June 25, 2014
Medicare & the Windsor Decision: Where do we stand?
By: Diverse Elders

By Aaron Tax and Kira Garcia

Last year’s Windsor decision has triggered a series of ongoing changes that impact many of us on a day-to-day basis. For LGBT older adults, Medicare is one of the most critical Federal programs undergoing change. So where do Medicare recipients currently stand? Our Q&A with Casey Schwarz of the Medicare Rights Center answers some important questions.

I live in a same-sex marriage state like Massachusetts, Iowa, New Mexico or one of the other 18 states and the District of Columbia (as of May 19, 2014) that allow for same-sex marriage. What new or increased Medicare benefits am I eligible for as a spouse in a same-sex married couple?

If you have to pay a premium for Medicare Part A (the part of Medicare that covers inpatient care) because you do not have enough Social Security working quarters, you may qualify for free Part A based on your spouse’s Social Security work record.

If you have been covered by insurance from your spouse’s current work since you became eligible for Medicare, you may be eligible for a Special Enrollment Period to enroll into Part B of Medicare (the part of Medicare that covers outpatient care and lab tests) when your spouse’s work-provided insurance ends and you need to enroll in Part B. In other words, you may be able keep your current coverage and delay enrolling in Part B of Medicare without a penalty.

If you are covered by insurance from your spouse’s work, and the employer has more than 20 employees, that insurance should pay first, before Medicare. If your spouse’s employer has fewer than 20 employees, then that insurance will usually pay second, after Medicare, and you should find out how to enroll in Medicare.

You may be eligible for the Extra Help program, the federal program that helps people with Medicare pay for some prescription drug costs. The income and asset limits for the Extra Help program are higher for married couples.

Are there possible downsides to getting married with respect to Medicare benefits?

If you are eligible for Extra Help, your spouse’s income will count in evaluating whether or not you continue to qualify for that benefit.

If your spouse’s income is high, and you file taxes jointly, you may be required to pay a higher premium for Medicare Part B and Part D, called the Income Related Monthly Adjustment Amount (IRMAA)

I live in a state that only provides civil unions (CUs) or registered domestic partnerships (RDPs), like Colorado, Nevada, or Wisconsin. Am I or my same-sex partner eligible for new or increased Medicare benefits by being a part of a CU or RDP?

If your state’s civil union or registered domestic partnership rules give you the right to inherit property in the same way a spouse would, you may be eligible for premium-free Part A under your partner’s social security work history. The rules are complicated and vary for each state depending on when you entered into the CU/RDP, so if you think you might be eligible for this benefit, you should apply.

If you have insurance as a result of your partner’s current work, and that employer chooses, that insurance will pay before Medicare. Be sure to check with the employer to ensure that they intend to pay as primary.

Coverage as a result of your partner’s work does not, however, give you access to a Special Enrollment Period to delay enrolling in Part B. If you delay enrolling in Part B, then you may have a late enrollment penalty.

I live in a non-marriage, non-CU or RDP state like Mississippi, but I got married to my same-sex spouse in one of the other 18 states and the District of Columbia (as of May 19, 2014) that allow for same-sex marriage. Am I eligible for any of new/increased Medicare benefits you’ve outlined above for individuals living in marriage states? Are there any differences because of where I live?

You are eligible for all of the benefits outlined above for individuals in Marriage states except you cannot get premium-free Part A based on your spouse’s work history unless your state recognizes your right to inherit as a spouse based on your marriage, CU or RDP. You may, however, be able to get a reduction in the amount of your Part A premium.

I’m eligible for Medicare because I am over 65 but my same-sex spouse is still working and I’m eligible to stay on his/her health plan. Is there any reason I’d want to stay on his or her health plan?

If your spouse’s employer has more than 20 employees, that insurance will pay primary to, or before, Medicare while your spouse is working. You will also have a Special Enrollment Period to enroll in Part B later, without a penalty, while you are still covered by that insurance and while your spouse is still working, and for 8 months after the coverage or employment ends.

Your premiums or cost sharing might be lower in your spouse’s health plan than they would be for Medicare Part B. If you delay enrolling in Part B you should be sure to enroll before your spouse stops working to ensure no gaps in coverage.

If your spouse’s employer has fewer than 20 employees, Medicare will be your primary insurance. It is very important to enroll in Part B when you first become eligible to avoid gaps in coverage. Your spouse’s employer coverage may pay secondary to Medicare, covering the co-pays and coinsurances that would otherwise be out-of-pocket costs. When you first enroll in Part B you have certain rights to buy supplemental insurance (Medigap) that you may not have again – you should evaluate whether these policies are a better fit for your needs than the employer plan.

If so, how does Medicare coordinate my benefits with my spouse’s employer? Is there anything in particular I should know or pay attention to with respect to the coordination of benefits?

Whether Medicare pays first or second depends on the size of the employer and why you are eligible for Medicare. Find out more about enrolling in Medicare on Medicare Interactive, or by contacting the Social Security Administration.

It is important to let the employer know that you are eligible for Medicare so that they can report your status to Medicare’s Coordination of Benefits office correctly.

It is important to let your doctors know that you have two forms of insurance, and which to bill first.

How do I go about signing up for Medicare or changing my marital status?

To enroll in Medicare, whether or not you are ready to retire or to sign up for Social Security Retirement benefits, contact the Social Security Administration. You can apply online, in person at a local office, or get more information over the phone.

You can change your marital status by contacting 1-800-MEDICARE, and you can correct errors regarding other insurance you have by contacting 1-800-MEDICARE or the Coordination of Benefits office.

I’ve applied but my application is stuck or I’ve been told it’s on hold – what should I do?

Follow up with the Social Security Administration. New rules putting the Windsor decision into effect are being released and applications put on hold should be processed.

If you are denied, consider appealing the denial. If the law in your state changes while your application is pending or during your appeal, you may be entitled to benefits back to the date of your application.

Keep good records of your conversations with Social Security – either on the phone or in person – record the time, date, name of the person you spoke to, and what you were told. Reach out to your elected officials to let them know about the delays. And if you face delays, please contact Lambda Legal’s Help Desk at 1-866-542-8336 or at http://www.lambdalegal.org/help.

What if I encounter a problem?

If you have additional questions contact the Medicare Rights Center helpline at 800-333-4114. If you face denials or other problems, please contact Lambda Legal’s Help Desk at 1-866-542-8336 or http://www.lambdalegal.org/help.

Contact your elected representatives to let them know that you are having problems accessing benefits that you are entitled to.

Aaron Tax is the Director of Federal Government Relations and Kira Garcia is the Director of Media Relations & Integrated Marketing for Services & Advocacy for GLBT Elders (SAGE). The opinions expressed in this article are those of the authors and do not necessarily reflect those of the Diverse Elders Coalition.

This post originally appeared on the SAGE Blog.