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Who Is Eligible For Medicare // Check Your Eligibility

Posted by Elliot Marks

Are you wondering whether you can enroll in Medicare, but everything you read is so complicated it doesn't make sense? The Medicare enrollment rules can be complicated, so we understand your frustration! Not to mention the fact that there is Part A, Part B, Part C, Part D, Medicare Advantage Plans, and Medigap coverage. This just adds to the complication and makes it difficult to figure out whether you qualify or not.

Luckily, you have come to the right place if you are trying to determine whether you are eligible. We will clearly explain the basic eligibility requirements as well as rules for special circumstances. You will also understand some of the differences between the different parts and when you can enroll in each. Keep reading to see if you can apply for coverage.

Who is Eligible For Medicare?

Let's start with the basics, and then we will explore special rules and circumstances. Medicare was started with the goal of helping provide health insurance for older individuals who no longer worked, thus had no employer-sponsored health plan in which to participate. Most health insurance plans in the U.S. are sponsored by an employer, so these older individuals did not have many options. If you are 65 or older and a U.S. citizen or permanent resident, then you are generally eligible for Medicare. This is in contrast to Medicaid, which is run jointly by state and federal governments and is intended to help low-income families get access to healthcare.

Medicare Eligibility Explained

Medicare is broken down into two main parts - Medicare Part A and Medicare Part B. There are parts C and D, but we will address those later. For now, just know that Original Medicare is made up of Parts A & B. Part A provides hospital coverage and coverage for inpatient services like hospice care or nursing facility care. Part B is traditional health insurance coverage that covers doctor's visits, outpatient services, and medical equipment.

In order to qualify for Part A under the normal guidelines, you need to be 65 years old and a United States citizen or permanent resident. If you or your spouse have worked and paid Medicare taxes for at least 10 years, then you do not have to pay a premium for Part A. However, if you do not meet the work requirement, you may still be able to pay a monthly premium and buy Part A coverage.

So, you can automatically receive Part A coverage when you reach age 65 premium-free if you meet any of these conditions:

  • You receive retirement benefits from Social Security or the Railroad Retirement board.
  • You are eligible to receive these benefits, but have not yet filed for them
  • You or your spouse had Medicare-covered government employment

You may also have access to premium-free Part A coverage if you have received Social Security disability benefits for 24 months or you have end-stage renal disease or Lou Gehrig's disease. These conditions will qualify you for coverage even if you are under 65. Once you have received disability payments for 24 months, you will be automatically enrolled in Part A. If your disability was approved due to ESRD or Lou Gehrig's disease, the 24 month waiting period does not apply. You become eligible immediately. You must manually apply if you have been diagnosed with ESRD, but you will be automatically enrolled if you have Lou Gehrig's.

In addition to the reasons listed above, you can also get premium-free Part A coverage if you are a kidney dialysis or kidney transplant recipient. You do not have to be 65 years old to qualify for coverage if you fall into either of these categories.

The great news is that if you are eligible for Part A benefits, then you are also eligible for Part B! However, there is a premium associated with Part B coverage. This premium can be deducted from your Social Security or Railroad Board retirement benefits. If you don't receive these benefits, then Medicare will send you a bill for your premium every three months. The Medicare Part B premium for 2021 is $148.50 per month. If your income is above $88,000 per year, then that premium increases as your income increases. Part B also requires a deductible of $203 per year.

Medicare Eligibility for Those Under 65

When Can I Start Receiving Medicare Part A Benefits?

You can start receiving Medicare benefits on the first day of the month that you turn 65 years old. If you have been receiving Social Security benefits or Railroad Board retirement benefits for at least 4 months, then you will be automatically enrolled in Part A coverage. If you are not yet receiving these benefits, you can still manually enroll in coverage. If your birthday falls on the first day of the month, then your benefits will start on the first of the month prior to your birthday. When you are ready to start coverage, you can apply for Medicare easily through their website.

If you are under 65 but receive SSDI benefits, you will be automatically enrolled in both parts A & B on your 25th month of disability benefits. If you receive disability due to Amyotrophic Lateral Sclerosis (ALS), you will be automatically enrolled as soon as your disability benefits begin. With ESRD, the rules are slightly different. You will need to manually apply for benefits. Your eligibility depends on a number of factors like whether you receive dialysis, whether you have had a kidney transplant, and whether you have worked and paid Medicare taxes. To check your eligibility, you can visit the Medicare eligibility checker directly on Medicare's website.

When Can I Start Receiving Part B Benefits

Since Part B coverage is optional, the enrollment rules are slightly different than Part A. Since Part B is optional and requires a premium, you will not be automatically enrolled in Part B. If you decide that you would like to receive this coverage, you can sign up during your initial enrollment period. This 7-month period begins three months before you turn 65, includes your birth month, and continues for three months after you turn 65.

Many people today are still working at the age of 65, and they choose to delay the start of their Part B coverage because they are still covered under their employer's health plan. In this case, you are entitled to a special enrollment period after retirement. When you stop working, you have 8 months to sign up for Part A/Part B after your employer provided coverage ends.

If you do not sign up for coverage during your initial enrollment period or a special enrollment period when your eligibility for Medicare begins, then Medicare provides for open enrollment periods each year from January to March. You can sign up during this time for coverage to begin on July 1. However, you will likely be required to pay a late enrollment penalty because you did not sign up when you become eligible.

Once you enroll in Part B coverage, you should also consider enrolling in a Medigap plan. This is Medicare supplement insurance that will help to cover out of pocket expenses and other items not covered by Medicare. This supplemental insurance can help save you money in the long run, and you will get the best rates if you sign up when you first become eligible.

Medicare Part C Eligibility

You might hear Medicare Part C also referred to as a Medicare Advantage plan. It is essentially a combination of Medicare Parts A & B, or hospital insurance and traditional health insurance. You must qualify for and be enrolled in Original Medicare (Parts A & B) in order to get Medicare coverage through Part C. In addition, you must live in the service area of the advantage plan you choose.

Part C is managed and administered by private insurance companies who contract with Medicare. The enrollment period for Part C is generally the same 7 month period as Original Medicare (3 months before turning 65, the month of your 65th birthday, and three months after turning 65). If you decide you want to sign up later, there is an Annual Election Period each year from October 15 to December 7 for coverage starting on January 1.

Coverage through Part C is optional, and there is no requirement to sign up for an Advantage plan. Each insurance company who administers a Part C plan can set their own amounts for out of pocket expenses. If you are considering a Part C plan, you should shop around to find the plan that works best for your situation.

Medicare Part D Eligibility

Traditional Medicare does not include prescription drug coverage, but coverage for prescriptions is available through Medicare Part D. Like Part C, Part D is administered through private insurance carriers who contract with Medicare. Also like Part C, you must live in the service area served by the Part D plan you choose.

To enroll in Part D coverage, you must be enrolled in either Part A, Part B, or both. These private insurers are approved by Medicare to administer these plans. You can contact your local insurance agent to inquire about Part D coverage or find a provider online through the Medicare.gov website.

Medicare Eligibility for People Under 65

Since Medicare is geared toward people 65 and older, can you get coverage if you are under 65? Yes, you can! If you are under age 65, you can obtain Medicare coverage in certain situations. If you have been deemed disabled by the Social Security Administration (SSA) for a period of 24 months, then you are entitled to enroll in Part A and/or Part B coverage. You are also eligible if you have been entitled to Railroad Retirement Board Disability benefits for a 24 month period.

In addition, if you have permanent kidney failure and receive dialysis or have had a kidney transplant, then you qualify for coverage. You may also qualify if you have been diagnosed with ALS, or Lou Gehrig's disease. Coverage typically begins automatically after your ALS diagnosis, but you need to enroll manually if you have kidney failure.

Am I Eligible for Medicare If I've Never Worked?

The short answer is yes, you are still eligible when you reach age 65 even if you have never worked. However, you will be required to pay a premium for Part A and B. If you have never worked, you will not receive Part A premium-free. You can also qualify if your spouse has met the work requirements for premium-free coverage. Another way to qualify is if your spouse had Medicare-covered government employment.

If you have never worked, then you cannot qualify for Social Security disability benefits, so that option would not qualify you for Medicare either. Kidney failure or ALS can still qualify you for Medicare even if you have never worked and you are under 65 years old.

Conclusion

While the Medicare rules might seem confusing at first, you can take it one piece at a time to make things much simpler. First, determine whether you meet the standard eligibility requirements of age and work history. If not, see if you meet one of the special requirements. If you are eligible, then you might consider signing up for a Medicare Advantage and/or Part D program as well through a private insurance company. If you are unsure, you can always visit the Medicare website or give them a call to answer your questions.

Elliot Marks

Elliot Marks

Author & Social Security Advisor

Elliot Marks has spent over 10 years providing clear and concise information to help Americans navigate the complex nuances of social security and many other government services in the United States. Elliot has a passion for helping those in need of these services to be able to find timely access to news and information that is relevant and helpful to their daily lives.

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