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 you can apply for coverage and enroll. 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 that people qualify is through the Medicare eligibility age requirement. If you are 65 or older, then you qualify for Original Medicare. Original Medicare 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. If you receive Social Security retirement benefits, you will not have to pay a premium for Part A coverage. Similarly, if you receive benefits from the Railroad Retirement Board or you or your spouse had Medicare-qualified government employment, then you can receive premium-free Part A coverage.
Enrolling in Medicare is not difficult for people over 65. If you are already receiving retirement benefits, then you will be automatically enrolled in coverage. For those not yet receiving Social Security retirement benefits, you simply need to apply for Medicare coverage online to get your benefits started.
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 will be required to pay a monthly premium, even for Part A.
Medicare Advantage Plan Eligibility
Medicare Advantage plans were formerly known as Medicare Part C. These plans 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 in most cases. Different plans have different deductibles, copayments, and premiums associated with them. Medicare Advantage plans allow enrollees to manage all their health care coverage in a single place. These plans combine all the parts of Medicare into a single plan, and many of them 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 Part B. You must also live in an area that is served by the particular plan for which you wish to enroll. Not all plans are available everywhere. Each private insurer serves a specific market, and their plans are not available outside of 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 who 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. You must also reside in the service area of the particular plan for which you wish to enroll. Many people looking to enroll in Part D coverage simply opt for a Medicare Advantage plan. Remember that in order to qualify for an Advantage plan, you must be enrolled in both Part A and Part B coverage.
Many people who enroll in a Part D plan or a Medicare Advantage plan also choose to purchase a Medicare Supplement plan. These supplemental insurance plans, also known as 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 receive treatments at no cost or very little cost in some cases.
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 start receiving benefits the month of your 65th birthday. The time that your benefits actually start depends on when you enroll. We will discuss Medicare enrollment periods more in the next section. But, assuming that you get enrolled in time, your coverage will begin the month that you turn 65.
For individuals receiving Social Security disability benefits, your coverage will begin in your 25th month of SSDI entitlement. Note that you might be considered entitled to SSDI benefits before your payments begin, so your Medicare coverage is based on your entitlement date and not your actual benefit payment start date. You will be automatically enrolled in coverage at this time, and your benefits will start right away. 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.
Medicare Enrollment Periods
Medicare has a few different enrollment periods, and the time at which you sign up can affect your monthly premium amounts. You can check Medicare.gov for more specific information on Medicare enrollment periods. However, there are a few basic details that you need to know about them. First is the initial enrollment period. This period begins three months before your 65th birthday, runs through your birthday month, and ends three months after that birthday. It is wise to go ahead and sign up for benefits during this time. Failure to sign up during this time can lead to higher Part B premiums each month for the rest of your lifetime. This is known as the late enrollment penalty. You can avoid this penalty, though, by qualifying for a special enrollment period.
If you are covered by a group health insurance plan through your employer or through your spouse’s employment during your initial enrollment period, then you qualify to sign up during the special enrollment period. You can sign up at any time you are covered under the group plan. The special enrollment period runs for eight months from the time your employment or the group coverage ends — whichever comes first. Again failure to sign up during this period will lead to higher premiums.
Finally, there is the general enrollment period that runs from January 1 to March 31 each year. This open enrollment period allows people to sign up for Premium Part A or Part B coverage, and coverage will begin on July 1 of that same year. Retirees who miss their initial enrollment or special enrollment may sign up during this period. However, their premiums will be higher because of the late enrollment penalty.
Medicare Eligibility For People Under 65
We have already 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 they will have to 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, then 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 start in your 25th month of SSDI entitlement — and those months do not have to be consecutive.
Frequently Asked Questions
Who is automatically eligible for Medicare?
Many people ask, “How old do you have to be to get Medicare?” Those who are 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 will need to enroll in Medicare coverage manually.
When does Medicare coverage start?
It depends on your situation. If you are automatically enrolled or enroll 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 begin on July 1 of that year.
What is the maximum income to qualify for Medicare?
There is no income limit on qualifying for Medicare. If you are over 65, then you qualify for Medicare regardless of your income. There is one caveat, though. The higher your income, the more you will have to pay for your Part B premium. The standard Part B premium in 2022 is $170.10. However, you might have to pay as much as $578.30 if your income is above $500,000.
What is the difference between Medicare and Medicaid?
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, and you must have limited income and resources to qualify.