that help
them stay healthy.
Managing chronic (long-term) conditions
Includes how often members with different
conditions got certain tests and treatments that
help them manage their conditions.
Ratings of health plan responsiveness and
care
Includes ratings of member satisfaction with the
plan.
Health plan member complaints and appeals
Includes how often members filed a complaint
against the plan.
But what exactly is the is the 5-star Special Enrollment Period?
Per CMS website (https://www.cms.gov/files/document/2015-5-star-plan-ratings-overview-job-aidpdf):
“The 5-star Special Enrollment Period provides an opportunity for you to switch to a 5-star Medicare
Advantage-only plan, a 5-star Medicare Advantage Plan with prescription drug coverage, or a 5-star Medicare Prescription Drug Plan. You may use this 5-star Special Enrollment Period one time between December 8 and November 30 of the next year, provided you meet the plan’s enrollment requirements (e.g., living within the service area, meeting requirements regarding end-stage renal disease, etc). People enrolled in a plan with a 5-star overall rating may also switch to a
different plan with a 5-star overall rating.” As with any decision, it’s wise to learn all you can about switching gears when it comes to making Medicare choices… This CMS website also warns that “You may lose your prescription drug coverage if you switch from a Medicare Advantage Plan that has drug coverage to a Medicare Advantage Plan that doesn’t have drug coverage. You will have to wait until the next Open Enrollment Period to get drug coverage, and you may have to pay a late enrollment penalty. If you move from a Medicare Advantage-only or Medicare Advantage-Prescription Drug coordinated care plan to a 5-star Medicare Prescription Drug Plan, you will lose your Medicare Advantage coverage and will revert to Original Medicare for basic medical coverage.”
AEP (Annual Enrollment Period)
Also referred to “Fall Enrollment” each year for Medicare beneficiaries, they can sign up for a Medicare Advantage Plan or Medicare Part D plan or switch Medicare Advantage Plans and Part D Plans entirely. This is also a time where a MAP (short way of saying Medicare Advantage Plan) can be dropped in lieu of an Original (or Traditional) one. This takes place each fall from Oct. 15-Dec. 7.
MAOEP (MAP Open Enrollment or Medicare Advantage Plan Open Enrollment)
Each new year from Jan. 1 until Mar. 31, a Medicare Advantage Plan (MAP) may be switched or dropped to return to Original Medicare (Traditional). During the MAOEP, you can also add or drop a Medicare Part D Plan.
MOEP (Medigap Open Enrollment Plan) not to be confused with the MAOEP
The MOEP is very important to know about if you are signing up for Original Medicare (Traditional). It begins the day you turn 65 yrs old and you are enrolled in Medicare Part B (Medical Insurance, remember!). Keeping in mind that Original Medicare covers 80% of healthcare costs under Original Medicare; after you meet your yearly Part B deductible for healthcare services under Part B, you will typically pay 20% of the Medicare approved amount. Your MOEP lasts only for 6 months. Medigap plans are offered by Private Insurance Companies and are referred to as Medicare Supplement Insurance Programs. Thus the 20% out of pocket costs that go along with Original Medicare may be offset by joining a local Medigap insurer. The CMS website has a nifty tool for finding your local Medigap providers. See https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m/? year=2025&lang=en.
GEP
GEP is when you can sign up for Part B if you missed you IEP (Initial Enrollment Period) and did not qualify for any SEP (Special Enrollment Period). This is when the MAOEP also occurs for those wanting to switch MAPs (Medicare Advantage Plans) or switch back to Original (Traditional) medicare primarily.
SEP (Special Enrollment Period)
A Special Enrollment period is obviously so named because there must be a special reason you can enroll outside of IEP (Initial Enrollment Period) or AEP (Annual Enrollment Period) or GEP (General Enrollment Period) respectively. If you sign up for Part A or Part B during a Special Enrollment Period because of an exceptional situation (like a natural disaster or emergency), you’ll have 2 months to join a Medicare Advantage Plan (with or without drug coverage) or a Medicare drug plan (Part D). Your coverage will start the first day of the month after the plan gets your request to join.It helps to categorize these SEP’s:
Part A and Part B SEP’s mostly occur when someone wants to switch from a Private Insurance Coverage while they are still working (for which they may do so up unitl 3 months), or they missed the IEP for some personal or natural disasters “outside of your control that Medicare determines to be exceptional” (Taken from the “Medicare & You 2025 Handbook”).
MAP (Medicare Advantage Plan) SEP’s occur when there again is a “Qualifying Life Event” for which Medicare will decide upon. Basically, when you join a MAP (Medicare Advantage Plan) you must keep it for the calendar year. The 5-star SEP is the best example of MAP SEP’s.
Part D (Drug Plan) SEP is best done during the IEP (Initial Enrollment Period) or GEP (General Enrollment Period). Generally, you won’t have to pay a Part B penalty if you “qualify” for a Special Enrollment Period.
More info for SEP’s go to: https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan/special-enrollment-periods
Avoiding a Coverage Gap
Some people decide to remain on the insurance they have with their work if it is still offered during their retirement years. However- and note this: If for any reason you DO NOT enroll in Part B within 8 months of losing your Private Insurance Coverage you may have to pay a lifetime late enrollment penalty. No fun at all. Add to that, you will only be able to actually enroll in part B during the GEP (Jan. 1-Mar. 31). Furthermore, your coverage will not begin until July as with all GEP enrollments. The worst case scenario with this not-so-great option or misfortune rather, is that in many circumstances where the regular enrollments are delayed a higher Part A and/or Part B premium are unavoidable. So avoid the unavoidable costs of avoiding a coverage gap if at all possible!
Are you confused still? Well if so, here is a simple way to remember the important times when you first start in the Medicare US Government Health Insurance System. Try to remember or write down “6-7-8.” 6 = 6 months for MOEP. 7 = 7 months for IEP and 8= 8 months post private insurance to get Part B and avoid the “Coverage Gap!” And try to remember to get a drug plan through Part D as soon as you are eligible for Medicare and do not have optional credible coverage, ie, Private Insurance Coverage. Here’s why (From the CMS website: https://www.medicare.gov/basics/costs/medicare-costs/avoid-penalties);
Example:
If you waited 14 months after you were eligible for Medicare to join a Medicare drug plan, and you didn’t have creditable drug coverage, you’ll have to pay a 14% late enrollment penalty in addition to your monthly plan premium.
- The penalty amount comes from the “national base beneficiary premium” ($36.78 in 2025).
- The national base beneficiary premium changes each year, so your penalty amount may also change each year. This monthly penalty is added for as long as you have Medicare drug coverage, even if you switch plans.
In 2025:
$36.78 (2025 national base beneficiary premium)
X 0.14 (14% penalty).
Avoid-Avoid-Avoid!!! Late Penalties– even the thought of this is no fun- at all… From CMS website:
Part A Late Enrollment Penalty
Some people have to buy Part A because they don’t qualify for premium-free Part A.
If you have to buy Part A, and you don’t buy it when you’re first eligible for Medicare, your monthly premium may go up 10%. You’ll have to pay the penalty for twice the number of years you didn’t sign up.
Part B late enrollment penalty
Generally, you won’t have to pay a Part B penalty if you qualify for a Special Enrollment Period. You’ll pay an extra 10% for each year you could have signed up for Part B, but didn’t.
Part D Late Enrollment Penalty
Generally, you won’t have to pay a Part D penalty if: You have creditable drug coverage (coverage that’s similar in value to Part D) OR You qualify for Extra Help. You’ll pay an extra 1% for each month (that’s 12% a year) if you: Don’t join a Medicare drug plan when you first get Medicare OR Go 63 days or more without creditable drug coverage.You may also pay a higher premium depending on your income. After you join a Medicare drug plan, the plan will tell you if you have to pay a penalty and what your premium will be.
Truth is, it’s about TIME. Know your Medicare Times. Medicare does care about what TIME it is!
Dawn Elledge, Geriatric Care Manager 