Why this 68 year old cancer patient can not sign up for Medicare Part B.

Medicare’s registration rules have put 68-year-old Scarlet Poulet in an unenviable situation.

The New Orleans resident, who is recovering from cancer, has been registered in Medicare Part A (hospital coverage) since 201[ads1]8 when she reached the qualifying age of 65. But because of how Medicare interacts with insurance through an employer – she lost coverage in August – Chicken is now not allowed to sign up for part B (outpatient) until January.

This is when a three-month registration window opens for recipients who did not sign up when they should. Even then, however, Poulet’s Part B coverage would not start until July due to the Medicare rules – and she could face life sentences for late registration.

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“The rules regarding Medicare qualification, especially when it comes to employer-based coverage, are unnecessarily complicated, with rather unfair results in some situations, such as this one,” said David Lipschutz, assistant director and senior policy attorney for the Center for Medicare Advocacy.

For most of Medicare’s 63.3 million recipients, there are not typical long delays before coverage begins or penalties for late registration. However, for individuals who have insurance elsewhere when they turn 65, errors in following the registration rules accurately can be problematic at best and costly at worst.

A bill passed by Congress last year, called the BENES Act, fixes the type of seven-month delay Poulet encounters between Part B registration and the start date, but it will not take effect until 2023. At that time, coverage will begin the month after a person signs up. .

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

In Poulet’s case, it only made sense to sign up for Part A at the time – she was covered through his wife Nadine Kujawa’s health plan at work. And the rules allow recipients to postpone Part B without penalty if they have coverage elsewhere that Medicare considers acceptable.

The problem arose when Kujawa quit his job to take care of Poulet – who was diagnosed with a rare head and neck cancer in 2019 – and the couple remained on Kujawa’s insurance as permitted under the Consolidated Omnibus Budget Reconciliation Act, or COBRA.

That law allows workers to stick to their health plan for up to 18 months (sometimes longer) when they leave a company, even if they have to cover the full cost of the premiums instead of having to be paid by the employer.

While the work-based plan was suitable instead of Medicare Part B for Poulet while his wife worked, Kujawa’s separation from work automatically made coverage unacceptable.

“Unfortunately, under the Medicare rules, everything changes when the insurance is not related to active employment,” Lipschutz said. “It’s confusing and stumbles a lot of people.”

Unbeknownst to Poulet, she had at that time an eight-month window to sign up for Part B under the Medicare rules to avoid penalties for late enrollment.

In 2019, around 764,000 people paid the Part B penalty for late enrollment, according to congressional research. The penalty is 10% for every 12 months a person should have been registered in Part B, but was not.

Unaware of the rules, Poulet remained covered under COBRA until three months ago. She did not qualify for a special Medicare enrollment period.

Without insurance for outpatient treatment, Poulet’s latest cancer-related agreement cost $ 5,563. And that was after asking for financial relief from the original price tag of $ 7,974.

Poulet said her next step would be to ask for “just relief.” This basically means asking the Social Security Administration to let her sign up for Part B immediately and eliminate penalties for late enrollment, although the request must generally involve proof that an agent from the authorities provided inaccurate information that led to the error.

There is no guarantee that the claim will work or how long a decision will take. Other federal rules prohibit Poulet from obtaining a health plan through the public marketplace. She also does not qualify for Medicaid, which sets limits on how much income and savings a person can have.

“I lost my insurance, I have cancer, the pandemic is getting worse, and I’ll have to wait [July] to sign up? “said Poulet.” It’s like they say you did not sign up for Part B, so we’ll put you out on the pasture and shoot you. “

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

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

Spokesmen say that when people are in Poulet’s situation – unable to sign up and / or face punishment – it is usually because they think they are doing the right thing, and that no one is telling them anything else.

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

“They say ‘of course I did not try to play anything because I paid more for prizes than I would have for part B,'” Schwarz said.

Chicken and Kujawa’s premiums under COBRA were $ 1686 monthly, compared to this year’s standard Medicare Part B premium of $ 148.50 a month ($ 170.10 next year).

A provision that did not enter into the BENES Act, but which is supported by spokesmen, would require the government to notify individuals approaching Medicare qualification of registration rules.

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