Who Qualifies for Medicare?


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Updated: August 15, 2024

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You are automatically eligible for Medicare when you reach 65 years old. Additionally, if you are under 65, you might qualify under specific circumstances, particularly if you have a disability.

Medicare is a federal program that offers important health coverage, ensuring that those who qualify can get the medical care they need, regardless of their age or health status. This program helps cover the cost of hospital visits, doctor appointments and other medical needs.

Who Is Eligible for Medicare?

Medicare eligibility primarily depends on age and specific health conditions. If you are 65 years old or older, you qualify for Medicare. Younger individuals with disabilities, End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) are also eligible. Additionally, you must be a U.S. citizen or a legal resident who has lived in the U.S. for at least five consecutive years.

Medicare is divided into different parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage, an alternative to Original Medicare) and Part D (prescription drug coverage). Each part of Medicare has different eligibility requirements, which helps ensure that participants receive coverage tailored to their medical and financial needs.

Medicare Penalties for Late Enrollment

 

Be sure to sign up for Medicare when you first become eligible, i.e., enroll during your initial enrollment period, as enrolling during this time ensures that you start receiving benefits right away. If you delay, you might face penalties that increase your monthly premiums.

  • Medicare Part A Late Fee: If you have to buy Part A and sign up late, your monthly cost might increase by 10%. You'd have to pay this extra cost for double the time you could have had Part A but didn't sign up.
  • Medicare Part B Late Fee: If you wait more than a year to sign up for Part B after you're supposed to, your monthly cost could go up by 10% for each year you waited. This extra fee lasts as long as you have Part B.
  • Medicare Part D Late Fee: If you don't sign up for Part D on time and don't have other good drug coverage for 63 days or more, you'll incur a fee. The fee is 1% of the national base beneficiary premium ($34.70 in 2024) for each month you didn't have coverage, and it's added to your monthly cost. This fee changes yearly and lasts as long as you have Part D.

Medicare Eligibility if You Are 65 Years Old

When you turn 65 years old, you typically qualify for Medicare, the U.S. health insurance program for seniors. Even if you don't feel ready to use Medicare benefits, signing up at 65 is important for maintaining your financial security and health benefits as you age.

1
Automatic Enrollment

If you've been receiving Social Security benefits for at least four months before your 65th birthday, you will be automatically enrolled in Medicare.

2
Manual Enrollment

If you're not automatically enrolled, you need to apply through the Social Security Administration. This is crucial to avoid delays in coverage.

3
Enrollment Period

The initial enrollment period for Medicare is seven months long. It begins three months before your birthday month, includes the month you turn 65, and continues for three months after that.

Medicare Eligibility if You Are Under 65 Years Old and With Disabilities or Medical Requirements

If you are under 65 and have disabilities or certain medical conditions, you might qualify for Medicare. If you think you are eligible, you should apply through the Social Security Administration (SSA). This is important as Social Security, not Medicare, determines eligibility for Social Security Disability Insurance (SSDI) and administers the benefits.

1
Disability and SSDI

If you are receiving SSDI benefits, you generally qualify for Medicare after a two-year waiting period. The coverage starts automatically at the beginning of the 25th month you receive your SSDI check.

2
Exceptions to Waiting Time
  • Amyotrophic Lateral Sclerosis (ALS): If you have ALS, you are eligible for Medicare as soon as your SSDI benefits start, with no waiting period.

  • End-Stage Renal Disease (ESRD): To qualify through ESRD, you must be receiving regular dialysis or need a kidney transplant. In addition, you, your spouse or your parent must have paid Medicare taxes for a required number of years, and you must be eligible to receive Railroad Retirement Benefits (RRB).

Your coverage can start four months after beginning dialysis or when you are admitted for a kidney transplant. Additionally, you can enroll in Medicare Part A and Part B together if you have ESRD. Part A coverage can be retroactive up to 12 months but no earlier than when you became eligible for ESRD Medicare.

3
Railroad Workers

If you receive an RRB disability pension, the process is similar, but you should check specifically with the SSA regarding your eligibility.

4
Eligibility Through Work History

You, your spouse or your parent must have paid Medicare taxes for a sufficient amount of time, typically at least 10 years.

5
Extended Coverage After Returning to Work

If you go back to work, you can still keep your Medicare Part A for over eight years as long as you meet the disability criteria, without needing to pay premiums.

Medicare provides the same comprehensive health benefits to those under 65 with disabilities as it does to those over 65.

For more detailed information about your specific situation, especially if you have complex medical or disability conditions, contacting the Social Security Administration directly at 800-772-1213 is recommended.

Who Qualifies for Medicare Part A?

To qualify for Medicare Part A without paying a premium, you need to have contributed to Medicare taxes through your work. Otherwise, you have to pay a premium to buy Medicare Part A. In any case, it’s important to apply for Medicare Part A as you approach your 65th birthday to ensure coverage when you need it.

Eligibility for Premium-Free Medicare Part A

You will be eligible for Part A and will not be required to pay any premiums if you:

  • Qualify Through Work: If either you or your spouse has contributed to Medicare taxes for a minimum of 10 years, which equals 40 Social Security credits, you are eligible for premium-free Medicare Part A when you turn 65. This applies whether the credits were earned through your own employment or a spouse’s employment.
  • Qualify Through Social Security or Railroad Retirement Benefits: You are also eligible for premium-free Part A if you qualify for retirement benefits from Social Security or the Railroad Retirement Board.
  • Are a Government Employee: If you are a government employee who paid the Medicare portion of the Federal Insurance Contributions Act (FICA) taxes while working, you are eligible for premium-free Part A, even if you do not qualify for other Social Security benefits.

Paying for Medicare Part A

You need to pay premiums for Part A under the following conditions:

  • Less Than 40 Quarters of Medicare Taxes: If you or your spouse didn't work for at least 10 years, you may have to pay every month for Part A. In 2024, the cost is $278 if you've paid into Medicare for 30 to 39 quarters. If you have paid for fewer than 30 quarters, it costs more, about $505.

However, if you continue working and earning credits until reaching the required 40 credits, you can stop paying premiums for Part A once you qualify.

  • Low Earnings: If you earned less than $6,920 per year while working, you might need a longer work period to earn enough credits for free Part A.

  • Voluntary Enrollment: Individuals 65 or older who do not meet the credit requirements can still enroll in Medicare Part A by paying the premium. This is also linked to enrolling in Medicare Part B, which covers outpatient services.

Who Is Eligible for Medicare Part B?

Medicare Part B, also known as Medical Insurance, provides coverage for preventive services and medically necessary outpatient care. Generally, if you qualify for premium-free Medicare Part A, you are also eligible for Part B. This includes those who are 65 or older, as well as individuals under 65 with certain conditions or disabilities.

Criteria for Part B Without Premium-Free Part A

If you don’t have premium-free Part A, you can still get Part B by meeting the following conditions:

  • You must be at least 65 years old.
  • You must be a U.S. resident.
  • You must be a U.S. citizen or a permanent resident who has resided in the U.S. continuously for five years before applying.

Enrollment in Medicare Part B is not automatic for everyone. If you are not receiving Social Security or Railroad Retirement Board benefits before you turn 65, you need to sign up for Part B during your Initial Enrollment Period.

Medicare Part B has a monthly premium. In 2024, the standard monthly premium is $174.70, but it can be higher based on your income.

Be sure to enroll in Medicare Part B when you first become eligible to avoid a late enrollment penalty. If you don't sign up during this time, you can also sign up during the General Enrollment Period, which runs from January 1 to March 31 every year. If you sign up during this period, your coverage begins on July 1.

Who Is Eligible for Medicare Part C?

Medicare Part C, or Medicare Advantage, is an alternative to traditional Medicare that often includes extra benefits. To qualify for Medicare Part C, you need to have enrolled in both Medicare Part A and Part B.

Medicare Advantage plans are available based on your specific location — you need to live in the area where the plan is offered. To find out which plans are available in your area, you can visit the official Medicare website or check with individual insurance companies.

When considering a Medicare Advantage plan, check the details of what each plan covers and what it costs. This includes looking at the network of doctors and hospitals to ensure they meet your needs and understanding the costs involved, especially for out-of-network services if you're considering a PPO plan.

ENROLLING IN MEDICARE ADVANTAGE PLAN WITH END-STAGE RENAL DISEASE (ESRD)

Starting in 2021, those with End-Stage Renal Disease (ESRD) can also sign up for Medicare Part C. This change allows more people to choose from a broader range of plans. But it's very important to make sure that your kidney doctors and the dialysis facilities you use are part of the plan's network before you join.

Who Qualifies for Medicare Part D?

If you are enrolled in Medicare Part A or Part B, you qualify for Medicare Part D, which helps cover the cost of prescription drugs. You can choose from two types of plans:

  • Stand-alone Part D plans for those with Original Medicare: For those with Original Medicare, enrolling in a stand-alone Medicare Part D plan, also known as Prescription Drug Plans, from a private insurance company can add prescription drug coverage. Choose a plan based on where you live, as availability varies by location. You can find plans in your area by searching on Medicare.gov or checking directly with insurance companies.
  • Medicare Advantage (aka Medicare Part C) plans that include drug coverage: If you prefer a Medicare Advantage plan, most of these plans include prescription drug coverage, combining health and drug benefits in one plan. However, if you are enrolled in certain types of Medicare Advantage Plans, like a Private Fee-for-Service (PFFS), Medical Savings Account (MSA), Medicare Cost plan or certain employer-sponsored plans, you might be able to join a stand-alone Part D plan without losing your Medicare Advantage benefits.

When selecting a Medicare Part D plan, whether stand-alone or as part of a Medicare Advantage plan, make sure the plan covers the medications you need. Each plan has a formulary, which impacts your costs and care. It also helps you avoid any gaps in coverage.

Who Is Eligible for Medigap Plans?

To be eligible for a Medigap or Medicare Supplement plan, which helps cover some of the health care costs that Original Medicare doesn't, you need to meet specific criteria. First, you must be enrolled in both Medicare Part A and Part B.

Medigap is designed to supplement your Original Medicare benefits by covering expenses like copayments, deductibles and co-insurance.

Importantly, if you have a Medicare Advantage Plan, you cannot use a Medigap plan. You must switch back to Original Medicare if you want to purchase Medigap. Additionally, Medigap policies are individual plans, meaning you and your spouse would need to buy separate policies if you both want Medigap coverage.

About Mark Fitzpatrick


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Mark Fitzpatrick is a Licensed Property and Casualty Insurance Producer and MoneyGeek's Head of Insurance. He has analyzed the insurance market for over five years, conducting original research and creating personalized content for every kind of buyer. He has been quoted in several insurance-related publications, including CNBC, NBC News and Mashable.

Fitzpatrick earned a master’s degree in economics and international relations from Johns Hopkins University and a bachelor’s degree from Boston College. He is passionate about using his knowledge of economics and insurance to bring transparency around financial topics and help others feel confident in their money moves.


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