Medicare can be confusing. Do you have to sign up when you turn 65? What if you haven’t retired and still have insurance from your employer? What if you get retiree benefits or are on Medicaid? What happens if you lose that coverage? If you don’t sign up right away, will you face late penalties? It’s understandable you would want to ask someone for help before you make a major decision. But what happens when that person gives you bad Medicare advice?

Equitable Relief*

Equitable relief protects you against late penalties in the case that a federal representative gives you bad Medicare advice that caused you to miss signing up during a designated enrollment period. That could be during your Initial Enrollment Period (the 7-month period starting 3 months before and ending 3 months after your 65th birth month), the General Enrollment Period (January 1 through March 31 every year), or a Special Enrollment Period (the 8-month window after you leave your job or employer health plan). For the purposes of equitable relief, a federal employee could be someone who works for Social Security or someone you speak to when you call 1-800-MEDICARE.

When You Can’t Reach Your Social Security Office
For a period of time in 2022, Social Security offices could not be reached by phone. That left many people without a way to enroll or disenroll from Medicare during their designated enrollment periods. For this reason, the Centers for Medicare & Medicaid granted equitable relief for anyone affected — as long as they enrolled/disenrolled in Medicare by December 31, 2022.

Bad Medicare advice could lead you to pay Part B late penalties that last as long as you have Medicare. It could also cause gaps in care. That can happen when you miss your Initial Enrollment Period (or Special Enrollment Period) and have to wait until the General Enrollment Period to sign up. If you don’t have other insurance in the meantime, you could be left without access to health care.

To request equitable relief, you will need to write a detailed letter to Social Security explaining your situation. You will want to include the name(s) of who you spoke to, the date(s) you spoke to them, the advice you were given, and any other information relating to the incident.

Exceptional Conditions

There are other situations that could cause you to miss one of your designated enrollment periods too. Social Security may or may not recognize them though. The following are approved Special Enrollment Periods (some of them new) that will protect you from late penalties. Check out this form.

Bad Advice from a Group Health Plan or Employer

Who Qualifies: Anyone who delayed Medicare enrollment because their group health plan or employer gave them misinformation on or after January 1, 2023

Special Enrollment Period: Starts the day you notify Social Security and lasts 6 months

An Emergency or Natural Disaster

Who Qualifies: Anyone who missed their designated enrollment period because they live (or lived) in an area where a federal, state or local government declared a disaster or other emergency

Special Enrollment Period: Starts the day the disaster is declared and lasts 6 months after the declaration ends

Formerly Incarcerated Individuals*

Who Qualifies: Anyone released from incarceration who either a) lost Medicare coverage because they did not pay their premiums while incarcerated, b) voluntarily ended their Medicare coverage while incarcerated, or c) became eligible for Medicare while incarcerated.

Special Enrollment Period: Starts the day incarceration ends and lasts 12 months after the month of release

Loss of Medicaid Coverage*

Who Qualifies: Anyone who lost Medicaid coverage after January 1, 2023

Special Enrollment Period: Starts the day you are notified you lost coverage and lasts 6 months

Retroactive Medicare

It’s great to get equitable relief and have your late penalties cancelled. It’s even better that you get additional Special Enrollment Periods for situations out of your control. In many of these situations (specifically, those headings with an asterisk above), you have another choice to make too. When do you want your Medicare coverage to begin?

• Immediate: You want to enroll in Medicare immediately, i.e., coverage starts when you apply. This is the default if you do not make your intentions clear to Social Security.
• Retroactive: You want retroactive Medicare coverage, i.e., coverage that goes back to when you were first eligible. This may be a good option if you required a lot of medical care while you went without Medicare. In that case, Medicare can help foot the bill. However, keep in mind that a request for retroactive coverage will require you to pay the Part B premiums that would have been due during that time too. You would also be responsible for any deductibles, coinsurance, or copays for any of the services Medicare would have covered during that time.

Application for Medicare Part A and Part B – Special Enrollment Period (Exception Conditions). (2022). Centers for Medicare & Medicaid Services. https://www.cms.gov/files/document/application-medicare-part-part-b-special-enrollment-period-exceptional-conditions.pdf

Bogle, D. (2022). Equitable Relief for Medicare Enrollment and Disenrollment. Social Security Administration. https://blog.ssa.gov/equitable-relief-for-medicare-enrollment-and-disenrollment/

SSA – POMS: HI 00805.384 – Exceptional Conditions Special Enrollment Period (SEP) for Group Health Plan (GHP) or Employer Misrepresentation. (2022). Social Security Administration. https://secure.ssa.gov/apps10/poms.nsf/lnx/0600805384