You may be eligible to request equitable relief for Marketplace enrollees, if you delayed enrolling in Medicare Part B so that you could stay in your Marketplace plan, known as a Qualified Health Plan (QHP).
You can also access equitable relief for Marketplace enrollees if you could have enrolled in Part B using the Part B Special Enrollment Period (SEP) but chose to enroll in coverage QHP instead.
Note that this kind of QHP is different from the kind sold through the Small Business Health Options (SHOP) program, which is how an employer can purchase coverage for its employees.
If you are eligible, equitable relief for Marketplace enrollees will let you 1) enroll in Medicare Part B without penalty or 2) eliminate or reduce your Part B late enrollment penalty (LEP) if you are already enrolled in Part B but delayed enrollment when you had a QHP. There are certain criteria you must meet in order to qualify for relief.
Specifically, you are eligible to use equitable relief for Marketplace enrollees if you are or were enrolled in a QHP, you are enrolled in premium-free Part A*, and
- You have an Initial Enrollment Period (IEP) that began between April 1, 2013 and March 1, 2020
- You were notified of retroactive premium-free Part A between October 1, 2013 and June 30, 2020
- Or, you have a Part B SEP that ended between October 1, 2013 and June 30, 2020
*If you do not have premium-free Part A but are eligible, you can enroll at any time. You must be enrolled in premium-free Part A in order to request equitable relief for Marketplace enrollees. If you want to request that your Part B late enrollment penalty be eliminated or reduced, you must have received your penalty after enrolling in Part B during the General Enrollment Period (GEP) between 2015 and 2020.
Note that you are not eligible to request equitable relief for Marketplace enrollees if:
- You delayed Part B enrollment to stay in SHOP.
- You pay a premium for Part A. If you pay a premium for Part A, you can choose to disenroll from Part A and continue to use your QHP coverage.
- You can currently enroll in Part B because you are in your IEP or Part B SEP. In either of these cases, you can enroll in Part B without penalty. Equitable relief for Marketplace enrollees cannot be used if you only want to change your Part B coverage start date but you are in your IEP or Part B SEP.
In general, you will not benefit from having a QHP and Medicare at the same time. This is because when you enroll in Medicare, you are generally no longer eligible to receive cost assistance for your QHP. Confusion about QHPs and enrolling in Medicare leads some people to make enrollment mistakes.
For example, maybe you enrolled in Medicare Part A and declined Part B when you first became eligible for Medicare because your subsidized QHP was cheaper than Part B. Or, maybe you enrolled in a QHP instead of Part B during your SEP for similar reasons. In either case, you may not have realized that you were supposed to sign up for Medicare and that you would lose your subsidy (cost assistance) because of your Medicare eligibility. In some instances, you may have continued to receive cost assistance even after enrolling in Part A. In other situations, you may have faced QHP coverage problems once your QHP realized that Medicare should be covering costs. For example, the QHP may have stopped paying primary for your health costs.
If you made these enrollment mistakes, you usually could only enroll in Medicare during the GEP. You would also potentially have a Part B late enrollment penalty.
Equitable relief for Marketplace enrollees helps you enroll in Medicare as soon as possible and can erase an LEP, if you have one.
Steps to request equitable relief for Marketplace enrollees
- Gather appropriate documentation. You will need proof of your QHP enrollment. You may also wish to bring a Part B enrollment form (Form CMS-40B) and your Medicare card. You can also fill out a Part B enrollment form at your Social Security office.
- Examples of proof of QHP can be:
- Letter you received about being enrolled in both Medicare and a Marketplace plan
- QHP premium bills and proof of payment
- IRS form 1095-A that shows months of coverage and/or cost assistance amounts
- A Marketplace eligibility determination notice
- Can be accessed through your Marketplace account
- Receipt from first premium payment you made to your QHP (also called a premium binder payment)
- If you enrolled in Marketplace coverage instead of Part B during your SEP, you should also provide proof of previous job-based insurance coverage using Form CMS-L564
- Examples of proof of QHP can be:
- Call the Social Security Administration (SSA) at 800-772-1213 or go to www.ssa.gov to find a local Social Security office that you can visit in person.
- Once at the office or on the phone with a representative, ask to use the equitable relief for Marketplace enrollees to enroll in Part B and/or eliminate your Part B LEP. You must mention that you were enrolled in both premium-free Part A and a QHP. If you are calling to eliminate an LEP, you must specifically request that you want the LEP eliminated.
Call the Medicare Rights Center helpline at 800-333-4114 for more information or for help requesting equitable relief for Marketplace enrollees.