Retention Date: June 30, 2020
Revision 6: The Centers for Medicare and Medicare Services (CMS) extended this equitable relief. The eligibility criteria has been updated to end on September 30, 2019. Beneficiaries who meet the eligibility criteria in this Emergency Message (EM) may request this relief at any time.
Revision 5: Corrected typographical error and added a visual sample of the Marketplace and Medicare notice listed in section D #3 to the list of acceptable forms of proof and added a sample of the notice that CMS is mailing the week of 8/20. Beneficiaries will bring in this notice to the FOs, and we want them to be prepared for it. The PDFs (508 compliant) of the notice are attached, along with the current EM with the small changes marked in the document, and flagged with comments for ease in finding them.
|EM-16033 REV 6|
|Intended Audience:||All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO/|
|Originating Office:||Centers for Medicare & Medicaid Services (CMS)|
|Title:||Limited Equitable Relief for Individuals with Medicare and Marketplace Coverage|
|Type:||EM - Emergency Messages|
|Link To Reference:||See References at the end of this EM.|
Revision 4: Updated the requirements for Equitable Relief in section D by adding “6. Receipt from issuer indicating payment of binder payment effectuating Marketplace enrollment; and” to the list of acceptable forms of proof.
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.
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. They 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.
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, 2018, or 2019 GEP.
Beneficiaries who meet the eligibility criteria can request the relief at any time.
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. 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, 2018, or 2019 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.
To be eligible, the beneficiary must have entitlement to premium-free Part A AND meet one of the following:
The beneficiary must also:
- Part A entitlement date must be between July 2013 and September 2019, OR
- Was notified of retroactive Part A entitlement between October 1, 2013 and September 30, 2019, OR
- SEP must have ended between October 1, 2013 and September 30, 2019.
Acceptable forms of proof may include, but are not limited to:
- Request enrollment in Part B or request premium surcharge rollback or removal;
- 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 between January 2014 and September 30, 2019.
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. Marketplace and Medicare notice;
Marketplace and Medicare Letter.pdf Marketplace and Medicare Spanish Letter.pdf
4. Form 1095 A that demonstrates months of coverage and/or subsidy amounts;
5. Marketplace premium invoices and proof of payment;
6. Receipt from issuer indicating payment of binder payment effectuating Marketplace enrollment; and
7. Other Marketplace notices confirming enrollment.
NOTE: This relief does not apply to individuals enrolled through the small business health options Marketplace through an employer (also referred to as SHOP).
The following beneficiaries are not eligible for the relief:
Examples for approval of equitable relief:
- Those who are in their 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.
- Those who are 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.
- Those who’s Part A start date is between September 30, 2013 or earlier, or were notified of retroactive Part A entitlement on September 30, 2013 earlier.
Examples that do not meet approval of equitable relief:
- Mr. Raimondi’s has premium-free Part A effective 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 has premium-free Part A effective 3/2016. 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 has premium-free Part A effective 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 has premium-free Part A effective 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 between October 1, 2013 and September 30, 2019.
- Ms. Jones has premium-free Part A effective 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.
E. Part B effective dates
- Mr. Chin has premium-free Part A effective 8/2016. 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 has premium-free Part A effective 8/2012. 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 premium-free Part A entitlement date began prior to 7/2013.
- Mrs. Richard has premium-free Part A effective 9/2012, but she refused Part B. She later enrolled in Part B during the 2016 GEP and was assessed a premium surcharge. She 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. Her request for Part B premium surcharge reduction is denied because her Part A entitlement began prior to 7/2013.
- Mrs. Parker has premium-free Part A effective 5/2010. 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 has premium-free Part A effective 9/2009. 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.
Individuals who meet the criteria for equitable relief can enroll in Part B. The effective date for Part B coverage can begin either:
F. Processing equitable relief
- The month the beneficiary enrolls, or
- At the beneficiary’s option, any of the two months prior to the month of enrollment.
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:
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.
- 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 whose SEP ended between October 1, 2013 and September 30, 2019, 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.
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.
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.
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.
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 6 - Limited Equitable Relief for Individuals with Medicare and Marketplace Coverage - 10/01/2018