Understanding Medicare Part A Coverage Requirements and Options
Explore the eligibility requirements for Medicare Part A, including age and work history criteria. Learn about the importance of Quarters of Coverage and FICA taxes in determining eligibility. Discover options for individuals who may not have enough Quarters of Coverage to qualify for premium-free Part A coverage.
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Youre 30 Cents Shy of a Quarter Medicare Part A when it s not premium-free
Part A Requirements 65 years of age, or Received SSDI for 24 months, or Have ESRD (3 months f/ dialysis treatment), or Have ALS (get MC 1stmonth receive SSDI) and Be a US citizen or an alien lawfully admitted for permanent residence who has resided in the US continuously for the 5 years preceding the month he/she effectively applies for health insurance Cannot have committed a crime against the United States (treason, espionage, sabotage, etc.).
Quarters of Coverage A person needs 40 Medicare Quarters of Coverage in order to be entitled to Premium-free Medicare Part A QC is a unit used to determine if someone is insured under the Social Security program To obtain 40 QC s, a person needs to work for 10 years For 2016, $1260 in earnings = 1 QC. Maximum a person can receive is 4 QC s per year. Need income of at least $5040 in 2016 for 4 QC s.
FICA Federal Insurance Contributions Act Social Security Tax = 6.2% paid by both employer and employee on first $118,500 of wages Medicare Tax = 1.45% paid by both employer and employee on ALL wages Additional Medicare Tax = 0.9% paid by employee once wages are over $200,000 for calendar year A person must pay Medicare Tax in order to be eligible for premium free Part A (10 years of payments).
Who Might not Have Enough QCs? Late arriving immigrants Infrequent workers Non-covered workers (clergy, public employees) Federal employees hired before 1984 Some state and local employees https://www.ssa.gov/policy/docs/ssb/v71n2/v71n2p17.html
What Options Do They Have? Pay for Part A Marketplace Plan QMB State pays for Part A
Pay for Part A Fewer than 30 QC s, $411/month premium 30-39 QC s, $226/month premium An aged individual qualifies for HI premium reduction if he/she: Has 30 or more QCs on his/her own E/R; or Has been married for at least 1 year to a number holder (NH) with 30 or more QCs; or Was married to a deceased NH with 30 or more QCs for at least 1 year prior to the death of the NH; or Is divorced, after at least 10 years of marriage, from a NH who had acquired 30 or more QCs, at the time the divorce became final.
Enroll into Part A People who have to pay a premium for Part A are not automatically enrolled. He or she must: File an application by contacting SSA, and - Enroll during a valid enrollment period, and - Also enroll in or already have Part B -
Part A Late Enrollment Penalty The penalty is 10% of the monthly premium. Pay the higher premium for twice the number of years you could have had Part A, but didn't sign up. Example: If you were eligible for Part A for 2 years but didn't sign up, you'll have to pay the higher premium ($452.10) for 4 years. If a person enrolls in Part A late but has obtained 40 QC s, they will not have an LEP (10% of $0 is $0).
Parts B & D Only? A person does not need any QC s to enroll in Parts B or D (or SeniorCare) just needs to be 65 or older + US citizen or legal resident for 5 years Person would have to pay premiums for B & D coverage A person cannot sign up and pay premiums for Part A coverage only (required to also have Part B) Part B does not constitute minimum essential coverage
Marketplace Medicare Part A is considered minimum essential coverage. It is against the law for someone to sell a Marketplace plan to someone they know has Medicare. Section 1882(d) of SSA prohibits sale or issuance of duplicate coverage to an individual who is entitled to benefits under Part A or enrolled under Part B If required to pay a premium for Part A, can enroll in a QHP
Marketplace contd Eligible for free Part A Eligible to buy Part A Can keep or enroll in Marketplace plan Can keep Marketplace plan Not eligible for tax credits. Any credits an individual receives will be discontinued once Part A coverage begins Eligible to receive tax credits if enrolls in Part B only Not eligible for tax credits if enrolls in Part A https://www.cms.gov/Medicare/Eligibili ty-and-Enrollment/Medicare-and-the- Marketplace/Downloads/Medicare- Marketplace_Master_FAQ_8-28-14_v2.pdf
Marketplace - Drawbacks Late enrollment penalties for Part A and Part B, if person ever wants to enroll in Medicare If under 100% FPL, will not be able to enroll in a Marketplace plan
QMB Benefits Payment of Medicare Part A premiums Payment of Medicare Part B premiums and annual deductible Payment of co-insurance and deductible amounts for services covered under both Medicare Parts A and B
QMB - Eligibility 32.2.1 The following persons are Medicaid members who are automatically eligible for QMB benefits. Persons who are receiving or are eligible to receive SSI . 503 AGs. Disabled adult children. Widows and Widowers. If the person does not belong to one of the above named groups, he or she must: Be non-financially eligible for Medicaid or BadgerCare Plus. Be entitled to Medicare Part A.
QMB Entitled to Medicare 32.2.2 2. He or she must pay a monthly premium to receive Medicare Part A, and he or she fits one of the following descriptions: a. He or she is a Medicaid member and has been enrolled in Medicare sometime in the past. In this case the State will attempt to enroll him or her in Medicare Part A. QMB eligibility cannot begin prior to the Part A begin date.
QMB Entitled to Medicare contd b. He or she is a Medicaid member or QMB or SLMB or QDWI applicant and has never been enrolled in the federal Medicare system. In this case he or she must apply at the local SSA office for Part A Medicare eligibility. He or she will receive a receipt which entitles him or her to enrollment in Part A on the condition that he or she is found eligible for QMB or SLMB. The receipt from SSA will have a Part A begin date on it. QMB OR SLMB or QDWI eligibility cannot begin prior to the Part A begin date
QMB Entitled to Medicare contd Example: Pearl was never enrolled in the federal Medicare system. She applies for QMB. Before she can become QMB eligible she must obtain a receipt for conditional eligibility for Part A Medicare. She goes to the SSA office during the January-March enrollment period and is conditionally determined eligible for Part A effective July 1st. She applies for QMB at the IM Agency on May 1st. She becomes QMB eligible as of July 1st
What about BadgerCare Plus? The following individuals are non-financially eligible for BadgerCare Plus: Children under 19, Pregnant Women, Parents/caretaker relatives of children under 18 years of age or dependent 18 year olds, including some parents and caretaker relatives whose children have been removed from the home and are in the care of the child welfare system (see Chapter 10 Child Welfare Parents), and Former foster care youth under age 26 who were in out-of-home care when they turned 18, and Effective April 1, 2014, adults ages 19-64, not receiving Medicare, who do not meet any of the conditions listed above
Example 1 Marta is a 75 year old legal immigrant from Macedonia. She has no income or assets and has been living with her daughter in the US for approximately 2 years. She has never paid FICA taxes. What options does Marta have? Medicare? o Medicaid? o Marketplace? o
Marketplace Exception Marketplace Savings (APTC and CSR eligibility) Generally: Consumers must have annual household income between 100% and 400% of the Federal Poverty Level (FPL) in order to be eligible for APTC. Exception: Immigrants who are lawfully present but have an immigration status that is not eligible for Medicaid based on immigration status may be eligible for APTC and CSRs even if their annual household income is under 100% FPL. https://marketplace.cms.gov/technical-assistance-resources/immigrants-with- income-under-100-percent-fpl.pdf
Example 2 Sister Mary Clarence is a 70 year old nun whose only work history involved teaching at the church. She received nominal wages for this work but did not pay FICA taxes on the wages. Accordingly, she has under 10 QC s. Her current income is $500 per month and assets are under $2,000. What options does Sister Mary Clarence have? Medicare? - Medicaid? - Marketplace? -
Example 3 Stuart is a 68 year old man with spotty work history. He is currently employed and his monthly income is $1200. He has acquired 32 QC s over his liftetime and has assets totaling $10,000. What are Stuart s options? Medicare? - Medicaid? - Marketplace? -
