Understanding the Extended Period of Medicare Coverage (EPMC)

Training Objectives Upon completion of this training, participants should be able to: Describe the CWIC’s role in advising beneficiaries about the impact of work on Medicare. Identify the eligibility requirements for the EPMC. Estimate the earliest EPMC end date for beneficiaries whose EPMC has begun. Identify strategies for explaining the EPMC to beneficiaries. Identify and describe the eligibility requirements, enrollment periods, and Part A premiums for Premium HI for the Working Disabled. Describe the QDWI program benefits and eligibility requirements.

Overview – Impact of Work on Medicare During Trial Work Period (TWP): Medicare continues simply because ongoing receipt of Title II disability benefit. After TWP: Title II benefit continues – non-SGA work – Medicare continues Title II benefit ceases due to work: Extended Period of Medicare Coverage (EPMC) Premium-HI for the Working Disabled

What is the EPMC? EPMC is a work incentive. The EPMC allows eligible individuals to keep premium free Medicare Part A coverage after a period of disability ends due to SGA. The Ticket legislation greatly expanded the EPMC provision.

Eligibility for the EPMC Medicare eligibility must be based on disability; Title II disability benefits must have been ceased due to SGA; and The individual must still be medically disabled per Social Security’s definition.

EPMC Rules “If an individual’s entitlement to disability benefits ends because he or she engaged in, or demonstrated the ability to engage in, substantial gainful activity after the 36 months following the end of the trial work period, Medicare entitlement continues until the earlier of the following: The last day of the 78th month following the first month of SGA occurring after the 15th month of the individual’s re-entitlement period, or if later, The end of the month following the month the individual’s disability benefit entitlement ends.” Centers for Medicare & Medicaid Services 42 CFR, Part 406, Federal Register: September 24, 2004 (Volume 69, Number 185, Pages 57224-57225.

YIKES!!! How am I supposed to explain THAT to a beneficiary?

Explaining When the EPMC May End There is no way to determine when the EPMC will end until it has started. It doesn’t start unless ALL 3 of the following events have occurred: TWP has ended; SGA has been determined and cessation month established; and The first 15 months of the EPE are over.

Keep it SIMPLE! Medicare continues unchanged as long as the beneficiary remains entitled to Title II disability payments. Premium free Medicare won’t end for AT LEAST 93 months after the TWP ends. Many beneficiaries keep it far longer than that! Even if the EPMC ends, beneficiaries can still buy into Medicare – all parts!

What do I do if the beneficiary has engaged in SGA? Determine when the TWP ended and identify the month of cessation (BPQY helps with this). Map it out on a TWP/EPE tracking chart to see when cessation occurred relative to the EPE. Did cessation occur in the first 15 months of the EPE or after the 15th month? If the EPE has not yet lasted 15 months, you can’t estimate the end date of the EPMC, but you can tell the beneficiary the EPMC should last at least 93 months after the TWP as long as the beneficiary is still disabled.

SGA Occurs BEFORE the 15th Month of the EPE - Example Delores ($1,200 SSDI), gets a job earning $2,000/month in January 2014. Her TWP ended 9/2014 and she continued earning $2,000/month. TWP ended: 9/2014 SGA occurred and cessation established: 10/2014 15th month of the EPE: 12/2015 Next month of SGA level work after the 15th month of the EPE: Delores earned more than the SGA guideline in 1/2016 (16th month of the EPE) and onward. Result: SGA occurred prior to the 15th month of EPE AND it occurred on the 16th month of the EPE. The EPMC starts counting 78 months from that first month of SGA level work after the 15th month of the EPE (1/2016). For Delores, the EPMC estimated to end at least 93 months after the end of the Trial Work Period (15 + 78 = 93).

Example – Delores Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TWP 1 TWP 2 TWP 3 TWP 4 TWP 5 TWP 6 TWP 7 TWP 8 TWP 9 EPE cess. EPE grace EPE >SGA EPE #15 EPMC begin >SGA EPE ends Term. Month 24 36 48 60 72 73 74 75 76 77 78 EPMC Over

SGA Occurs AFTER the 15th Month of the EPE If the beneficiary continues to have a disability, and initially engages in SGA sometime AFTER the 15th month of the EPE, Medicare will end no sooner than 78 months after benefit payments cease due to SGA (after the cessation and grace period). Premium free Medicare will never end due to work before the benefit termination month.

SGA Occurs AFTER the 15th Month of the EPE - Example Charles ($1,050 CDB), worked part time earning less than the SGA guideline and his TWP ended 9/2011. His earnings remained below SGA until 6/2015 when he got a job earning $2,500/month. TWP ended: 9/2011 SGA occurred and cessation established: 6/2015 15th month of the EPE: 12/2012 Charles initially engaged in SGA after the 15th month of the EPE. Result: Charles didn’t engage in SGA until AFTER the 15th month of EPE (12/2012) so if the situation remains the same, the EPMC will end 78 months after the Grace Period.

Example – Charles Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TWP 1 TWP 2 TWP 3 TWP 4 TWP 5 TWP 6 TWP 7 TWP 8 TWP 9 EPE <SGA EPE work ends EPE #15 EPE ends >SGA cess. >SGA grace Term. EPMC Begin 4 16 28 40 52 64 76 77 78 EPMC over

SGA Occurs Before the 15th Month of the EPE but no SGA After 15th Month Let’s go back to Delores. She started a job earning $2,000 a month in Jan 2014 but now she quits in August of 2015. How would that affect her EPMC? Here are the facts: TWP ended: 9/2014 SGA occurred and cessation established: 10/2014 Delores is past 15th month of EPE: 12/2015 Delores has NOT earned more than SGA after 12/2015 (15th month of the EPE) The EPMC has not yet begun and WON’T begin until Delores again earns more than SGA. At that point the 78 month count will begin.

Example – Delores Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TWP 1 TWP 2 TWP 3 TWP 4 TWP 5 TWP 6 TWP 7 TWP 8 TWP 9 EPE cess. EPE grace EPE >SGA EPE Quits #15 EPE ends

Advising Beneficiaries about the EPMC Beneficiary has: Not used TWP yet: Can only give general information “EPMC provides at least 93 months of premium free Medicare coverage after the end of TWP” TWP used, but no cessation within 15th month of EPE: same as above. No cessation and past 15th month of EPE: “EPMC provides at least 78 months of Medicare coverage following the Grace Period” as long as the beneficiary continues to have a disability.

Help with Estimating End of the EPMC If the EPMC has begun, CWICs are responsible for advising beneficiaries about when it may end. Medicare Wizard at http://www.medicarewizard.org/ The current version of the BPQY will show the EPMC end date if the EPMC has begun and Social Security has entered this data.

Medicare Premiums During the EPMC During EPMC all basic Medicare costs remain the same No premium for Medicare Part A Part B premium and 20% coinsurance Part D premium (depending on plan) and copays/coinsurance Help with Part B and D premiums and other out-of-pocket costs may end due to earned income. No Title II benefit check – Part B premium billed quarterly in advance if not paid by financial assistance program.

Delores Again Let’s change the situation for Delores again. She was earning $2,000 a month but quit that job in August 2015. She gets another job earning $2,300 in May of 2015. TWP ended: 9/2014 SGA occurred and cessation established: 10/2014 Delores is past 15th month of EPE: 12/2015 Delores earns more than SGA in May 2015 which is after 12/2015 (15th month of the EPE) Result: Delores engages in SGA again after the 15th month of the EPE so the 78 months count from May of 2015 onward. If the situation remains the same, the EPMC should end Oct 2022.

Example – Delores Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TWP 1 TWP 2 TWP 3 TWP 4 TWP 5 TWP 6 TWP 7 TWP 8 TWP 9 EPE cess. EPE grace EPE >SGA EPE Quits #15 >SGA EPMC Begins 8 EPE ends 20 32 44 56 68 69 70 71 72 73 74 76 77 78 EPMC ends

Warnings for People Like Delores Delores ends up quitting her second job before the end of the EPE so she comes back into cash payment status. Delores’s EPMC has begun and like the EPE, there is no way to stop it once it has begun. Delores is guaranteed to keep premium free Medicare as long as she is eligible for Title II disability payments. However, if Delores goes back to SGA level work a third time and her she is beyond her EPMC (Oct. 2022), premium free Medicare coverage will stop.

Options After the EPMC Ends Once EPMC has ended, if a beneficiary’s Title II terminates due to SGA, Medicare can continue through Premium-HI for the Working Disabled Must pay the Part A premium – all other cost requirements remain the same No time limit on Premium-HI – but must continue to meet eligibility requirements

Eligibility Premium-HI for the Working Disabled Ineligible for Medicare on any other basis, Lost entitlement to premium-free Part A solely because of SGA, and Continue to have a disabling physical or mental impairment. MIRS used – EXCEPT work activity can not be used in determining whether disability continues.

Enrollment Periods Premium-HI for the Working Disabled Initial Enrollment Period (IEP) 8-month period beginning with the month an individual is notified about the loss of premium-free HI General Enrollment Period (GEP) January, February and March of each year Special Enrollment Period (SEP) 8-month period after the Group or Large Group Health Plan (GHP/LGHP) coverage based on current employment status ends

Part A Premium Amounts Premium-HI Part A premium: $411, reduced amount $226 Eligibility for Reduced Part A Premium ($226) Has 30 or more quarters of coverage (QCs) on own earnings record; Has been married at least 1 year to a number holder (NH) or deceased NH with 30 or more QCs; If divorced, after at least 10 years of marriage, from a NH who had 30 or more QCs at the time the divorce was final. Part A premium for Premium-HI for Working disabled is NOT subject to increases due to late enrollment

Financial Assistance for the Part A Premium Qualified Disabled Working Individuals (QDWI) One of the Medicare Savings Programs. Individuals with limited income and limited resources may qualify for Part A premium assistance. States are required to pay the Part A Hospital Insurance premium for those who meet the QDWI requirements.

Eligibility - QDWI Entitled to Medicare Part A by paying premiums. Countable income can’t exceed 200% of Federal Poverty Level (FPL) which is $1,980/month in 2016. Countable resources cannot exceed twice the SSI resource limit (unless state exception) which is $4,000 for an individual or $6,000 for a couple. Can’t be otherwise eligible for Medicaid. More information on QDWI in Lesson 3.

Final Words The EPMC rules can be confusing. Focus your counseling on the main points. If a beneficiary has started the EPMC, it’s your responsibility to explain when it may end. Don’t forget to discuss options for retaining health insurance after the EPMC ends. Remember that situations change, so use “at least” when you estimate an EPMC date in the future.