Identification Number:
EM-16033 REV 3
Intended Audience:All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO/
OCO-CSTs/OHO
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Limited Equitable Relief for Individuals with Medicare and Marketplace Coverage
Type:EM - Emergency Messages
Program:Medicare
Link To Reference:See References at the end of this EM.
 
Retention Date: September 30, 2018

Corrected 05/24/2018: E. to "Individuals who meet the criteria for equitable relief can enroll in Part B from September 1, 2016 through September 30, 2018."

    Revision 3: The Center for Medicare and Medicaid Services (CMS) expanded this equitable relief to include certain individuals who were in their Special Enrollment Period (SEP) when the Health Insurance Marketplace opened or later. Beneficiaries who meet the eligibility criteria listed in this Emergency Message (EM) may request this relief at any time through September 30th, 2018, and do not have to wait until the General Enrollment Period to enroll in Part B.

    Revision 2: 10/12/2017: CMS extended the deadline for this equitable relief to September 30, 2018.

    A. Purpose
    This emergency message (EM) provides instructions for handling Medicare Part B (Supplementary Medical Insurance) enrollment requests from beneficiaries with premium-free Medicare Part A (Hospital Insurance) who are or were enrolled in an individual Marketplace plan. It also contains instructions for Part B premium surcharge rollback for certain beneficiaries with both Medicare Part A and Part B who have or had Marketplace coverage.

    B. Background of issue
    Coverage under Medicare Part A meets the legal requirement for minimum essential coverage. Individuals with Medicare Part A are not eligible to receive premium and cost-sharing assistance (often referred to as advanced payments of the premium tax credit (APTC) or income-based cost sharing reductions (CSRs) to help pay for a Marketplace plan premium and covered services to make the costs of a Marketplace plan more affordable. Individuals receiving APTC while dually-enrolled in coverage through the Marketplace and Medicare may have to pay back all or some of the APTC received for months an individual was enrolled in both Marketplace coverage with APTC and Medicare Part A when they file their federal income tax return.

    CMS believes that many of these individuals did not receive the information necessary at the time of their Initial Enrollment Period (IEP) or Special Enrollment Period (SEP) to make an informed decision regarding their Medicare Part B enrollment and Marketplace coverage.

    Individuals may not have found out they were not eligible for APTCs or CSRs or did not learn about the coverage rules prior to the end of their Medicare Initial Enrollment Period (IEP) or Special Enrollment Period (SEP), resulting in them either:

    1) declining to enroll in Medicare Part B at all;
    2) dropping Part B; or
    3) enrolling in Medicare Part B during the General Enrollment Period (GEP) and being assessed a Medicare Part B late enrollment penalty.

    In addition, some people with Medicare Part A coverage may have enrolled in coverage through the Marketplace believing it was an alternative way to get medical coverage equivalent to Medicare Part B at a more affordable cost. The individual may have thought the costs for Marketplace coverage (with financial assistance) were more affordable than Medicare Part B.

    In the summer of 2016, CMS mailed a notice to Federally-facilitated Marketplace enrollees who were enrolled in Medicare Part A, over age 65 and receiving advanced payments of the premium tax credit informing them of their dual enrollment, loss of eligibility for the tax credits and encouraging them to follow the instructions listed on their notice to either end their APTC or drop their Marketplace coverage and enroll in Medicare Parts A and B.

    Beneficiaries who drop Marketplace subsidy assistance and continue their Marketplace coverage may find the full cost of their Marketplace plan unaffordable or may be disenrolled if they stop paying their premiums.

    In February and June 2017, CMS mailed a
    notice to beneficiaries who have Medicare Part A and are enrolled in an individual Marketplace plan. The notice explains that dually-enrolled beneficiaries are not eligible to receive subsidies (APTC or CSRs) that help lower the cost of Marketplace plans. The notice also advises beneficiaries to end Marketplace coverage to help reduce a possible financial liability at tax time and provides an offer of equitable relief. Go to https://marketplace.cms.gov/applications-and-forms/notices.html and scroll to the section called “Periodic Data Matching Notices” for a sample of the February notice.

    In March 2018, CMS mailed a notice to beneficiaries who have Medicare Part A and are enrolled in an individual Marketplace plan. The notice informs dually-enrolled beneficiaries that they are not eligible to receive subsidies (APTC or CSRs) and they should end Marketplace coverage to avoid a possible financial liability at tax time. The notice also provides an offer of equitable relief to either enroll in Part B or, if the person has Part B, have their late enrollment penalty reduced. Go to https://marketplace.cms.gov/applications-and-forms/notices.html and scroll to the section called “Periodic Data Match Notices” to see a sample of the March notice.

    As such, CMS is providing limited equitable relief to individuals who refused or dropped Part B because they are or were enrolled in an individual Marketplace plan.

    C. Limited availability of equitable relief
    Equitable relief will be considered on a case-by-case basis for certain dually-enrolled beneficiaries (those who have or had both Medicare and Marketplace coverage) of any age who refused or dropped Part B and for those who subsequently enrolled in Part B during the 2015, 2016, 2017, or 2018 GEP.

    Beneficiaries who refused or dropped Part B may receive equitable relief in the form of an enrollment opportunity with an effective date outlined in Section E of this instruction. The ability to provide the enrollment opportunity under equitable relief is limited to Part B enrollment requests received September 1, 2016 through September 30, 2018. No late enrollment penalty will be applied for individuals who enroll in Part B under this limited equitable relief.

    Beneficiaries eligible for equitable relief who enrolled in Part B during the 2015, 2016, 2017, or 2018 GEP and are paying a premium surcharge, may request to have the surcharge reduced. Premium surcharge reductions will be reduced to zero for eligible individuals. Excess premiums will be refunded or applied to retroactive premiums, if applicable.


    D. Criteria for equitable relief

    Certain criteria must be met for consideration of equitable relief.

    The beneficiary
    may not:
    · Be in his or her Initial Enrollment Period (IEP). For a beneficiary with Part A entitlement and still in the IEP, process the Part B enrollment as outlined in HI 00805.110.

    · Be uninsured and filing an initial application for Part B or premium Part A (see HI 00801.131 for premium Part A eligibility and HI 00801.138 for the premium Part A application). Process such enrollments following HI 00805.110B.3.

    · Have an IEP or SEP that ended September 30, 2013 or earlier, or were notified of retroactive Part A entitlement on September 30, 2013 or earlier.

    The beneficiary must:
    · Have entitlement to premium-free Part A;
      · Have either:
            · an IEP that began on April 1, 2013 or later, or were notified of retroactive Part A entitlement on October 1, 2013 or later (but not be in a current IEP as noted above); or
            · a Part B SEP that ended October 1, 2013 or later.
        · Request enrollment in Part B, premium surcharge rollback or removal and mention equitable relief or being enrolled in both a Marketplace plan and Medicare Part A; and
          · Present proof of Marketplace enrollment for any period of time since Marketplace coverage was first available (January 2014 through the present). Acceptable forms of proof may include, but are not limited to:

          1.
          Periodic data match (PDM) notice mailed to dually-enrolled aged beneficiaries (those enrolled in both Medicare and the Marketplace);
          2. Marketplace
          Eligibility Determination Notice;
          3.
          Form 1095 A that demonstrates months of coverage and/or subsidy amounts;
          4. Marketplace premium invoices and proof of payment;
          5. Receipt from issuer indicating payment of binder payment effectuating Marketplace enrollment; and
          6. Other
          Marketplace notices confirming enrollment.
            NOTE: This assistance does not apply to individuals enrolled through the small business health options Marketplace through an employer (also referred to as SHOP).

            Examples for approval of equitable relief:
            · Ms. Jones’s IEP for entitlement to premium-free Part A began 6/2014. She visits her local Field Office (FO) to enroll in Part B and says that she found out she has to repay all the discounts she got while in the Marketplace plan because she has Medicare Part A. She submits Form 1095-A that indicates she is a Marketplace enrollee. This meets the requirement to mention being enrolled in both a Marketplace plan and Medicare Part A and the Form 1095-A shows proof of Marketplace enrollment.
              · Mr. Raimondi’s IEP for entitlement to premium-free Part A began 2/2015. He indicates in his interview that he received a letter that says he should drop his Marketplace plan because he has Medicare Part A. He presents the PDM notice and expresses interest in enrolling in Part B. This meets the requirement to mention dual enrollment in a Marketplace plan and Medicare, and the PDM notice shows proof of Marketplace enrollment.
                · Ms. Levin’s IEP for entitlement to premium-free Part A began 3/2016 and she has Part A. She contacts her local FO asking about Medicare Part B enrollment. She says that she enrolled in the Marketplace instead of enrolling in Part B because she got approved for the tax credits. She submits a receipt of binder payment indicating Marketplace enrollment. This meets the requirement to request Part B coverage and her receipt of binder payment shows proof of Marketplace enrollment.
                  · Mr. Simon’s IEP for entitlement to premium-free Part A began 7/2014. He enrolled in Part A but refused Part B because Marketplace coverage was cheaper than Part B. He later discovered that this Marketplace plan did not provide the coverage he needed. He subsequently enrolls in Part B during the 2016 GEP and is assessed a premium surcharge. He also terminates his Marketplace coverage as of 7/2016. Mr. Simon contacts his local FO in 8/2016 to inquire about the amount of his Part B premium and provides a copy of the invoices and the payments for his Marketplace coverage for the period from 7/2014 through 6/2016. This meets the requirement to request a premium surcharge reduction, and the invoices and payment receipts shows proof of Marketplace enrollment.
                  · Mrs. Shuman’s IEP for entitlement to premium-free Part A began 4/2011, and she has Part A. She refused Part B when first eligible because she was working and had group health plan coverage through her employer. She retired in 2014 and her SEP eligibility ended 11/2014. She visits her local FO in 07/2018, requests to enroll in Part B and submits Form 1095-A indicating her Marketplace enrollment. This meets the requirement to have an SEP that ended October 1, 2013 or later.
                    Example that does not meet approval of equitable relief:
                    · Mr. Chin’s IEP for his entitlement to premium-free Part A began 8/2016 and he has Part A. He contacts his local FO in 1/2017 and asks about enrollment in Part B. He states that he chose to enroll in Marketplace coverage instead of Part B because it has dental coverage. He was recently diagnosed with a serious illness and wants Medicare Part B. This does not meet the requirements for equitable relief because he is still in his IEP at the time he requests enrollment. His Part B enrollment request must be processed under IEP processing rules
                      · Mr. Chin’s IEP for his entitlement to premium-free Part A began 8/2016 and he has Part A. He contacts his local FO in 1/2017 and asks about enrollment in Part B. He states that he chose to enroll in Marketplace coverage instead of Part B because it has dental coverage. He was recently diagnosed with a serious illness and wants Medicare Part B. This does not meet the requirements for equitable relief because he is still in his IEP at the time he requests enrollment. His Part B enrollment request must be processed under IEP processing rules.
                        · Ms. Moody’s IEP for her entitlement to premium-free Part A ended 8/2012 and she has Part A. She asks about enrollment in Part B stating she chose to enroll in Marketplace coverage with the subsidy instead of Part B. She shows her Form 1095-A as proof of her Marketplace enrollment. This does not meet the requirements for equitable relief because her IEP ended prior to 9/2013.
                          · Mrs. Richard’s IEP for her entitlement to premium-free Part A began 6/2012, and she has Part A, but she refused Part B. She later enrolled in Part B during the 2016 GEP and was assessed a premium surcharge. Mrs. Richard contacts her local FO and requests to have her Part B premium surcharge reduced. She explains that her neighbor’s Part B premium was reduced because she was eligible for equitable relief. Mrs. Richard’s request for Part B premium surcharge reduction is denied because her IEP began prior to 4/2013.
                            · Mrs. Parker’s IEP for entitlement to premium-free Part A began 5/2010, and she has Part A. She refused Part B when first eligible because she was working and had group health plan coverage through her employer. She retired in 2012 and her SEP eligibility ended 9/2012. She contacts her local FO in 7/2017 and requests to enroll in Part B. Mrs. Parker’s request for Part B enrollment is denied because her SEP eligibility ended 9/2012.
                              · Mr. Harper’s IEP for entitlement to premium-free Part A ended 9/2009, and he has Part A. He refused Part B when first eligible because he and his wife were working and he had group health plan coverage through his wife’s employer. He retired 2/2016. He visits his local FO on 2/15/2017 and requests to enroll in Part B. His SEP eligibility ended 10/2016 and he has no proof of Marketplace enrollment. His request for Part B enrollment is denied.
                              E. Part B effective dates
                              Individuals who meet the criteria for equitable relief can enroll in Part B from September 1, 2016 through September 30, 2018. The effective date for Part B coverage can begin either:
                              The month the beneficiary enrolls, or
                              At the beneficiary’s option, any of the two months prior to the month of enrollment.

                              F. Processing equitable relief

                              FO steps:


                                1. Consider whether all the requirements in Section D of this instruction are met.

                                2. Collect the beneficiary’s statement, proof of Marketplace coverage, and any available evidence.

                                3. For beneficiaries requesting Part B enrollment, complete the following steps:

                                    · If the beneficiary expresses dire need of medical attention, refer the action to the program service center (PSC) of record following existing instructions in GN 01070.228.

                                    · Complete Form CMS-40B (Application for Enrollment in Medicare Part B (Medical Insurance)).

                                    · For beneficiaries who were in their SEP October 1, 2013 or later, obtain evidence of Group Health Plan (GHP) coverage or Large Group Health Plan (LGHP) coverage based on current employment via Form CMS-L564 (Request for Employment Information).

                                    · If the beneficiary wants a retroactive effective date, explain that payment of all premiums for all months of coverage is required. Explain that the total amount of premiums for all months, including the next coverage month, may be deducted all at one from his or her benefit amount. Be sure the beneficiary understands the implications for a retroactive effective date before processing.

                                    · Include in the remarks sections of the CMS-40B the beneficiary’s Part B effective date choice according to section E of this EM.

                                    · Print the CMS-40B barcode from NDRED.

                                4. Prepare a Form SSA-5002 (Report of Contact) giving your analysis of the information, any evidence provided, request for surcharge removal, and your decision as to whether relief should or should not be provided. Include the reasons for approval or disapproval based on your review.

                                5. Fax the completed CMS-40B, SSA-5002 and supporting documentation (e.g., the CMS-L564 and the beneficiary’s notice from CMS) into CFRMS.

                                6. Forward the case to the appropriate PSC for review and processing.


                              PSC steps:


                              1. Review the beneficiary’s statement, proof of Marketplace coverage, proof of GHP/LGHP coverage based on current employment, and any available evidence in support of SSA-5002 determination.

                              2. Process approved equitable relief case following normal Equitable Relief procedures.

                              3. If the beneficiary is eligible for surcharge reduction, remove the existing surcharge. Apply excess premiums to any past-due premium amounts owed. If no past-due amounts are owed, refund the excess premiums to the beneficiary.


                            After September 30, 2018, this equitable relief is no longer available. Any enrollment request received after September 30, 2018 should be processed following normal enrollment period rules as outlined in HI 00805.025.

                            Direct all program-related and technical questions to your Regional Office (RO) support staff or Program Service Center (PSC) Operations Analysis (OA) staff. RO support staff or PSC OA staff may refer questions or problems to their Central Office contacts.

                            G. References
                            HI 00801.131 Eligibility for Premium HI
                            HI 00801.138 Application for Premium HI
                            HI 00805.010 Rules on Enrollment Periods
                            HI 00805.015 Initial Enrollment Period
                            HI 00805.025 General Enrollment Period
                            HI 00805.275 Special Enrollment Period (SEP) Enrollments



                            EM-16033 REV 3 - Limited Equitable Relief for Individuals with Medicare and Marketplace Coverage - 05/18/2018