Today we’re going to talk about Original Medicare, the basics of Medicare that all originate from Social Security. That’s a big reason we have Frank with us today. This likely isn’t the first time you’ve heard from or seen Frank. We’re fortunate to have him speak at our Medicare Connections conference every year, and hopefully we’ll have him back again this August. He joins us because Original Medicare is always changing. He’ll be discussing some updates for 2023, and I’m sure there will be even more to talk about for 2024 later this year. Like everything else under CMS, insurance keeps us on our toes.

This session is a great refresher if you’re already an expert in Medicare, but it’s also a strong educational foundation if you’re new. If you don’t understand the basics of Parts A and B, it’s very difficult to effectively sell Medicare Advantage or Medicare Supplement policies. You need to understand how those products tie in, what exposure exists, and what risk your client may be taking on if they don’t purchase a policy.

I’ll quickly walk you through the screen. You should see Frank and me live, along with the slides displayed clearly. On the bottom right of your screen, you’ll see a blue chat box. If you click on that, it will open the chat. There’s a public view if you’d like to chat with everyone, as well as a Q&A section. Feel free to submit questions as we go, and if anything comes up, I’ll alert Frank so we can address it during the presentation or at the end.

Today’s presentation is being recorded and will be available in our training library, accessible with your username and password through our website. If you need to reference it later, it will be there. We typically host one or two training webinars each week, so if you’ve missed anything recently, those recordings are also housed in the training library. Be sure to check it out. We also have some great sessions coming up next week, including PACE, which is always well attended, so make sure you register for that.

Without further ado, I’ll turn it over to Frank. Frank, thank you so much for joining us.

Thank you, and good afternoon everyone. As mentioned in the introduction, I know some of what you’ll see on the slides may feel basic. I understand these are pre-approved slides through the Social Security Administration. That said, I think the most valuable part of today’s presentation will be my experience working in this space.

I’m currently the Public Affairs Specialist for Central Pennsylvania, which covers the entire state except Philadelphia and Pittsburgh. I’ve been in this role since May of last year. Prior to that, I worked in the Lancaster, Pennsylvania field office as a service technician processing forms, and later as an operations supervisor for three years. Through those roles, I’ve seen congressional inquiries, complex special enrollment period situations, and many of the challenges individuals face. I’ll reference that experience as much as possible throughout this presentation.

I’ll also talk about online services, which are important for brokers like yourselves, and I’ll spend time discussing the Income-Related Monthly Adjustment Amount. With that, let’s get into the slides.

Before we begin, I want to provide a quick update on our services. This information has been evolving, so it’s important to understand where we currently stand. Field offices have been open since April 1st, and we’re approaching one full year of reopening. In-person appointments are available, but the majority of services are still handled over the phone. Even when field offices are open, many staff members are working in a hybrid model, which is why phone appointments remain the preferred method.

You’re still speaking directly with field office representatives, and if documents such as marriage certificates or identification are required, those can still be brought into the office. However, many applications are completed by phone with offices such as Greensburg, Erie, or Altoona. This approach helps streamline operations. While offices are open, the process does look different post-pandemic. We continue to be cautious, especially given the populations we serve, and some safety measures were only recently lifted.

We strongly promote online services, which is one of the reasons I’m speaking with you today. As for calling Social Security for help, you’ll often find the national 1-800 number listed prominently online. While that number is useful, I recommend encouraging individuals to contact their local field office whenever possible, especially for more complex Medicare enrollment situations or when forms have already been submitted. Local office numbers are usually listed as secondary options online, though many searches will still route calls to the national line.

For individuals who have not applied for their monthly benefits in advance, an application is still required. This is especially important in cases involving spousal benefits. In those situations, scheduling an appointment with the field office is often the best approach. Establishing Medicare Parts A and B may involve an online application or one completed through the field office so the necessary forms can be processed.

Field offices are generally open from 9:00 a.m. to 4:00 p.m. We ask individuals experiencing COVID symptoms to use alternative service channels. Traffic has returned to pre-pandemic levels, which means certain times can be busier, especially the first day of the week, the first week of the month, or the day after a holiday. Visiting later in the day, later in the week, or later in the month typically results in shorter wait times, often around 30 to 40 minutes in Central Pennsylvania. Urban centers may experience longer waits.

This is especially relevant for individuals who are within 30 days of wanting their Medicare to start. In those cases, I often recommend either calling the field office or bringing forms such as the CMS-40B and CMS-L564 directly to the office to confirm documentation and ensure timely processing. While many people prefer to avoid visiting a field office, doing so can provide peace of mind when timing is tight. Faxing documents using methods outlined on SocialSecurity.gov is another option.

One important update I like to share is that individuals can now request a replacement Social Security card online without visiting a field office. Those with login credentials through Login.gov or ID.me and a valid driver’s license or state ID can complete this process online. Most states support this option, including Pennsylvania. This has been a significant improvement and reflects our ongoing push toward online services.

From a Medicare perspective, online services are extremely valuable. They allow individuals to apply for Medicare, replace Medicare cards, access tax documents, and obtain other necessary records after eligibility is established. These tools are helpful for both beneficiaries and professionals assisting them.

The Social Security Administration plays a key role in the Medicare process, though it is a separate agency from the Centers for Medicare and Medicaid Services. Historically, this separation created challenges, as Social Security staff were required to follow CMS rules and guidance. In 2023, some of those barriers have been reduced, and I’ll touch on those changes shortly.

Social Security administers Medicare Parts A and B. One important clarification involves Medicare Part A. It was once commonly advised that individuals should enroll in Part A at age 65 even if they were deferring Part B. That guidance has changed. Enrolling in Part A can impact eligibility for certain employer-sponsored Health Savings Accounts, so individuals continuing to work past 65 may want to delay Part A as well. Part A and Part B can be enrolled in simultaneously later through equitable relief once employment ends.

Social Security is also involved in administering Extra Help for Medicare Part D. Recent legislation has renewed attention on this program, particularly for low-income Medicare beneficiaries, and I’ll discuss that shortly.

Most individuals you’ll work with become eligible for Medicare at age 65. If someone is already receiving Social Security benefits before age 65, their Medicare enrollment is automatic at 65. Otherwise, age 65 triggers the Initial Enrollment Period, which has undergone some recent changes.

There are also individuals who qualify for Medicare before age 65, most commonly through Social Security Disability benefits. Individuals receiving disability benefits become eligible for Medicare 24 months after their disability eligibility date. Because disability claims can involve retroactive decisions, Medicare eligibility timing can vary. For example, someone may learn they are eligible for disability benefits months or even years after the initial eligibility date, which can affect when Medicare begins. It’s important to remember that the 24-month period is tied to the disability eligibility date, not when benefits first start being paid.

The Initial Enrollment Period includes the three months before turning 65, the month of the 65th birthday, and the three months after. Under prior rules, individuals enrolling after their birthday month often experienced delays in coverage start dates. These rules created confusion and frustration, particularly for those enrolling in the months immediately following age 65.

Under the old rules, the month in which someone turned 65 or the months after dictated when coverage could start. The new Initial Enrollment Period rules are much simpler. Coverage now generally starts the month after an individual contacts us. If someone reaches out three months in advance, coverage can start right at age 65. If they contact us during their birthday month, coverage can start the following month. These same timing rules now apply to the General Enrollment Period as well.

As I mentioned earlier, the Initial Enrollment Period is followed by the General Enrollment Period. This applies when someone does not start Medicare at age 65 or enrolls later. As you may know, for every 12-month period someone goes without coverage after age 65, they can accrue a 10 percent penalty. The important change, effective from 2022 into 2023, is how coverage start dates work under the General Enrollment Period.

Previously, if someone signed up in January, February, or March, their coverage would not begin until July of that year. This created difficult situations, especially when someone learned late in the year that they had to wait until the next General Enrollment Period and then several additional months for coverage to begin. While insurance often works this way, it was understandably frustrating.

Now, if someone enrolls in January, coverage begins in February. If they enroll in February, coverage starts in March. If they enroll in March, coverage begins in April. This makes Medicare much more accessible. In some cases, individuals who want to delay coverage slightly and keep their non-enrollment period under 10 months may choose to use the General Enrollment Period strategically, although that is not something I would generally recommend. Still, the rules are far more user-friendly than before.

Between the Initial Enrollment Period at age 65 and the General Enrollment Period, coverage now typically begins the month after contact. This eliminates many of the arbitrary delays we used to see. I know many brokers and PA MEDI counselors run into situations where they are trying to help someone enroll and assume Special Enrollment Period rules will apply, when the individual is actually still within their Initial Enrollment Period. These updates should reduce many of those challenging public service situations.

Now let’s talk about Special Enrollment Periods, because this is where some of the most significant changes have occurred. I’ve worked for the agency for 12 years, and I’ve personally handled dozens of difficult cases involving Medicare enrollment. These new rules are going to help prevent many of those situations.

Most individuals do not take Medicare at age 65. Instead, they stay on employer-based health coverage through their own active employment or their spouse’s employment. When that coverage ends, they typically enroll through a Special Enrollment Period. It’s important that the coverage be based on active employment and provided by the employer. There are some complicated situations involving self-employed individuals and small employers, particularly when determining whether coverage qualifies as a large group health plan.

A key red flag to watch for is someone who is self-employed or works for an employer with five or fewer employees. In those cases, the coverage may not qualify for a Special Enrollment Period. If you’re working with someone like this before age 65, it’s important to verify whether their employer coverage qualifies. This is a situation where contacting the field office in advance can prevent problems later.

Most commonly, individuals come to Social Security when they stop working. At that point, many also want to start collecting their retirement benefits. For many people, full retirement age is 67, which allows them to work without earnings limits, and benefits increase until age 70. There is generally no advantage to waiting beyond age 70 if someone is eligible for Social Security benefits.

There are also some unique situations involving Old Order Amish or Mennonite communities, where individuals may have opted out of Social Security and Medicare and may not be eligible even if they worked for a period of time. However, for most people, the process is straightforward. When they stop working, they contact Social Security.

For single individuals with simple cases, online applications work very well, whether they are applying for Medicare only or starting retirement benefits. For married individuals, or those with disabled family members, children under 18, or spousal claims, I strongly recommend scheduling a field office appointment. In some cases, it is required. During that appointment, Medicare enrollment can be completed and the Special Enrollment Period recognized.

If the individual is prepared with the CMS-40B and CMS-L564 forms, the process is smooth. The CMS-40B must clearly indicate the month and year coverage should start, and the CMS-L564 must document continuous active employment-based coverage going back to age 65. When these forms are completed correctly, the Special Enrollment Period is granted.

Some of this guidance is still very new. Information is gradually being added to SocialSecurity.gov, and once more formal public-facing materials are available, they will be shared. Many of these updates may also come through CMS.

Several new Special Enrollment Period categories are worth highlighting. One applies to formerly incarcerated individuals. In the past, these individuals often had to wait for the General Enrollment Period, sometimes resulting in long delays and penalties. Under the new rules, formerly incarcerated individuals can generally start Medicare coverage the month after release, and in some cases avoid penalties. The specifics depend on whether they were enrolled in Medicare prior to incarceration, but the process is far more accessible than before.

Another Special Enrollment Period applies to individuals whose ability to enroll was impacted by a federally, state, or locally declared emergency or disaster. In these situations, field offices may allow late enrollment outside standard timeframes.

There is also a new Special Enrollment Period for misrepresentation by an employer or group health plan regarding Medicare enrollment. While I haven’t personally encountered one of these cases yet, documentation will be required, including evidence of the misrepresentation and, in some cases, records showing prior contact with Social Security. These rules are brand new, and we’re still gaining experience applying them.

One Special Enrollment Period that I see more frequently involves termination of Medicaid eligibility. During the COVID public health emergency, states were not allowed to remove individuals from Medicaid, even if they would normally lose eligibility. That emergency declaration is ending, and as a result, many individuals who were temporarily kept on Medicaid are now losing coverage.

Previously, individuals in this situation might have been referred to the marketplace or forced to wait for the General Enrollment Period, with coverage not starting until July of the following year. Under the new rules, if someone loses Medicaid, Medicare coverage can begin the month after Medicaid ends, provided documentation is available. This is a major improvement and one you are likely to encounter this year.

There is also a Special Enrollment Period for other exceptional circumstances that prevented timely enrollment. While I haven’t yet worked a case under this category, it provides flexibility for unusual situations. International volunteers who serve outside the United States for more than 12 months may also qualify for a Special Enrollment Period upon returning. This provision has existed since 2007.

Medicare applications can be submitted by fax, and fax numbers for specific field offices are available on SocialSecurity.gov through the office locator. The CMS-40B and CMS-L564 can be faxed or submitted through the online application portal, and both methods feed into the same paperless system used by field offices.

It typically takes two to three business days for faxed or electronically submitted documents to be assigned and processed internally. For that reason, if someone submits documents and immediately calls the field office, staff may not yet be able to locate them. It’s best to wait a day or two before calling to confirm receipt. This approach works well for individuals who are within 30 days of wanting coverage to start and want to avoid visiting a field office in person.

Once Medicare enrollment appears in the system, coverage such as Medicare Advantage or supplemental plans can often be initiated quickly, even if physical documentation has not yet been received. This is important for brokers, as official system enrollment is what ultimately allows coverage to proceed.

One of the most important topics I want to emphasize is the Income-Related Monthly Adjustment Amount. This is an area where you provide tremendous value to your clients. If an individual’s modified adjusted gross income exceeds certain thresholds, their Medicare Part B and Part D premiums increase incrementally. These thresholds are published and easily accessible through Social Security.

Many individuals encounter this when they are nearing retirement. They may be earning more, cashing out retirement accounts, selling property, or receiving other income near the end of their working years. Medicare enrollment and Social Security benefits often begin around the same time, which is also when income tends to be highest.

Because Social Security uses tax data from two years prior, individuals may pay standard premiums for a year or two before receiving notice that higher premiums apply. For example, in 2023, determinations are based on 2021 tax data. This delay often catches people off guard.

Situations that commonly trigger higher premiums include converting retirement accounts, receiving inheritances, selling property, or experiencing other one-time income spikes. Many of these situations do not qualify as life-changing events, even though they significantly increase income for a single year. As a result, individuals may face hundreds of dollars per month in additional premiums, adding up to thousands of dollars annually.

Life-changing events that can reduce or eliminate these adjustments include work stoppage, work reduction, marriage, divorce, or the death of a spouse. The most common qualifying event is stopping or reducing work, which often results in lower income after retirement.

Notices about Income-Related Monthly Adjustment Amounts are typically sent in late November or early December. While the term “modified adjusted gross income” is used, most people simply recognize this as adjusted gross income with certain tax-exempt interest added back in.

We also encourage individuals to use Medicare.gov alongside SocialSecurity.gov. Medicare.gov is an excellent resource for understanding coverage options and navigating the system after enrollment, which can feel overwhelming for many new beneficiaries.

Field offices remain involved in administering Extra Help with Medicare prescription drug costs. This program serves lower-income individuals and often results in Part D coverage at little or no cost. Importantly, the Inflation Reduction Act increased the income eligibility threshold from 130 percent to 150 percent of the federal poverty level. As a result, individuals who were previously just over the limit may now qualify beginning in 2023.

There will be mass mailings coming from the Social Security Administration to individuals who have applied for these benefits in the past. You may start to see these mailings circulating, and this could become a common topic of discussion. Individuals can apply either through a Social Security field office or through a human services office. In some cases, I actually recommend the human services office over the field office.

The reason is that human services offices may also be able to determine eligibility for what is commonly referred to as the state buy-in. This applies to lower-income individuals and, in some cases, allows Medicaid to pay the Medicare Part B premium. The individual would otherwise have Medicare, but the premium is covered on their behalf. People sometimes notice this when they hear about the Part B premium being added to or deducted from a Social Security check.

Because many of you work in referrals, including referrals related to the marketplace, this is an important point. When you encounter individuals with lower income—generally around $25,000 per year or less, depending on marital status—a strong referral is either the Social Security office or the human services office. These programs also serve as pathways to prescription assistance, including insulin pricing changes that have received media attention and potential caps on prescription drug costs over the course of the year.

Much of this is new, and we are all learning together. I expect to have more detailed information later in the year, but this terminology and these programs will be part of everyday discussions throughout 2023.

I also want to briefly address the topic of insolvency, since it has been appearing frequently in the headlines. At this time, the Medicare Trust Fund is not in as immediate a position as the Social Security Disability and Retirement Trust Funds. While reforms may eventually be required, we are not talking about the elimination of these programs. Rather, discussions tend to focus on possible reductions in benefits, coverage, or payment amounts. While those possibilities are serious, they are not the doomsday scenarios that are sometimes portrayed. I believe it is important to acknowledge this reality during presentations like this.

I strongly recommend contacting local field offices for spousal claims, widow or widower claims, and similar situations. Individuals who are single, finished working, or confident in their eligibility may be well served by online services. Those who are self-employed, still working but need Medicare, or managing more complex family situations are often better served by working directly with a field office.

Online services are an excellent option for many people, but they are not appropriate for everyone. Our redesigned website is more tailored to smartphone use and streamlined navigation. While the visuals may take some adjustment, it is important that individuals always confirm they are using a website with a .gov address when interacting with Social Security or Medicare.

For individuals planning ahead for retirement, Medicare.gov is an excellent resource. Access now uses Login.gov or ID.me credentials. While these credentials can be more challenging to establish than the older system, they allow access to multiple federal agencies. Many people already have them through TSA PreCheck, the IRS, veterans’ services, or federal employment applications. I generally recommend Login.gov, as it is a government-managed credential.

Once an individual has these credentials, they can access their my Social Security account. This allows them to request replacement Social Security cards, obtain benefit verification letters for programs such as rent rebates, verify Medicare enrollment, update banking and address information, and view benefit estimates. Individuals who are not yet receiving benefits can also access retirement statements and benefit estimators. These statements were once mailed annually but are now primarily accessed online. They provide valuable projections for retirement, spousal benefits, and entitlement timelines.

Family members can assist older relatives in creating and managing a my Social Security account, which can help avoid unnecessary visits to field offices. However, individuals need both identity credentials and an email address, which can be a barrier for some. If credential verification is difficult, visiting a field office can bypass some of the online authentication steps. Acceptable identification includes a state driver’s license or ID, passport, military ID, or other government-issued identification.

Many changes have occurred over the years, and staying informed is important. Social Security shares updates through social media, including cost-of-living adjustments and annual Medicare premium changes, which typically occur at the end of the year.

Regarding customer service and timely processing of Medicare Part A and Part B applications, particularly for individuals with credible coverage, my recommendation is to contact the local field office about three months before employment ends. Online services work well for those who plan ahead, but as the desired coverage start date approaches, working directly with a field office is often more effective. Bringing the CMS-40B and CMS-L564 forms to the office allows staff to review them immediately. A common issue is failure to indicate the requested coverage start month and year on the CMS-40B, which prevents enrollment from being processed.

There is a penalty for Medicare Part B for each 12-month period without coverage, unless the individual had credible coverage through employment. The updated enrollment rules reduce the amount of time individuals go without coverage, which should help minimize penalties and reliance on the General Enrollment Period.

A frequent source of confusion involves automatic Medicare enrollment. Individuals who begin receiving Social Security retirement benefits before age 65 typically receive their Medicare card automatically about 90 to 120 days before their 65th birthday. Many people discard this mailing, not realizing that Part A will begin automatically unless they refuse coverage. Instructions are included to return the card and prevent coverage from starting, but this must be done promptly—generally within 60 days of receiving the mailing.

If an individual waits too long, returning the card may not stop enrollment. However, a field office can still process a refusal as long as the individual contacts Social Security before their 65th birthday. A refusal treats the situation as if coverage never started and avoids premiums and penalties. This is different from a withdrawal, which occurs after coverage has begun and may require payment for months of unwanted coverage.

Even if an individual contacts the field office just before turning 65, that contact is sufficient to backdate the refusal. Advising individuals to call the field office immediately in these situations can prevent serious problems.

Regarding the Railroad Retirement Board, individuals with railroad employment still receive Medicare, but their applications are processed through the Railroad Retirement Board rather than Social Security. All railroad-related cases are handled centrally through that agency.

Online enrollment with document uploads can be fast and efficient for individuals who are planning ahead. However, when someone is within weeks of needing coverage to start, online services can sometimes slow the process. In those cases, visiting a field office may be the fastest option.

There is only a Part A penalty if an individual must pay a premium for Part A due to having fewer than 40 work quarters. There is no Part B penalty when enrollment is delayed due to credible employer coverage.

Concerns about internet security are understandable, which is why maintaining open field offices remains essential. Field offices allow in-person support for individuals who are not comfortable with or able to use digital services. This is similar to maintaining physical bank branches. While online access continues to improve, in-person service remains a critical component of equitable access.

In central Pennsylvania, field offices are generally providing timely service. When issues do arise, maintaining strong working relationships allows them to be resolved quickly. As these new enrollment rules take effect, collaboration will be even more important moving forward.

This partnership helps ensure that individuals receive accurate information and timely assistance. We are all working toward the same goal: helping people navigate Medicare and Social Security during what is often a major life transition.