Medicare and the Affordable Care Act: Separating Rumor from Reality

By now, most adult Americans have seen and heard a lot about the Affordable Care Act (ACA), and most are confused about how the ACA will affect them and their insurance coverage. If you are an older American with Medicare coverage, or will be eligible for Medicare coverage in 2014 as an older American, you may be wondering what kind of impact the ACA will have on your Medicare. The simple answer is not a whole lot.

Medicare is federal health insurance coverage for Americans who are (1) eligible for Social Security retirement income and 65 years or older, or (2) under age 65 and entitled to Social Security disability benefits, or (3) of any age with End-Stage Renal Disease. You must enroll in the Medicare program when you become eligible or face late enrollment penalties for as long as you carry Medicare coverage, UNLESS you have other creditable insurance coverage through your employer, your spouse’s employer when you reach age 65, or the Health Insurance Marketplace.

The ACA was passed by Congress in 2010 and some provisions effecting Medicare have already been implemented. Those include:

  • Coverage under Medicare for annual wellness visits;
  • Elimination of cost-sharing for most preventative services;
  • Increased consumer protections to Medicare Advantage (or Medicare Part C) benefit plans;
  • Phase down of the Part D coverage gap (a.k.a. the “donut hole”);
  • Higher-income Medicare beneficiaries (those earning more than $85,000 for an individual or $170,000 for a couple) will pay slightly more for their Part D prescription drug coverage; and
  • Introduction of initiatives for health care providers in the areas of improved coordination of care and quality of care, and initiatives to reduce unnecessary hospital readmissions.

Unscrupulous opportunists (a.k.a. “scammers”) have been taking advantage of the confusion surrounding the ACA and the annual Medicare open enrollment period (October 15th to December 7th) to obtain private medical and financial information from seniors. There have been reported cases of scammers phoning seniors and telling them they must take certain actions under the ACA or lose their Medicare coverage. The ACA is not replacing or terminating Medicare coverage.

A key part of the ACA, the Health Insurance Marketplace, will be effective in 2014. Individuals, families and employees of small businesses can get coverage using the Health Insurance Marketplace. The Marketplace is geared primarily towards people who are under age 65 and uninsured.

Medicare is not part of the Health Insurance Marketplace. Medicare beneficiaries don’t have to do anything in terms of signing up for health insurance through the Marketplace. If you have Medicare, you have health insurance coverage under the requirements of the ACA. The Marketplace also won’t affect your Medicare choices or coverage. You will still have the same benefits you have now under Medicare, whether you’ve opted for coverage under Original Medicare or a Medicare Advantage Plan.

You cannot get a Health Insurance Marketplace plan in addition to your Medicare coverage. In fact, it is against the law for someone who knows that you have Medicare to sell you a Marketplace plan. In Ohio, because we use the federal exchange for our Health Insurance Marketplace, Medicare Supplement Insurance (or Medigap) policies and Medicare Part D drug plans are not offered in the Marketplace. However, some states that operate their own exchanges for their Health Insurance Marketplace can and do offer Medicare Supplement Insurance and Part D drug plans. You can learn more about Medicare supplement plans at In Ohio, you can purchase these policies through the same avenues as before – either through, directly from an insurance company providing these types of plans, or through a qualified insurance agent/broker.

You also cannot choose Marketplace coverage instead of Medicare in most cases. One exception is if you are eligible for Medicare (you are age 65), but have not enrolled because you would have to pay a premium or because you are not collecting Social Security benefits yet. In this situation, it is important that you have some kind of creditable health insurance coverage (either through an employer, a spouse’s employer plan, or the Marketplace) so that you do not incur late enrollment penalties under Medicare.

The Health Insurance Marketplace may be a good option for people under age 65 who are disabled and waiting for Medicare eligibility. If someone is receiving Social Security Disability Insurance (SSDI) benefits and waiting out the 24-month Medicare eligibility period, they can potentially source health insurance coverage through the Marketplace during that time, and take advantage of any subsidies and assistance they may qualify for to pay for the coverage they find. However, once eligible for Medicare, the SSDI recipient must enroll in Medicare on time (or face late enrollment penalties), and should strongly consider disenrolling in their Marketplace plan because they will lose any Marketplace subsidies (most likely making their previous coverage very expensive). Unfortunately, there are still very few affordable choices in terms of Medicare supplement plans for this younger population of Medicare beneficiaries – Medicaid maybe the only practical “supplement” to Medicare for them.

Please contact your attorney at Hickman & Lowder if you have any questions about your or your loved one’s Medicare benefits and other long-term care planning issues. We are available to assist you with your elder law and special needs planning matters.

– Posted by Attorney Lisa Montoni Garvin

Posted in Blog, Older Adults.