On April 22, 2022, the Centers for Medicare & Medicaid Services (CMS) proposed implementation of parts of the Consolidated Appropriations Act, 2021 (CAA) to simplify Medicare insurance enrollment. According to Medicare.gov, these changes will go into effect January 1, 2023. Generally speaking, the new Medicare insurance enrollment rules will allow for a more straightforward enrollment process that reduces potential gaps in coverage. They also allow for more Special Enrollment Periods and extend some Part B coverage to certain beneficiaries. But, what are the specifics?

All facts and figures can be found in CMS’ fact sheet on the provisions, unless specifically linked elsewhere.

Current Medicare Program Enrollment Rules

Currently, when Medicare insurance coverage actually starts after enrollment can be pretty confusing. When your coverage becomes effective can depends on when you enrolled during your Initial Enrollment Period (IEP), the roughly seven-month window generally starting three months before your 65th birthday and running three months after. (There is an exception if your birthday is on the first of a month. Your birthday month is considered the month before your true birthday month. For example, if your birthday is September 1, your birthday month would be August, not September.)

Right now, the Medicare insurance enrollment rules look like this:

  • Enroll before your birthday month during your IEP — Coverage starts during your birthday month
  • Enroll during your birthday month during your IEP — Coverage starts the month after you sign up
  • Enroll after your birthday month during your IEP — Coverage starts two to three months after you sign up
  • Enroll during the General Enrollment Period (GEP) from January 1 to March 31 — Coverage starts July 1, up to six months after you sign up

The last two rules meant that many Medicare insurance beneficiaries had gaps in their coverage as they waited months for coverage to kick in.

Medicare Program Enrollment Rules for 2023 & Beyond

CMS’ recent changes modify the effective dates of Medicare insurance coverage for someone enrolling in the last three months of their IEP (after their birthday month) or during the GEP, getting rid of the long waiting periods by mandating that their Medicare insurance coverage must be effective the month after enrollment.

Here’s what the new Medicare program enrollment rules for the IEP and GEP look like:

  • Enroll before your birthday month during your IEP — Coverage starts during your birthday month
  • Enroll during your birthday month during your IEP — Coverage starts the month after you sign up
  • Enroll after your birthday month during your IEP — Coverage starts the month after you sign up
  • Enroll during the General Enrollment Period (GEP) from January 1 to March 31 — Coverage starts the month after you sign up

More Part A & B SEPs Allowed

The latest changes also give the Secretary of the Department of Health & Human Services (the Secretary) authority to establish Special Enrollment Periods (SEPs) for enrolling in Medicare Parts A and B for those with exceptional circumstances. Individuals who newly qualify for certain SEPs will no longer have to wait until the GEP to enroll and won’t be subject to late enrollment penalties.

The Secretary will now consider awarding Part A and B SEPs for those:

  • Impacted by an emergency or disaster
  • Impacted by a health plan or employer error
  • Formerly incarcerated
  • With ending Medicaid coverage
  • With other exceptional conditions, determined on a case-by-case basis

CMS hopes to increase insurance enrollment opportunities and give people the coverage they need without having to wait or pay penalties.

Increased Access to Coverage for Immunosuppressive Drugs

Some individuals are eligible for the Medicare program even if not yet 65, including those with End-Stage Renal Disease (ESRD). CMS’ new rules expand Part B drug coverage for those receiving kidney transplants.

Currently, after receiving a kidney transplant, individuals have coverage for certain drugs up to 36 months after surgery. After that, coverage ends unless the person is entitled to the Medicare program because of age or disability. Starting in October 2022, with coverage effective January 1, 2023, kidney transplant patients will be able to apply for extended immunosuppressive drug coverage past the 36 months. CMS calls this the immunosuppressive drug benefit or Part B-ID benefit. This coverage will only apply to immunosuppressive drugs; individuals utilizing this benefit will not have access any other Part B benefits or services.

The premium for the Part B-ID benefit will be less than the standard Part B premium. Individuals cannot be enrolled in, or expect to be able to enroll in, certain other types of coverage. For more details on features of the Part B-ID benefit, see the CMS fact sheet.

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Besides some additional administrative and documentation streamlining, the simplified enrollment rules, expanded SEP qualifications, and extended immunosuppressive drug benefit are the three big enrollment changes consumers can expect to see January 1, 2023. These Medicare program changes, along with the recent ones from the Inflation Reduction Act, the FDA’s ruling on hearing aids, and CMS’ lower 2023 Part D cost projections, lead us to believe 2023 will be a great year for the Medicare program!