Medicare Eligibility - Who gets Medicare ?

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Medicare is the federal government health insurance program that covers medical costs for most of America’s over-65 population and people with certain disabilities such as end-stage renal disease or ALS. 

This program gives you the peace of mind of knowing that your medical costs will be reimbursed during your golden years.

But who qualifies for Medicare? Read on to learn more about who is eligible for the program and how to enroll in it.

What you need to know about Medicare eligibility

Medicare eligibility depends on your age or if you have a qualifying medical condition.

At what age can you get Medicare? Most people become eligible for Medicare by turning 65, but Americans with a qualifying medical condition can receive Medicare after they’ve been on disability coverage for a period. 

Also, Americans with end-stage renal disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease) are eligible for the federal health insurance program.

Key Takeaways

People newly eligible for Medicare have seven months to choose a plan when they turn 65.
During the initial enrollment period, you can choose between Original Medicare or Medicare Advantage, which private health insurance companies offer.
People who pick Original Medicare can also add Part D prescription drug benefits and a Medicare supplement plan to help them with out-of-pocket costs.
Medicare doesn’t generally cover health care services outside the 50 states and American territories.

When to apply for Medicare

Medicare will send you information about sign-up as you approach your 65th birthday. You have seven months to enroll in Medicare — from three months before your birth month to three months after your birth month.

Medicare beneficiaries pick between Original Medicare or Medicare Advantage.

Original Medicare is Part A (hospitals) and Part B (physicians). Original Medicare doesn’t include prescription drug coverage, but you can get that insurance in a Part D plan.
Private insurance companies provide Medicare Advantage (Part C) plans, which incorporate hospital, physician, prescription drugs and may include supplemental benefits, such as dental and vision.

After you choose a plan, you have an opportunity to change plans once during annual enrollment. Medicare Annual Enrollment runs from October 15 to December 7 each year.

During that time, you can:

Switch Medicare Advantage plans
Move from Medicare Advantage to Original Medicare
Swap Original Medicare for Medicare Advantage and change Part D plans

There’s also a limited Medicare Advantage open enrollment from Jan. 1 to March 31. At that time, you can only change an existing Medicare Advantage plan or move from Medicare Advantage to Original Medicare.

Besides those times, you can only change Medicare plans during the year if you have a qualifying life event that creates a special enrollment period. Those life events can include moving, losing other health insurance coverage or a spouse’s death.

How to apply for Medicare

Wondering how to sign up for Medicare? A month or two before you plan to retire is a good time to start preparing for your Medicare coverage future, says Casey Schwarz, senior counsel, education and federal policy at the Medicare Rights Center.

“You’re going to need to start to think about and choose the type of coverage you are going to want,” she says. This also gives you more time to shop for the right Medicare Advantage or Medigap policy.

In addition, it can be wise to contact Social Security, as you and your employer will need to fill out paperwork showing you have been covered by insurance as a result of your current work since you turned 65.

“If you contact Social Security before you leave employment or lose that insurance, you can choose the date you want your Medicare to start,” Schwarz says. “If you wait until you’ve already left employment, then your coverage will start the first of the next month.”

As soon as they’re eligible, most people who sign up for Medicare get both Part A (hospital insurance) and Medicare Part B (medical insurance coverage). It typically makes sense to sign up right away because signing up later can result in a gap in your coverage or having to pay a penalty.

If you’re signed up for Social Security benefits for at least four months before turning 65, you automatically will be enrolled in Medicare Part A, which is free for most Americans. You also will be enrolled in Medicare Part B. There is a premium with Part B, so you can decide whether or not you want to keep the coverage.

There are three primary methods you can use to sign up:

Online at the Social Security website. The federal government says this is the “easiest and fastest way to sign up.”
By calling Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.
By contacting your local Social Security office.

If you or your spouse worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772.

The U.S. Centers for Medicare and Medicaid Services (CMS) says it will mail out a welcome package — complete with your Medicare card — about two weeks after you sign up.

Are you eligible for Medicare benefits if you’re under 65?

It’s possible to qualify for Medicare even if you are younger than 65, but you must meet certain criteria. These include being diagnosed with:

Specific disabilities that allowed you to receive Social Security Disability Insurance benefits for at least 24 months
Permanent kidney failure or end-stage renal disease
Amyotrophic lateral sclerosis also known as ALS (Lou Gehrig’s disease)

Can you get Medicare if you never worked?

You’re still eligible for Medicare, even if you haven’t worked or only paid Medicare taxes for a short period, as long as you meet age qualifications and you’re a U.S. citizen or a legal resident for at least five years. However, you may have to pay for Part A coverage if you have not paid Medicare taxes for a full 10 years.

How much does Medicare cost if you need to purchase Part A? According to CMS¹:

Part A premiums for people who paid Medicare taxes for fewer than 30 quarters are $506 monthly.
Part A premiums for people who paid Medicare taxes for between 30 and 39 quarters are $278 monthly.

Medicare eligibility if you move out of the United States

Generally, Medicare doesn’t cover health care services outside the 50 states of the U.S. and the following U.S. territories:

District of Columbia
Puerto Rico
U.S. Virgin Islands
Guam
American Samoa
Northern Mariana Island

If you move outside the U.S. and hope to maintain Medicare coverage in case you return, not much will change with your Medicare Part A insurance. This benefit is free for most people. So, if you return to the U.S. later, Part A coverage will be available to you.

The situation is trickier with Medicare Part B coverage. You must continue to pay for this coverage to keep it active. If you’re living overseas, that means spending money for coverage you won’t use.

However, if you opt not to pay for Part B while overseas and then move back to the United States, you will be subject to penalties for delaying coverage. In addition, if you decide to re-enroll for Part B after dropping it, you only will be able to do so between the months of January and March, with benefits kicking in the following July. Again, penalties may apply.

If you move back to the U.S. after living abroad and you enroll in a Part D drug plan within two months, Medicare coverage begins on the first day of the month after you enroll. You won’t be liable for late penalties. However, if you miss the deadline, you will have to wait until the Annual Enrollment Period — October 15 to December 7 — to sign up, and you will owe permanent late penalties.

Frequently Asked Questions

What qualifies you for Medicare Parts A and B?

Generally, when you turn 65 – and in a handful of other circumstances – you qualify for Medicare Part A and Medicare Part B, which together are known as Original Medicare.

What is Medicare Part A? This covers hospitalizations, skilled nursing facilities, and hospice care.
What is Medicare Part B? This covers things like physician services, preventive care, and outpatient care among others.

You’re eligible for Part A with no monthly premium costs if you’re 65 or older and either you or your spouse worked and paid Medicare taxes for at least a decade.

Part A is available premium-free to those who:

Receive retirement benefits from Social Security or the Railroad Retirement Board or are eligible to receive them but have not yet filed for them
You or your spouse had Medicare-covered government employment
You have a qualifying disability such as end-stage renal disease or ALS

If you’re not eligible for premium-free Part A, you still may be able to buy it.

How do you become eligible for Medicare Part C?

You also qualify for Medicare Part C upon turning 65. What is Medicare Part C? This type of health coverage is known as Medicare Advantage and private insurance companies offer this insurance. It is an alternative way to receive Medicare coverage.

To be eligible for Part C, you must be enrolled in Medicare Part A and Part B and you must live in the same area that a Part C plan covers.

Part C coverage plans often cover prescription drugs and many have vision, dental and fitness benefits, in addition to other perks not found in Original Medicare. When choosing a Medicare Advantage plan, make sure to read the fine print from each health insurance company to find the plan that works for you.

How do you become eligible for Medicare Part D?

As with the other types of Medicare coverage, most people are eligible for Part D coverage when they turn 65 or if you have a qualifying condition.

What is Medicare Part D? Private insurance companies offer this Medicare prescription drug coverage, which is paired with Original Medicare. That means you must enroll in Medicare Part A and Part B to be eligible for this coverage. People with Medicare Advantage aren’t eligible for Part D coverage.

How do you become eligible for Medicare supplement plans?

You’re first eligible for a Medicare supplement plan — also known as “Medigap” — the first month you have Medicare Part B and are age 65 or older. CMS says this is the best time to purchase a Medigap policy, as you generally get better prices and more choices among policies.

During this six-month window, you can purchase any Medigap policy sold in your state. That is true even if you have health issues. Crucially, you may not be able to purchase a Medigap policy after this enrollment period elapses if you have health problems. Or, you may pay more for this coverage.

Medigap plans are only for people with Medicare Parts A and B. Medicare Advantage plan members can’t buy Medicare supplement plans.

When is Medicare annual enrollment?

Medicare’s general enrollment period runs from October 15 to December 7 each year. During this time, you can join, change or drop a plan, but only one change can be made. Enrolling by December 7 ensures that you will have coverage on Jan. 1 of the following year.

The Medicare Advantage open enrollment period dates are different — January 1 through March 31. At this time, you can enroll in a Medicare Advantage plan, switch to a different plan, or switch back to Original Medicare. Again, only one change is allowed during this time.

Source:

Medicare.gov. “Costs.” Accessed August 2022.

Disclaimer:

Insure.com is not affiliated with or endorsed by the government or Federal Medicare program. Plans are insured or covered by a Medicare Advantage organization with a Medicare contract and/or a Medicare approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY 1-877-486-2048), 24 hours a day/7 days a week, to get information on all of your options. Not all plans offer all of these benefits. Benefits and availability may vary by carrier and location. Limitations and exclusions may apply. Every year, Medicare evaluates plans based on a 5-star rating system. Part B Premium give-back is not available with all plans. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

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Chris Kissell

Contributing Researcher

Chris Kissell is a Denver-based writer and editor with work featured on U.S. News & World Report, MSN Money, Fox Business, Forbes, Yahoo Finance, Money Talks News and more.