Most beneficiaries can only lose their Medicare coverage if they fail to pay their premiums.
There are two scenarios in which you can join Medicare: You qualify because of a disability, or because you turn 65. If you qualify due to a disability, there could be a circumstance where you could lose your Medicare; however, if you qualify because of age, you cannot lose your eligibility unless you do not pay your premiums.
There are a few other reasons you could lose your coverage depending on the type of plan you’re enrolled in to receive your benefits.
Because having insurance coverage is important to ensure you can get the medical care you need without having to pay for everything out-of-pocket, it’s essential to be familiar with how you can lose Medicare coverage, as well as eligibility requirements and what to do if you lose coverage.
Losing Medicare Coverage
When you turn 65, you qualify for Medicare and it’s yours for life. However, there is only one circumstance in which you would lose Medicare coverage, and that’s if you don’t pay your Part B premium.
If you qualify for Medicare due to a disability, there are some circumstances in which you could lose coverage. This is dependent on the disability you have.
For example, if you qualify because you have ALS, you will never lose Medicare coverage because there is no cure for ALS.
On the other hand, if you have Medicare because of permanent kidney failure, you are not 65 years old and you do not have another disability, your Medicare coverage will typically end 12 months after the month you stop kidney dialysis treatments, or 36 months after you have a kidney transplant.
Depending on the type of Medicare plan you are enrolled in, such as if you have Original Medicare Part A and Part B, Part C (Medicare Advantage) or Part D (prescription drug coverage), there are a few additional circumstances in which you could lose coverage, including:
- You fail to pay your plan’s premiums. This includes your Medicare Part B premium, as well as Part C or Part D premiums (if applicable). Before you lose your coverage, you will receive a “first notice” (typically your month’s bill), and then a Second Notice. If you do not pay your premiums by the deadline in the Second Notice, you will receive a Delinquent Notice. You have until the 25th of the month you receive this notice to pay your premium, or your coverage will be terminated.
If you’re enrolled in a Medicare Advantage or Medicare Supplement plan, your coverage is typically contingent on being enrolled in Part A and Part B. If you lose Part A or Part B coverage because you didn’t pay the premiums, you may be disenrolled from your other plan.
- You move outside your plan’s coverage area. This is specifically for Part C or Part D plans. These plans are usually only offered within a certain service area, and if you move outside that service area, you will likely lose your coverage. However, after you move you’ll likely be granted a Special Enrollment Period (SEP) in which you can enroll in a new plan in your new location.
Part A and Part B do not have provider networks or service areas, so moving would not affect your enrollment.
- Your plan is discontinued. A Medicare plan, specifically Part C or Part D plans, may be discontinued for a few reasons. First, low-performing plans may be discontinued by the Centers for Medicare and Medicaid Services (CMS). Or, because Part C and Part D plans are offered by private insurance companies, the company may close the doors altogether or simply restructure offerings and decide to drop a plan.
In each of these cases, you would be offered an SEP so you can enroll in a new plan.
- You provided misleading information on your plan application. This is particularly applicable for medical underwriting required for Medicare Supplement plans. An example would be if you said you did not smoke even though you do just to secure a lower rate on your plan. Or, if you say you live at an address you do not in order to meet a plan’s service area criteria.
If it’s discovered you intentionally provided false information on your application, you can lose your coverage.
- You engage in Medicare fraud. If you do anything to defraud Medicare in any way, like let someone else use your Medicare card to obtain covered services, you will likely lose your coverage.
Can I Still Get Medicare Coverage if My Disability Benefits Stop?
Even if your Social Security Administration (SSA) disability benefits stop, your Medicare benefits may continue. This is the case if:
- You have not recovered from your qualifying medical condition
- Your benefits stopped because you are able to work
If you get better, and the SSA reports to Medicare that you’re no longer eligible for benefits, your Medicare coverage will end because you’ve recovered from the disability that made you eligible in the first place. The coverage typically ends one month after you receive notice from the SSA.
Will I Lose Medicare Cover if I Return to Work?
If you are eligible for Medicare before age 65 because of a disability, you don’t automatically lose your Medicare benefits if you return to work.
According to the Social Security Administration, you’re eligible to receive 93 months of Part A (hospital insurance) and Part B (medical insurance) as long as you still have a disabling impairment. In this case, Part A would be premium-free. Then, after 93 months, if you continue to have a disability, you can purchase Medicare Part A and Part B coverage. (This includes your nine-month trial work period.)
Additionally, even if you qualify because you are 65, you won’t necessarily lose your Medicare coverage, even if you get healthcare coverage through work. In most cases, your employer’s coverage is the primary payer, and Medicare is secondary.
Do I Lose Coverage if My Medicare Card Is Lost, Stolen, or Damaged?
Your red, white and blue Medicare card is what you will show when you go to the doctor or get other health or physician services. If you lose your card, it’s stolen, or you can no longer use it because it’s damaged or faded, you can replace it by calling 1-800-MEDICARE (633-4227) or by logging into your mymedicare.gov account.
You will not lose your coverage if you need a replacement card, but you may have trouble ensuring your services are covered until you get your replacement. Because doctors and other health care providers typically need to see your insurance card as proof of insurance, you should always keep a copy of your card in a safe place just in case.
What Do You Do if You Lose Your Medicare Coverage?
If you lose your Medicare coverage, you have a few options.
1. If you don’t have other health insurance, you may be eligible for Medicaid. Medicaid is a state-run program that provides hospital and medical coverage for people with low income. Each state has rules regarding who is eligible and what is covered, but eligibility is determined partially by your Modified Adjusted Gross Income.
For more information on Medicaid, contact your Social Security office or visit www.Medicaid.gov.
2. You may be eligible to purchase insurance through a private insurance company. Compare plan options and eligibility requirements online or by contacting individual plans.
Medicare is generally available to those who are age 65 or older, have a qualifying disability, or have End-Stage Renal Disease. However, there are different eligibility criteria depending on whether you’re enrolling in Part A, B, C or D, as well as requirements to be met based on your specific circumstances.
Who is eligible for Part A and B?
In order to be eligible for Original Medicare Part A and Part B:
- You must be a U.S. citizen, or permanent legal resident who has lived in the U.S. for at least five years.
- You or your spouse worked and paid Medicare taxes for at least 10 years.
In addition, you must meet at least one of the following criteria:
Turning 65 (or older) and eligible for Social Security.
You may sign up for Medicare beginning three months before the month you turn 65. If you are close to turning 65 and are not getting Social Security or Railroad Retirement Board (RRB) benefits, you must sign up for Medicare. Even if you are eligible for premium-free Part A coverage, you still must enroll.
If you are receiving benefits from Social Security or RRB for at least four months before you turn 65, you’ll be automatically enrolled in Part A and Part B starting the first day of the month you turn 65.
Permanently disabled and received (or been entitled to) disability benefits for at least two years (24 months).
After 24 months of receiving disability benefits from Social Security or RRB, you’ll automatically be enrolled in Part A and Part B. The two-year period begins the first month you receive an SSDI check, and you will automatically be enrolled in Medicare on the first day of the 25th month.
Have End-Stage Renal Disease (ESRD).
With ESRD, you have permanent kidney failure that requires dialysis treatment or a kidney transplant. If this is the case, you must sign up for Medicare - you are not automatically enrolled. You must also:
- Have worked the required amount of time under Social Security, RRB, or as a government employee; or,
- Are getting or are eligible for Social Security or RRB benefits; or,
- Are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee; or are getting Social Security or RRB benefits.
Have Lou Gehrig’s Disease.
If you have Lou Gehrig’s disease, also known as Amyotrophic Lateral Sclerosis (ALS), you automatically get Part A and Part B the month your disability benefits begin. There is no waiting period.
If you or your spouse did not pay Medicare taxes while you worked, but you meet other eligibility criteria, you are likely eligible to purchase Part A.
In 2023, you will pay the following costs:
- Premium: You typically won’t pay a monthly premium for Part A. (If you do have to purchase Part A, you will pay either $278 or $506 per month).
- Deductible: $1,600
- Coinsurance based on number of inpatient hospital days
- Premium: $164.90
- Deductible: $226
- 20 percent coinsurance after you meet your deductible
- Premium: Varies by plan
- Deductible: Varies by plan
- Out-of-pocket costs vary by plan
- Premium: Varies by plan
- Deductible: Varies by plan
- Out-of-pocket costs vary by plan
How to Apply for Medicare
If you qualify for Medicare, there are a number of ways you can apply:
- Apply online at www.ssa.gov.
- Visit your local Social Security office.
- Call Social Security.
- Call the RRB (if you worked for a railroad).
- If you already have Part A and want Part B, you must complete an Application for Enrollment in Part B.
You are eligible for free Part A coverage if you’ve worked a specified number of quarters and file an application for Social Security or RRB benefits. You may not be eligible if you never worked and never paid Medicare taxes, but you can still purchase Part A coverage (with a premium). If you are not eligible for a free premium for Part A, you must:
- File an application to enroll by contacting Social Security.
- Enroll during a valid enrollment period.
- Enroll in or already have Part B.
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