Enrollment and Eligibility (ENR) FAQ
Guidance for FAQ regarding Medicare and Eligibility
Program Area: Enrollment and Eligibility (ENR)
Question: How should an Issuer handle a situation where an individual on Medicare has been unknowingly enrolled in a Marketplace plan?
Answer: Consistent with the prohibition on the sale and issuance of duplicate coverage to people with Medicare (section 1882(d) of the Social Security Act, referred to as the Medicare anti-duplication provision), it is illegal to knowingly sell or issue a qualified health plan (QHP) to a Medicare beneficiary. Issuers may not terminate enrollees whom they subsequently find to be eligible for or enrolled in Medicare based on their Medicare coverage. However, consistent with the Medicare anti-duplication provision, if an issuer learns an individual is a Medicare beneficiary prior to the individuals coverage effective date, the issuer may cancel the enrollment. The current work around for cancellations is via the 834 non-payment transaction. Once the coverage is effectuated, consumers can request a prospective termination in accordance with 45 C.F.R. 155.430, or, if their state has a free look period, they can retroactively cancel their coverage in accordance with the state policy. To request prospective termination, consumers can call or log into healthcare.gov and select 'End All Coverage.' If there are other applicants on the consumers' application who wish to retain their coverage, the consumer can remove specific applicants (e.g., Medicare-eligible applicants) by selecting 'Report a Life Change.'
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 11, 2014
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