Medicare Deadlines After a Virginia Workers’ Compensation Settlement

Do not agree to settle your workers’ compensation case or sign a resignation agreement without first consulting an experienced Virginia workers’ compensation lawyer.

If your Virginia workers’ compensation settlement calls for you to resign, find out when your employer health insurance will end before you sign. Your last day of employment, the last day your health plan covers you, and the date you receive a termination notice can start different enrollment clocks. Losing your job-based insurance can open a Medicare enrollment period. Whether it also gives you the right to buy Medicare Supplement Insurance, commonly called Medigap, depends on your age, how you qualified for Medicare, and the coverage you are losing.

The deadlines at a glance

Before you sign the resignation agreement

Ask HR or the health plan administrator for written confirmation of your last day of employment, last day of medical and prescription coverage, and any continuation rights. Ask whether the plan pays first or pays after Original Medicare for you. Request the plan’s Coordination of Benefits provision, its prescription drug creditable coverage notice, and a written termination notice. Check when coverage ends for your spouse or children as well. Their replacement coverage may have a different deadline.

Ask your workers’ compensation lawyer whether the settlement leaves work-injury medical benefits open or closes them. Employer group health insurance and workers’ compensation medical benefits cover different things. If your settlement includes a Medicare Set-Aside, those funds are for qualifying future medical expenses related to the settled work injury. You still need to arrange coverage for your other health care. Virginia workers’ compensation medical benefits · CMS Medicare Set-Aside guidance

If you are approaching Medicare eligibility

Turning 65. Your Initial Enrollment Period generally runs from three months before your birthday month through three months after it. If employer coverage will end as you turn 65, contact Social Security before the coverage ends. For most people, signing up before the birthday month makes Part B effective in that month. Signing up in the birthday month or in one of the next three months generally makes Part B effective the following month. If your birthday is on the first day of the month, ask Social Security to confirm your dates because special timing rules apply.

Qualifying through disability. If you receive Social Security Disability Insurance (SSDI), Medicare generally starts after 24 months of SSDI entitlement. ALS can qualify you sooner, and end-stage renal disease has its own eligibility and coverage rules. A workers’ compensation award or settlement does not start Medicare on its own. Use the effective dates on your Medicare card and keep any Social Security notice awarding coverage retroactively. Medicare start dates · Social Security disability and Medicare · Medicare and kidney failure

If you still need Medicare Part A or Part B

Part A covers hospital care. If you qualify for premium-free Part A by age, you can generally enroll after 65. If you enroll late, coverage can be retroactive by up to six months, but no earlier than your first month of eligibility. If you or your employer are still contributing to a health savings account (HSA), check the retroactive date before you apply. If you have to pay a Part A premium, ask Social Security which enrollment period applies.

Part B covers doctor and outpatient care. If you delayed Part B and qualify based on group coverage through current employment, you can generally enroll while that coverage is in place or during the eight months after employment or that coverage ends, whichever happens first. If you qualify through disability, ask Social Security whose employment and what group coverage count. Apply before the employer plan ends and confirm your Part B start date. Social Security generally uses forms CMS-40B and CMS-L564 when you already have Part A and are adding Part B based on job coverage.

COBRA and retiree coverage do not extend the Part B clock. If you miss your applicable enrollment period and have no other special enrollment right, you may have to wait for the January 1 through March 31 General Enrollment Period and may owe a late penalty. If you already have Parts A and B, check that both remain active and move on to the Medigap and prescription deadlines below. Medicare and current employment · Medicare enrollment forms · Enrollment periods and start dates

If you are 65 or older and want Medigap

First check your six-month window. It starts the first month you are both 65 or older and enrolled in Part B. For example, if you are already 65 and Part B starts July 1, your initial Medigap window runs through December 31. During that period an insurer cannot turn you down or charge you more because of your health. If you started Part B while you still had employer coverage, the six months were already running. The annual Medicare fall enrollment period does not restart them. Virginia’s initial Medigap rule · Medicare’s Medigap guide

If the six months have passed, check who paid first. If you have Original Medicare and lose qualifying group medical coverage that pays after Medicare, Virginia generally gives you a separate guaranteed-issue right for certain Medigap policies. You generally have 63 days after the later of the coverage end date or the date you receive the termination notice. If no termination notice arrives and you learn of the loss through a denied claim, the notice of denial can affect the deadline. Keep the notices and apply promptly. If your employer plan paid first, losing it generally does not create this particular right. For age-based Medicare, group plans through current employment generally pay first at employers with 20 or more employees. Medicare generally pays first when a business with fewer than 20 employees has its own group plan. Multi-employer plans can work differently. If no guaranteed-issue right applies, you can still ask to buy a policy, but an insurer can review your health history and may decline your application. Virginia’s guaranteed-issue rule · Medicare’s payment order

Check before canceling coverage. Losing eligibility under the employer plan is different from dropping coverage while you can still keep it. If you have Medicare Advantage, separate rules determine whether leaving or losing that plan gives you a Medigap right when you return to Original Medicare. If you already have Medigap, Virginia also gives you a 60-day window starting on your birthday to switch to a policy with the same benefits without medical underwriting. Virginia’s guaranteed-issue rule · Virginia’s Medigap birthday rule

If you have Medicare before age 65

Virginia has a separate protection. If you live in Virginia, qualify for Medicare under the disability or end-stage renal disease provisions, and have Parts A and B by the policy’s effective date, an insurer selling Medigap in Virginia must offer you at least one of its policies during the applicable window. You can generally apply within six months beginning with your first month of Medicare eligibility. If Social Security retroactively enrolls you in Part B, the six months start in the month you receive notice of that decision. Virginia also gives eligible people under 65 63 days after voluntary or involuntary termination of group health coverage to apply. The under-65 statute does not require the group plan to have paid after Medicare. When you turn 65, you get the regular six-month Medigap window if you have Part B. Virginia Code § 38.2-3610 · Virginia’s age-65 Medigap rule

Do not miss your guaranteed-issue deadline. If you qualify, apply while that protection is available. A serious work injury can mean multiple surgeries, ongoing treatment, or complications that make medical underwriting harder. Just getting records from several doctors, hospitals, or rehabilitation providers can take time. If you miss the deadline and have no other enrollment protection, an insurer may ask about your medical history, request records, charge more based on your health, or decline your application. Ask early which policies you can buy under guaranteed issue and what proof of coverage loss the insurer needs. Submit your application with that proof before the deadline and keep a dated confirmation.

Make a separate plan for prescriptions and any coverage gap

Part D has its own deadline. If you leave employer or union coverage, you generally have two full months after the month it ends to join a Medicare drug plan or a Medicare Advantage plan. If you go 63 consecutive days or more without Medicare drug coverage or other creditable prescription coverage after you become eligible, you may owe a Part D late penalty. Confirm when the new drug coverage starts and keep the employer’s creditable coverage notice. This 63-day rule concerns the drug penalty. The Medigap application deadline runs separately. Medicare plan enrollment after a coverage loss · Medicare late penalties

If Medicare has not started or you are not yet eligible, arrange coverage for the gap. Ask about COBRA or other continuation coverage and check Virginia’s Insurance Marketplace promptly. Losing job-based coverage generally opens a Marketplace enrollment period, and your dependents may need a separate plan. Virginia’s Insurance Marketplace · U.S. Department of Labor COBRA guidance

Before your employer coverage ends, put each deadline and each replacement coverage start date on your calendar. Keep copies of the resignation agreement, the plan’s coverage and termination notices, your Medicare card, and any application confirmations. For free, individualized Medicare counseling, call the Virginia Insurance Counseling and Assistance Program (VICAP) at 800-552-3402. Review the resignation date and any work-injury medical terms with your workers’ compensation attorney before signing. VICAP contact information

Medicare Glossary for Injured Workers

The coverage

Original Medicare and Parts A and B. The federal Medicare program. Part A generally covers inpatient hospital care. Part B covers doctor visits, outpatient care, and certain medical equipment and preventive services.

Medicare Advantage or Part C. A private plan that provides your Part A and Part B benefits. Most plans include drug coverage. Plan networks, costs, and approval requirements vary.

Part D. Medicare prescription drug coverage. With Original Medicare, you can join a separate drug plan. Many Medicare Advantage plans include Part D.

Medigap or Medicare Supplement Insurance. Private insurance that helps pay your share of Original Medicare bills. Plan G and Plan N are examples. Medigap works with Original Medicare and cannot pay your Medicare Advantage costs.

COBRA and coordination of benefits. COBRA can temporarily continue job-based coverage after employment ends. Coordination of benefits determines which plan pays first. Ask your plan administrator whether Medicare or your employer plan pays first.

SSDI and Medicare Set-Aside. SSDI is Social Security Disability Insurance and can lead to Medicare before age 65. A workers’ compensation Medicare Set-Aside reserves settlement money for certain future medical costs of the work injury.

The enrollment windows

Initial Enrollment Period. Your first chance to enroll in Medicare. For most people qualifying by age, it lasts seven months around the month they turn 65.

Special Enrollment Period. A chance to enroll or change coverage after a qualifying event, such as losing job-based insurance. Part B and Part D have different rules and deadlines.

Fall Medicare Open Enrollment. October 15 through December 7. You can change Medicare Advantage or Part D coverage or switch between Original Medicare and Medicare Advantage. This does not reopen your Medigap window.

Two different January through March periods. January 1 through March 31 is the General Enrollment Period for people who still need Part B. During those same dates, people already in Medicare Advantage can switch plans or return to Original Medicare.

Medigap Open Enrollment and guaranteed issue. Medigap open enrollment is your initial protected buying window. A guaranteed-issue right can arise after a qualifying event. If you apply on time with the required proof, an insurer cannot turn you down for an eligible policy or charge you more because of your health. Outside a protected window, an insurer may use medical underwriting to evaluate your health history, price your coverage, or decline your application.

Medicare enrollment periods · Virginia Medigap protections

Terms You Hear in Medicare Ads

What the plan costs

Premium. What you pay to keep coverage, usually each month. A $0 Medicare Advantage premium means the plan itself has no monthly premium. You generally still pay your Part B premium and may pay when you get care.

Part B giveback. An ad may use this term for a Part B premium reduction. Some Medicare Advantage plans help pay part or all of the Part B premium. Check the amount and availability for the specific plan.

Deductible, copay, and coinsurance. A deductible is the amount you pay before coverage starts paying for certain services. A copay is a fixed charge, such as $30 for a visit. Coinsurance is a percentage of the cost, such as 20%.

Out-of-pocket maximum. The most you pay in a year for covered Part A and Part B services under a Medicare Advantage plan, subject to its rules. Prescription drug costs follow separate rules. Original Medicare by itself has no yearly out-of-pocket limit.

What the plan covers

Network and service area. The network is the group of doctors, hospitals, and other providers that contract with a plan. The service area is where the plan is offered. Check your specific doctors, hospital, and physical therapy providers for the plan year you are considering.

HMO and PPO. These are common plan types. An HMO usually limits routine care to its network. A PPO generally allows out-of-network care for covered services, usually at a higher cost.

Prior authorization. Permission a plan may require before it covers a service or drug. If you are in treatment, check whether upcoming care needs approval.

Formulary and drug tier. A formulary is the list of drugs a plan covers. A tier is a cost group for those drugs. Check your exact medications, doses, and pharmacy.

Creditable drug coverage. Prescription coverage expected to pay, on average, at least as much as Medicare drug coverage. Keep the written notice from your employer. It can help you show you had coverage when you apply for Part D.

Extra benefits and Annual Notice of Change. Some Medicare Advantage plans offer extras such as dental, vision, or hearing benefits. Check what the plan actually covers and the dollar limits. If you already have a Medicare plan, its Annual Notice of Change explains what will change for the coming year.

Compare Original Medicare and Medicare Advantage · Medicare health plan costs · Medicare Advantage plan guide