You have more than likely seen Medicare commercials on television before, but many people have no idea how Medicare works. Not just anyone can sign up for Medicare coverage. There are a few different eligibility groups, but you must qualify for benefits before applying for coverage and enrolling.
These same rules apply to Medicare Part A, Medicare Part B, Medicare Advantage plans, and Medicare Part D, or prescription drug plans. So, who is eligible for these benefits, and how do you get signed up? Keep reading, and we will give you all the details about Medicare eligibility and how you can enroll in this health insurance coverage.
Medicare Eligibility & Enrollment
There are a few different ways you can qualify for Medicare. The most common way people qualify is through the Medicare eligibility age requirement.
- If you are 65 or older, you qualify for Original Medicare, which consists of Medicare Part A and Medicare Part B.
This includes both hospital insurance and medical insurance. Some people who fall into this category will qualify for Part A coverage at no cost. You will not have to pay a premium for Part A coverage if you receive Social Security retirement benefits. Similarly, you can receive premium-free Part A coverage if you receive benefits from the Railroad Retirement Board or your spouse has Medicare-qualified government employment.
Enrollment Options
Enrolling in Medicare is not difficult for people over 65. You will be automatically enrolled in Medicare if you have already received retirement benefits.
Those not yet receiving Social Security retirement benefits need to apply for Medicare coverage online to get their benefits started.
Alternative Eligibility Options
Younger individuals with disabilities can also qualify for Medicare. Those who receive Social Security disability benefits will qualify for coverage and be automatically enrolled once they have received benefits for 24 months.
If you have amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, then your Medicare benefits will start the first month you receive your SSDI payments.
Finally, people with end-stage renal disease (ESRD), or permanent kidney failure, can qualify for Medicare regardless of their age. These people should be receiving kidney dialysis or a kidney transplant. Although they qualify for coverage, they must pay a monthly premium, even for Part A.
KEY TAKEAWAYS
- If you are 65 or older, you qualify for Original Medicare, which consists of Medicare Parts A and B. If you are enrolled in Medicare Part A or B, you will also be eligible for Medicare Part D.
- Those under 65 may be eligible for Medicare if they have a qualifying disability such as ALS or End-Stage Renal Disease (ESRD) or receive SSDI benefits for over 24 months.
- There are three designated times for enrollment: Initial Enrollment Period (IEP), General Enrollment Period (GEP), and Special Enrollment Period.
Medicare Advantage Plan Eligibility
Medicare Advantage plans, formerly known as Medicare Part C, are managed and administered by private insurance companies. These providers can set many of their own rules for each plan, although each plan must have at least the same minimum coverage as that provided by Medicare.
Most plans go above and beyond what Medicare covers. Different plans have different deductibles, copayments, and premiums associated with them. Medicare Advantage plans allow enrollees to manage all their healthcare coverage in a single place. These plans combine all the parts of Medicare into a single plan, and many even provide additional benefits like dental or vision coverage.
So, who qualifies for Medicare Advantage plans? To enroll in one of these Medicare plans, you must already be enrolled in Medicare Part A and B. You must also select a plan that is available in your location. Not all plans are available everywhere. Each private insurer serves a specific market, and their plans are unavailable outside those geographic markets. It is often wise to speak to a trusted insurance agent to discuss your options for one of these Advantage plans.
Medicare Part D Eligibility
Medicare Part D provides prescription drug coverage, and like Medicare Advantage plans, these Medicare prescription drug plans are administered by private insurance companies that contract with Medicare. Remember that Original Medicare only provides basic health coverage — both inpatient and outpatient services. However, your monthly prescription drugs are not covered under Original Medicare.
To enroll in a Part D plan, you must be enrolled in either Medicare Part A or Medicare Part B. If you are enrolled in both, that is fine as well. The plan you wish to enroll in must be offered where you live. Many people enrolling in Part D coverage opt for a Medicare Advantage plan. Remember that to qualify for an Advantage plan, you must be enrolled in Part A and B coverage.
Part D + Medigap
Many people who enroll in a Part D plan also purchase a Medicare Supplement plan. These supplemental insurance plans, or Medigap, help with out-of-pocket costs for items not covered by Medicare. They can also assist with the cost of deductibles and copays. Remember that Medicare follows a cost-sharing model, so you will incur some out-of-pocket expenses when you receive most treatments. This is unlike Medicaid, which is a needs-based program. Most Medicaid recipients sometimes receive treatments at no cost or minimal cost.
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When You Can Start Receiving Medicare Part A & B Benefits
We have already outlined who is eligible for Medicare, so when can you start receiving the benefits? If you qualify based on age, then you can begin receiving benefits the month of your 65th birthday. The time that your benefits start depends on when you enroll. We will discuss Medicare enrollment periods more in the next section. But, assuming you get enrolled in time, your coverage will begin the month you turn 65.
Coverage Start Date – Disabled
For individuals receiving Social Security disability benefits, your coverage will begin in your 25th month of SSDI entitlement. You will be automatically enrolled once you reach the 25th month. Note that you might be entitled to SSDI benefits before your payments start, so your Medicare coverage is based on your entitlement date and not your actual benefit payment start date.
For those on SSDI with ALS, your benefits will start the same month as your SSDI payments. There is no waiting period for Medicare coverage for those individuals.
The same is true for those with ESRD, although the initial enrollment period for these individuals varies based on their specific circumstances.
TIP
Most people sign up for Medicare during the initial enrollment period to avoid higher premiums and late fees. However, if you have existing healthcare coverage through an employer, you may be eligible for a special enrollment period at a later date to avoid late fees.
Medicare Enrollment Periods
Medicare has a few different enrollment periods, and the time you sign up can affect your monthly premium amounts. You can check the Medicare website for more specific information on Medicare enrollment periods. However, there are a few basic details that you need to know about them.
Initial Enrollment Period (IEP):
This period begins three months before your 65th birthday, runs through your birthday month, and ends three months after. It is wise to sign up for benefits during this time.
Failure to sign up during this time can lead to higher monthly Part B premiums for the rest of your lifetime. This is known as the late enrollment penalty. You can avoid this penalty by qualifying for a special enrollment period.
As of January 1, 2023, your Medicare Part B coverage starts the first day of the month after you sign up if you sign up during the last three months of your IEP.
General Enrollment Period (GEP):
Retirees who miss their EIP or special enrollment periods may still sign up during the general enrollment period, which runs from January 1 to March 31 each year. This open enrollment period allows people to sign up for Premium Part A or B coverage.
Beginning January 1, 2023, your coverage begins the first day of the month after you sign up. Previously, coverage began on July 1 of that same year.
Special Enrollment Period:
If a group health insurance plan covers you through your employer or your spouse’s employer during your initial enrollment period, you qualify to sign up during the special enrollment period. You can sign up whenever you are covered under the group plan.
The special enrollment period runs for eight months from the time your employment or group coverage ends—whichever comes first. Again, failure to sign up during this period will result in higher premiums.
Medicare Eligibility For People Under 65
We have touched briefly on qualifying for Medicare when you are under 65, but we will discuss the details again here. If you are under 65, you can qualify for Medicare if you receive Social Security disability benefits. You will be automatically enrolled in coverage after you receive benefits for 24 months. If you have ALS, then your Medicare coverage will start the same month as your first SSDI payment.
Similarly, those with kidney failure can receive Medicare regardless of their age. They must be in complete kidney failure and either receive dialysis or a kidney transplant. These individuals will need to apply for coverage and pay a premium for both Part A and Part B coverage.
The Bottom Line
Medicare benefits are available to U.S. citizens age 65 and older and younger individuals with disabilities. The program is funded through Medicare taxes and managed by the Social Security Administration.
If you meet the eligibility requirements, applying for coverage is not difficult. In most cases, your benefits will start within about a month. The exception is those on SSDI benefits. Your coverage will begin in your 25th month of SSDI entitlement — and those months do not have to be consecutive.
Frequently Asked Questions
Many ask, “How old do you have to be to get Medicare?” Those 65 and older and already receiving Social Security retirement benefits have reached the Medicare age and will be automatically enrolled in Medicare coverage.
Similarly, SSDI beneficiaries will be automatically enrolled in coverage following their 24th month of SSDI entitlement. These people will not need to apply for coverage as they are automatically eligible.
Others who may qualify still need to apply manually for their Medicare benefits. For example, a person who is 65 but not yet receiving Social Security is eligible for Medicare. Since they are not already receiving SS benefits, they must manually enroll in Medicare coverage.
It depends on your situation. If you are automatically enrolled or enrolled before your 65th birthday, your benefits will begin the month in which you turn 65. For those who enroll later, coverage will usually begin the following month.
If you miss your initial enrollment period and have to enroll during open enrollment, then your coverage will start the first day of the month after you sign up.
There is no income limit on qualifying for Medicare. If you are over 65, you qualify for Medicare regardless of your income. There is one caveat, though. The higher your income, the more you must pay for your Part B premium. The standard Part B premium in 2024 is $174.70 per month.
However, depending on your income, you might have to pay a higher amount. If you don’t qualify for premium-free Part A, you might be able to buy it. You will pay $278 or $505 per month in 2024 for Part A, depending on how long you or your spouse worked and paid Medicare taxes.
Medicare is a Federal program managed by the Social Security Administration. It provides health insurance for people over 65 and younger people with disabilities regardless of their income.
Medicaid, however, is a state-funded program that provides insurance to low-income individuals. Medicaid is a needs-based program; you must have limited income and resources to qualify.
You can find a Social Security Administration office near you by using our SSA office locator and searching for your closest location.
