Moving from a Marketplace (Health Care Exchange) or SHOP (Small Business Health Option) plan to a Medicare Plan

Do You Have Questions? We've Got Answers.

What if I have a Marketplace Qualified Health Plan (QHP) plan but will qualify for Medicare soon?

If you have a Marketplace plan, you can keep it until your Medicare coverage starts. Then you can cancel it without penalty. Once you qualify for Medicare, you’ll have a limited time (an initial enrollment period) to sign up. For most people, the enrollment period starts 3 months before their 65th birthday and ends 3 months after their 65th birthday.

In most cases, it’s to your advantage to sign up for Medicare when you’re first eligible because:

  1. Once your Medicare Part A (hospital costs) coverage (which is free for most people) starts you won’t be able to keep any premium tax credits or lower out-of-pocket costs for a Marketplace plan based on your income. If you like, you can keep your Marketplace plan too but you’ll have to pay full price for the Marketplace plan.

  2. If you miss the seven-month sign-up window for Medicare Part B* (doctor costs), you'll have to wait until the next "general enrollment period" which runs from Jan. 1 to March 31 with benefits beginning the following July 1. If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty.

    *(or Part A if you have to pay a premium for it)

Once my coverage in Medicare starts, can my Marketplace Qualified Health Plan (QHP) disenroll me without my consent?

No, your plan may not terminate you if you are enrolled in Medicare unless you request it.

If I sign up for Medicare, when do I cancel my QHP?

Once your Medicare coverage starts, you can cancel your Marketplace health plan without penalty by contacting the Marketplace call center or cancelling online. If you have Medicare coverage, you’re considered covered under the health care law. You won’t have to pay the fee that some people without insurance must pay. Be sure not to cancel your Marketplace plan before your Medicare coverage begins. Otherwise your coverage may be delayed.

Can Medicare beneficiaries with coverage under SHOP plans delay enrollment in Medicare Part B without penalty?

Yes. A Medicare beneficiary who is enrolled in employer purchased SHOP coverage is treated the same as any other person with employer group health plan coverage. You can delay enrollment if you are covered under an employer’s health plan for you or your spouse current employment.

If you’re covered under an employer’s plan, you can sign up for Part B without penalty:

  • Any time you are still covered by the plan.

  • During the eight-month period that begins the month after the employment ends or the coverage ends, whichever happens first.

If you do not sign up during this special enrollment period, late enrollment penalties may apply, and you will only be able to sign up during the General Enrollment Period, which occurs annually from January through March with coverage beginning July 1.

I want to purchase health insurance through the Marketplace. What if I have Medicare?

It’s against the law for someone who knows that you have Medicare to sell or issue you a Marketplace policy.

Medicare isn’t part of the Health Insurance Marketplace, so you don’t need to do anything. If you have Medicare, you’re considered covered. The Marketplace won’t affect your Medicare choices or benefits. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan (like an HMO or PPO), you won’t have to make any changes.

Why should I join a Medicare Advantage Plan (Part C)?

Medicare Parts A and B offer the most basic Medicare coverage available. To get more complete coverage, you have a number of options, including Medicare Advantage Plans, which offer more benefits than Original Medicare, usually for the same cost. EmblemHealth offers both HMO and PPO plans and most of our plans also offer prescription drug coverage and Original Medicare does not. Plans also offer coverage for eyeglasses, annual checkups, chiropractic care, hearing and dental.

View an EmblemHealth plan in your area.

There are some exceptions and we know that each person’s situation is different. We have representatives standing by to help you with additional information daily, 8 am to 8 pm at 1-800-447-9169. TTY/TDD users call 711.

More Helpful Resources

Marketplace Matters: Medicare & the Marketplace Video – A Centers of Medicare and Medicaid Services (CMS) video that explains what consumers who have a marketplace plan and may soon be eligible for Medicare need to know to switching to Medicare.

Medicare and the Health Insurance Marketplace (PDF) – CMS also provides a list of frequently asked questions regarding the transition from the Marketplace to Medicare.

Changing from the Marketplace to Medicare - provides information for people who are changing to Medicare.

Enroll in a Medicare plan
We have representatives standing by to help you daily, 8 am to 8 pm with at 1-800-447-9169. TTY/TDD users call 711 Learn More