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Benefit Coordination and Medicare Eligibility 

These FAQs clarify that pursuant to the essential health benefits (EHB) and actuarial value (AV) requirements under the Affordable Care Act, a health insurance issuer offering non-grandfathered health insurance coverage in the individual and small group market may not change the plan payment level or refuse to pay for otherwise covered services on the basis that an individual is eligible for Medicare due to age but not actually enrolled in Medicare.

Download the Guidance Document


Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: May 24, 2023

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.