Special Enrollment Periods (S.E.P.): When Can I Sign Up for Medicare?

by | Dec 30, 2025 | General, Original Medicare, Rules & Enrollment

If you missed your Initial Enrollment Period or need to change your Medicare plan during the year, you may still have options through a Special Enrollment Period (SEP).

These are life events or special circumstances that allow you to sign up or switch Medicare plans outside the usual windows—and they can help you avoid coverage gaps or penalties.

At Emerald Medicare, we walk clients through these exceptions every day. Here are the most common SEPs you should know about.

✅ 1. Losing Employer or Union Coverage

If you or your spouse are still working at 65 and covered under an employer group plan, you’re allowed to delay Medicare Part B and Part D without penalty.

But once that coverage ends, you have an 8-month SEP to:

  • Enroll in Medicare Part B
  • Enroll in a Part D drug plan (within 63 days of losing coverage)
  • Choose a Medicare Advantage or Medigap plan

📌 This SEP begins the month after your employment or coverage ends—whichever comes first.

🏠 2. Moving to a New Service Area

You may qualify for a SEP if you:

  • Move to a new address that is outside your current Medicare Advantage or Part D plan’s service area
  • Move within the same state, but your current plan isn’t offered in your new county
  • Return to the U.S. after living abroad

🕒 SEP window: You can switch plans up to 1 month before your move and for 2 months after.

💡 This is especially important for snowbirds, relocations, or moves into senior communities

🏥 3. Losing Medicaid or Extra Help Eligibility

If you no longer qualify for Medicaid, Extra Help, or a Medicare Savings Program (MSP), you’ll be granted a SEP to change your drug or Advantage plan.

🕒 SEP window: Usually 2 months from the loss of eligibility.

🚨 4. Plan Terminates or Changes Contract with Medicare

If your Medicare Advantage or Part D plan is discontinued or doesn’t renew its Medicare contract, you can:

  • Enroll in a new Advantage or Part D plan, or
  • Return to Original Medicare with or without a Medigap plan

🕒 SEP window: 2 months after notification.

💊 5. Entering or Leaving a Skilled Nursing or Rehab Facility

You qualify for a SEP if you’re:

  • Admitted to, or discharged from, a skilled nursing facility, rehab center, or long-term care hospital

This SEP allows you to join, switch, or drop Medicare Advantage or Part D plans during your stay and up to 2 months after discharge.

💻 6. Other Less Common SEPs

You may also qualify for a Special Enrollment Period if:

  • You’re released from incarceration
  • You gain or lose eligibility for other coverage like TRICARE or VA
  • You make a Medicare enrollment mistake due to misleading information
  • You qualify for a 5-star plan SEP (available once per year)

⚠️ Penalties Apply If You Miss Your SEP

Missing your SEP windows can result in:

  • Permanent late enrollment penalties
  • Delayed access to care
  • Higher drug costs

That’s why we always recommend scheduling a free review when your life circumstances change.

Life Changes? Let Us Help You Make the Right Medicare Moves

Moving, retiring, or losing coverage? Don’t guess—get expert help. At Emerald Medicare, we’ll guide you through your Special Enrollment Period and help you choose the best plan for your next chapter.

Get in Touch with the Emerald Medicare team!

📞 (888) 683-6372 or (845) 358-1220
📧 office@emeraldmedicare.com

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How Medicare Beneficiaries Can Advocate for Themselves

by | Dec 23, 2025 | General, Industry Shifts & Updates, Rules & Enrollment

If you’re on Medicare, you may feel like getting clear answers has become harder than it used to be… Shorter appointments, longer phone waits, and more portals, forms, and follow-ups.

For many Medicare beneficiaries, the healthcare experience can feel rushed, fragmented, and increasingly difficult to navigate. You’re not imagining it — and it’s not because your doctors / their staff don’t care.

The Reality Behind the Front Desk

Medical offices today are under real pressure, facing:

  • Staffing shortages
  • Increased administrative requirements
  • Higher patient volume
  • More insurance rules to navigate

Most offices are doing the best they can with fewer resources than ever before. That makes self-advocacy more important—not confrontational, just informed and prepared.

Advocacy Doesn’t Mean Arguing — It Means Being Organized

The most effective Medicare patients aren’t the loudest ones; They’re the most prepared. Simple steps make a big difference:

  • Bring an updated medication list to every appointment
  • Keep notes from specialist visits and tests
  • Ask for written instructions when possible
  • Confirm next steps before leaving the office

Clear communication saves time for you and for your provider.

Ask the Questions That Matter

You are allowed—and encouraged—to ask questions such as:

  • “Is there a less expensive alternative to this medication?”
  • “Is this service considered preventive or diagnostic?”
  • “Will this test require prior authorization?”
  • “Who should I contact if I get a bill I don’t understand?”

These aren’t complaints. They’re responsible questions.

Use Your Medicare Coverage Strategically

Many people don’t realize how much flexibility they have.

  • You can ask your doctor to review medication options annually
  • You can request generics when appropriate
  • You can confirm network status before non-urgent care
  • You can review plan coverage before scheduling major services

A few minutes of verification can prevent months of billing frustration.

Don’t Wait Until Costs Become a Crisis

One of the biggest challenges we see is people waiting until something feels unmanageable.
Instead, look for early signals that medication and/or , such as:

  • Prescriptions costing more than expected
  • Copays increasing visit by visit
  • Bills arriving that don’t match explanations
  • Avoiding care because of uncertainty

These are signs it’s time to review—not signs you’ve done something wrong.

Partnership Is The Goal.

The best outcomes happen when Medicare beneficiaries, providers, and advisors work as partners. Healthcare may feel more complicated—but with preparation, questions, and the right guidance, you can still navigate it confidently.

Self-advocacy isn’t about pushing back. It’s about staying informed, engaged, and prepared.

Get in Touch with the Emerald Medicare team

📞 (888) 683-6372 or (845) 358-1220
📧 office@emeraldmedicare.com

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Understanding Medicare’s “3-Midnight Rule” for Skilled Nursing Facility Coverage

by | Oct 21, 2025 | General, Rules & Enrollment

If you ever need short-term rehabilitation or skilled nursing care after a hospital stay, one Medicare rule could make all the difference in whether your care is covered — the 3-midnight rule. This often-overlooked guideline determines when Medicare Part A will pay for a Skilled Nursing Facility (SNF) stay, and misunderstanding it can lead to costly surprises.

As a trusted, independent Medicare brokerage, Emerald Medicare helps clients across the country navigate these details with confidence. Here’s what you need to know about how the 3-midnight rule works — and how to protect yourself from unexpected expenses.

What is the 3-Midnight rule?

To qualify for Medicare coverage of a skilled nursing facility stay, you must first have a 3-day inpatient hospital stay. This means:

  • You must be formally admitted as an inpatient, not under observation or emergency status.
  • The stay must include three consecutive midnights in the hospital.
  • The day of admission counts, but the day of discharge does not.

For example, if you’re admitted on a Monday, stay through midnight on Wednesday, and are discharged on Thursday, your stay meets the 3-midnight requirement.

This rule exists because Medicare only covers skilled nursing facility care when it follows a qualifying inpatient hospital stay. Without it, you may be responsible for the full cost of care — which can add up quickly.

Why Observation Status Matters

A common point of confusion is the difference between being “admitted” and being “under observation.”
Even if you stay overnight or longer, observation status is considered outpatient care. Unfortunately, that time does not count toward the 3-day inpatient requirement.

Before you leave the hospital, ask a simple but crucial question:

“Was I officially admitted as an inpatient?”

Hospital staff can verify your status so you know whether your SNF stay will qualify for Medicare coverage.

    Are There Exceptions to the Rule?

    Yes — and they’re becoming more common. Some programs waive the 3-day requirement altogether:

    • Medicare Advantage Plans: Many Medicare Advantage (Part C) plans waive the 3-midnight rule, allowing coverage for SNF care without a prior hospital stay. Check with your specific plan to confirm.
    • Other programs: Medicaid or Veterans’ benefits may help cover costs if you don’t meet the Medicare rule.

    What You Should Do Before Leaving the Hospital:

    1. Confirm your admission status. Make sure your stay was inpatient, not observation.
    2. Talk to your care team. Ask if your hospital participates in any ACO or waiver program.
    3. Contact your Medicare plan. Whether you have Original Medicare or a Medicare Advantage plan, confirm coverage and potential exceptions before discharge.

    Plan Ahead with Emerald Medicare
    Understanding Medicare’s 3-midnight rule can protect you from major out-of-pocket expenses and ensure your care transitions are covered. At Emerald Medicare, our licensed Medicare specialists are here to explain these rules in plain language — and help you plan ahead for the unexpected.

    If you have questions about skilled nursing coverage or your Medicare plan, we’re here to help.

    Reach out to Emerald Medicare Today!

    Contact Us
    📞 (888) 683-6372 or (845) 358-1220
    📧 office@emeraldmedicare.com

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    How Do I Apply for Medicare?

    by | Oct 9, 2025 | Medicare Advantage, Medicare Supplement, Original Medicare, Prescription Drug Coverage, Rules & Enrollment

    Understanding the Medicare Application Process

    Enrolling in Medicare is a major milestone in your healthcare journey, but it doesn’t have to be confusing. Whether you’re approaching age 65 or qualifying earlier due to disability, knowing when and how to apply ensures you avoid gaps in coverage or penalties. Here’s a step-by-step guide to applying for Medicare with confidence.

    Eligibility: Who Can Apply for Medicare

    You are generally eligible for Medicare if:

    • You’re 65 or older, and either a U.S. citizen or a permanent resident who’s lived in the U.S. for at least five years.

    • You’re under 65, but have received Social Security Disability Insurance (SSDI) for 24 months.

    • You have End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s Disease).

    If you’re already receiving Social Security benefits, you’ll be enrolled automatically in Medicare Parts A and B. Otherwise, you’ll need to apply manually through the Social Security Administration.

    How to Apply for Medicare Parts A & B (Original Medicare)

    You can apply for Original Medicare in one of three ways:

    Online: Visit SSA.gov/Medicare

    By Phone: Call Social Security at 1-800-772-1213.

    In Person: Visit your local Social Security office.

    • Part A (Hospital Insurance) covers inpatient hospital stays, skilled nursing, and hospice care.

    • Part B (Medical Insurance) covers doctor visits, preventive care, outpatient services, and durable medical equipment.

    If you’re still working and covered under employer insurance, you may choose to delay Part B to avoid paying unnecessary premiums—but it’s important to confirm this with your HR department or a licensed Medicare advisor before making that decision.

    Applying for Medicare Advantage (MAPD) Plans

    After enrolling in Parts A and B, you may decide to choose a Medicare Advantage Plan (Part C) instead of using Original Medicare as your primary insurance. These plans are offered by private insurance companies and often include additional benefits such as:

    • Bundled Prescription drug coverage

    • Additional dental, vision, and/or hearing benefits

    • Wellness programs and gym memberships

    Enrollment in a Medicare Advantage Plan is handled through the private insurer offering the plan, not through Medicare directly. The benefit of using a brokerage (like Emerald Medicare) to enroll in a MAPD plan is they will usually handle the enrollment & application process on your behalf, acting as the middleman between you and your insurance provider.

    Medigap (Medicare Supplement) Plans

    If you prefer to stay with Original Medicare, you can add a Medigap policy to help pay for costs that Parts A and B don’t cover—such as deductibles, coinsurance, and copayments.

    • You must have both Parts A and B to buy a Medigap plan.

    • Depending on your home state, you may or may not have to go through medical underwriting and wait for approval.

    Just like with a Medicare Advantage (MAPD) Plan, the best & easiest way to enroll in a Medigap plan is to reach out to your Medicare broker, who will advise you on the coverage options available in your zip code. Otherwise, you can reach out to the carriers directly to get prices and/or compare options, and even enroll directly with the carrier by reaching out to their customer service and/or new enrollment department. 

    Prescription Drug Plans (PDP – Part D)

    If you choose Original Medicare (if you do NOT choose an MAPD plan) you’ll likely also need a standalone Part D prescription drug plan.

    • These plans are also available through private insurance companies.

    • Enrollment is typically completed via Medicare.gov or directly through the plan’s website.

    • Make sure to review each plan’s formulary (drug list) to ensure your prescriptions are covered affordably.

    With Emerald Medicare, once you enroll in Original Medicare (Parts A/B), we walk you through all your coverage options and thoroughly explain how these options differ. We also handle your enrollment application(s) along with reviewing your list of Medications & Doctors to make sure there are no gaps in your coverage. 

    Get Guidance from the Medicare Experts

    Applying for Medicare doesn’t have to be stressful. At Emerald Medicare, our licensed experts can walk you through every step—from choosing Parts A and B to comparing Supplement, Advantage, and Part D options personalized to your needs.

    Start your Medicare journey confidently—contact Emerald Medicare today!

    (888) 683-6372 or (845) 358-1220

    info@emeraldmedicare.com

    Do I Need Medicare Part A and/or Part B If I Am Still Working?

    by | Sep 18, 2025 | Original Medicare, Rules & Enrollment

    Of course, turning 65 doesn’t mean you have to retire—but it does mean Medicare eligibility begins, and many people still wonder:

    “If I’m still working and have health insurance through my employer, do I need to enroll in Medicare when I turn 65?”

    The answer depends on several factors—including your employer size, your current health coverage, and whether you’ve already started Social Security. At Emerald Medicare, we help clients evaluate these decisions every day to avoid penalties, gaps, or unnecessary costs.

    Let’s break it down…

    ✅ Start with Medicare Part A: Most People Enroll

    Medicare Part A (hospital insurance) is premium-free for most people and generally covers inpatient hospital stays, skilled nursing, and hospice care.

    • If your employer has coverage and you’re still working, you can usually enroll in Part A at 65 without any downside.
    • HOWEVER—if you’re contributing to a Health Savings Account (HSA), you may want to delay Part A to avoid tax issues.

    🧾 What About Part B? It Depends on Employer Size

    Medicare Part B covers outpatient care, doctor visits, and preventive services. Unlike Part A, you do pay a monthly premium for Part B—so enrolling unnecessarily could cost you.

    IF YOUR EMPLOYER HAS 20 OR MORE EMPLOYEES:

    • You can delay enrolling in Part B without penalty.
    • Your employer coverage remains primary, and Medicare is secondary.
    • You’ll qualify for a Special Enrollment Period (SEP) when you retire or lose coverage—no late penalty.

    IF YOUR EMPLOYER HAS FEWER THAN 20 EMPLOYEES:

    • You must enroll in Medicare Part A and B when first eligible.
    • In this case, Medicare becomes your primary insurance, and your employer plan pays second—or not at all.
    • Failing to enroll could leave you uninsured and/or penalized.

    Always check with your HR department—don’t assume your employer coverage counts as “creditable” for Medicare.

    💼 Still Working with an HSA? Be Careful

    If you’re contributing to a Health Savings Account (HSA) and you enroll in any part of Medicare, including Part A, you must stop HSA contributions.

    • Enrollment in Medicare (even Part A) disqualifies you from contributing.
    • Retroactive Part A enrollment (up to 6 months) can create IRS penalties if you’re not careful.
    • We typically recommend stopping HSA contributions at least 6 months before you apply for Medicare.

    📍 Why It Matters

    Making the wrong choice about when to enroll can lead to:

    • Late enrollment penalties
    • Gaps in coverage
    • Unexpected bills if Medicare should have paid primary
    • Tax consequences for HSA users

    ✅ When to Enroll (or Delay) Original Medicare: A Quick Recap

    Situation Part A Part B
    Employer has 20+ employees, no HSA Usually enroll Delay OK
    Employer has fewer than 20 employees Enroll Enroll
    Still working and using an HSA Delay Delay
    Retiring soon or leaving coverage Enroll Enroll (within 8 months of losing coverage)

    Click below to schedule an appointment with one of our Medicare Experts.

    Or, Contact Us
    📞 (888) 683-6372 or (845) 358-1220
    📧 office@emeraldmedicare.com

    Mark Brownstein, CSA® | Calendly

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    An Essential Guide for Medicare Advantage Plans

    by | Feb 5, 2025 | Medicare Advantage, Rules & Enrollment

    As your trusted Medicare experts, Emerald Medicare is committed to helping you navigate your healthcare options with ease. Medicare Advantage (Part C) plans are a popular choice among beneficiaries, offering comprehensive coverage with additional benefits not included in Original Medicare. If you’re considering Medicare Advantage, this guide will walk you through how these plans work, their benefits, and how to choose the best plan for your needs.

    What is Medicare Advantage?

    Medicare Advantage (Part C) is an alternative to Original Medicare (Parts A & B) offered by private insurance companies approved by Medicare. These plans bundle hospital (Part A), medical (Part B), and prescription drug coverage (Part D) into one all-inclusive plan. Many also offer extra benefits like dental, vision, hearing, and even wellness programs—making them an attractive option for those seeking added value beyond traditional Medicare.

    With Medicare Advantage, all healthcare services are managed through your plan’s network of doctors, hospitals, and pharmacies. While this structure helps control costs, it’s important to understand how provider networks function before enrolling, and how this may limit your options for medical care.

    —————

    What Do Medicare Advantage Plans Cover?

    Unlike Original Medicare, which requires separate coverage for prescriptions (Part D) and supplemental benefits (Medigap), Medicare Advantage plans integrate multiple types of coverage into a single, bundled plan. Here’s what’s typically included:

    Hospital Coverage (Part A) – Inpatient stays, skilled nursing facility care, and some home healthcare services.
    Medical Coverage (Part B) – Doctor visits, outpatient services, diagnostic tests, preventive care, and durable medical equipment.
    Prescription Drug Coverage (Part D) – Most Medicare Advantage plans include built-in drug coverage, covering a range of prescription medications.

     

    Additional Benefits – Many Medicare Advantage plans also offer:

    • Dental Coverage (routine cleanings, fillings, dentures, etc.)
    • Vision Coverage (eye exams, glasses, and contacts)
    • Hearing Coverage (hearing exams and hearing aids)
    • Fitness Benefits (gym memberships, virtual exercise programs)
    • Transportation (rides to medical appointments)
    • Over-the-Counter (OTC) Allowances (stipends for medical supplies and everyday wellness products)

    Because benefits vary by plan, it’s essential to compare options carefully or consult a Medicare expert to find the best fit for your healthcare needs.

    —————

    Why Should I Choose a Medicare Advantage Plan?

    Medicare Advantage plans combine coverage, convenience, and cost savings into a single plan, making them a great option for many beneficiaries. Here’s why they appeal to millions of Medicare enrollees:

    1. Comprehensive Coverage

    Unlike Original Medicare, which requires additional plans for prescriptions and supplemental coverage, Medicare Advantage offers all-in-one protection with extra benefits.

    2. Lower Out-of-Pocket Costs

    Many Medicare Advantage plans have low or $0 monthly premiums, and they cap out-of-pocket expenses, protecting beneficiaries from excessive costs. In contrast, Original Medicare has no limit on annual medical expenses unless paired with a Medigap policy.

    3. Extra Benefits Beyond Original Medicare

    With dental, vision, hearing, and wellness perks, Medicare Advantage covers services not included in traditional Medicare, making healthcare more affordable and accessible.

    4. Preventive Care & Care Coordination

    Many Medicare Advantage plans focus on preventive care and managed healthcare, offering case management services, wellness incentives, and telehealth options for added convenience.

    —————

    Medicare Advantage vs. Medigap: Key Differences

    Understanding the distinction between Medicare Advantage and Medigap (Medicare Supplement Insurance) is crucial when choosing a plan.

    Feature Medicare Advantage (Part C) Medigap (Supplement)
    Coverage Type Combines hospital, medical, and drug coverage Supplements Original Medicare, filling cost gaps
    Network Limited to plan’s provider network (HMO/PPO) No network restrictions—see any provider nationwide who accepts Medicare
    Premium Costs Often lower premiums, but may have higher copays/coinsurance Higher premiums but lower out-of-pocket costs
    Out-of-Pocket Maximum Yes (protects against high medical bills) No limit on costs under Original Medicare
    Extra Benefits Includes dental, vision, hearing, fitness, etc. No additional benefits beyond medical cost coverage
    Prescription Drug Coverage Usually included (Part D) Requires separate Part D enrollment
    Travel Coverage Limited outside your service area Nationwide and some foreign travel coverage

    Medicare Advantage is best for those who prefer bundled coverage and lower upfront costs, while Medigap is ideal for those who want broad provider access and more predictable expenses.

    —————

    How to Choose the Right Medicare Advantage Plan

    When selecting a Medicare Advantage plan, consider the following:

    🔹 Provider Network: Does your preferred doctor, hospital, or pharmacy accept the plan? HMOs require referrals and network providers, while PPOs offer more flexibility.
    🔹 Prescription Drug Coverage: Check the plan’s formulary (covered drug list) to ensure your medications are included.
    🔹 Extra Benefits: Need dental or vision care? Want access to telehealth or home fitness programs? Compare added perks to find a plan that suits your lifestyle.
    🔹 Out-of-Pocket Costs: Compare premiums, deductibles, copays, and maximum out-of-pocket (MOOP) limits to determine your total expected expenses for the year.
    🔹 Star Ratings: Medicare.gov rates plans on a 5-star scale based on customer satisfaction and quality of care. A higher-rated plan often means better coverage and service review from real beneficiaries.

    —————

    How to Enroll in a Medicare Advantage Plan

    You can enroll in a Medicare Advantage plan during specific enrollment periods:

    📌 Initial Enrollment Period (IEP) 
    Starts 3 months before you turn 65 and continues 3 months after your birthday month.
    📌 Annual Enrollment Period (AEP) 
    October 15th – December 7th each year. You can switch, join, or drop a Medicare Advantage plan.
    📌 Medicare Advantage Open Enrollment Period
    January 1st – March 31st each year. If you’re already enrolled in a Medicare Advantage plan, you can switch to a different plan or return to Original Medicare during this time.

    —————

    Explore Medicare Advantage with Emerald Medicare

    Choosing a Medicare Advantage plan is an important decision that requires careful consideration of your healthcare needs, provider preferences, and financial situation. At Emerald Medicare, we’re dedicated to helping you find the best-fit plan with zero-cost expert guidance.

    If you’re considering a Medicare Advantage plan or need help comparing options, we’re here for you! Click below to schedule an appointment with one of our expert brokers through Calendly or contact us directly:

    Contact Us:
    Phone: (888) 683-6372 or (845) 358-1220
    Email: office@emeraldmedicare.com

     

    Click below to schedule an appointment with one of our Medicare Experts.

    Mark Brownstein, CSA® | Calendly

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