Are You Eligible for Medicare? Eligibility Explained

Posted by Elliot Marks

Medicare provides coverage to over 60 million people in the US. When it was first created in 1965, the program only targeted Americans who were 65 years old and above. However, that changed in 1971 to allow certain people to be eligible for Medicare.

With the changing laws and policies, the eligibility requirements for this program have been somewhat confusing for most people. This is particularly true for the new groups that Medicare now covers: younger people with disabilities and patients with End Stage Renal Disease (ESRD).

In this post, we want to help you understand the eligibility requirements for Medicare and how you can qualify as an individual. Read on!

Medicare Eligibility Explained

Who Is Eligible for Medicare?

Before we delve into the requirements, it's vital to know the groups that the program covers.

Generally, it covers those aged 65 and above, kids with disabilities, Lou Gehrig's disease patients, and people suffering from end-stage renal disease. It helps to meet the cost of medical care services, including preventive services, prescription drugs, hospice care, physician visits, hospitalizations, and home health care.

Medicare has two parts: Part A (hospital insurance) and Part B (Medicare insurance). Each of them has different requirements, and we'll cover that.

Part A Eligibility

You're eligible for part A if you have reached 65 years old and you've been a legal US citizen for at least five years. The gov't will automatically enroll you to Medicare Part A when you hit 65 years old at no cost. At this point, you should be already collecting Social Security or Railroad Retirement benefits.

Those with Social Security or Railroad Retirement Benefits

If you're already receiving Social Security or Railroad Retirement benefits, you should check your mail for your Medicare Card. The card will be sent three months before your 65th birthday.

For those who are eligible for Medicare due to a disability, you'll receive the card on the 25th month of your disability.

The card will arrive with more information about Medicare. You'll also have the option of opting out of part B. However, it's usually advisable to opt out only if you still have your employer-sponsored coverage that offers the same or better coverage.

Those without Social Security or Railroad Retirement Benefits

If you're not receiving the benefits, you'll need to enroll in Medicare during the enrollment period. The period includes the three months before you turn 65, your 65th birthday month, and the three months after you turn 65.

If you enroll in Medicare before turning 65, the benefits will start on the month you turn 65. If you register in the three months after turning 65, you'll be given a date when you'll the coverage will be active.

Part B Eligibility

When you get notified that you're eligible for Medicare Part A, you'll also be informed that you're eligible for Part B. As noted before, Part B is optional, and it comes with a premium for those who opt to accept it.

In 2019, the standard Part B premium amount is $135 per month for new enrollees. It can also cost more if your income in more than $$85,000 or $170,000 for couples.

If you get benefits payments, from Social Security, Railroad Retirement Board or the Office of Personnel Management, your Part B premium will be automatically deducted from the amount.

It's advisable to enroll in both parts A and B of Medicare. Enrolling early in Part B will help to prevent gaps in your coverage. If you fail to join, you'll be locked out, and you'll have to wait until the next general enrollment period for Part B.

Plus, your premium will be 10 percent more every year you fail to enroll.

Medicare Eligibility for Those Under 65

Medicare Eligibility for Those Under 65

If you're under 65 years old, you become eligible for Medicare if:

  • You've received Social Security Disability Insurance (SSDI) checks for at least 24 months
  • You've been diagnosed with End-Stage Renal Disease (ESRD)
  • You're diagnosed with Lou Gehrig's disease

These are special cases, but you can still get the same coverage as for those who have hit 65.

Disability Medicare

If you've been receiving SSDI checks for more than 24 months, you can qualify for Medicare due to a disability. Keep in mind that the two-year waiting period starts the first month you receive the first SSDI check. You'll be then automatically enrolled in Medicare at the beginning of the 25th month.

For those who receive SSDI due to Amyotrophic Lateral Sclerosis, or ALS, your Medicare coverage automatically begins on the first month you receive your SSDI benefits. In this case, you don't have to wait for two years.

Social Security determines whether you need SSDI checks; not Medicare.

ESRD Medicare

You may also be eligible for Medicare if you've been diagnosed with ESRD. In this case, the program will cover the cost when you're getting dialysis treatments or when you need a kidney transplant.

If you're under 65 and have ESRD, the time when your Medicare coverage begins depends on:

  • When you apply for Medicare
  • Whether you receive dialysis treatments at home or a facility
  • Whether you undergo a kidney transplant

If you're eligible for ESRD Medicare, you can apply for parts A and B at the same time. Keep in mind that there are no premiums once you qualify for Part A.

Medicare Parts C and D Eligibility

You also need to know that Medicare has two more parts: C and D.

Medicare Part C, also known as Medicare Advantage, is an alternative option for receiving parts A and B benefits. However, you will get this policy through authorized private insurers.

To be eligible for Part C, you must have been enrolled in Medicare Part A and Part B. You must also be living in the area where the plan is offered. This plan is optional, and it's not meant for ESRD patients.

Keep in mind that you'll continue paying your Part B premium if you have Part C. Your Part C premiums depend on the insurer you choose.

On the other hand, Medicare Part D covers prescription drugs, and it's also available from Medicare-approved private insurers. To be eligible for this plan, you must have already registered for Medicare Part A and/or Part B. You must also be living in the service area of the plan you want.

Alternatively, you can enroll in a Medicare Advantage plan with prescription drug coverage (MAPD). You must have parts A and B to be eligible. You should also be living in the location it's offered.

If You Don't Qualify, But You're 65

In some cases, some people don't qualify on their own or their spouse's work record. This can happen because both of you have work for less than 10 years. If this case applies to you, you can still qualify for full Medicare coverage as long as you're 65.

One of the ways if to pay premiums for Part A. If you have fewer than 30 work credits, you'll pay the maximum amount. If you have about 30 to 39 credits, you'll premium amount will be reduced. If you continue working and hit 40 credits, you'll no longer need to pay Part A premiums.

You can also pay for Part B coverage, which is necessary when you enroll in Part A. However, when you pick Part B alone, enrolling in Part A isn't necessary. Bear in mind that Part B covers doctor visits and other outpatient services.

Still, you can pay a premium for Part D to get your prescription drugs.

What Medicare Covers

If you're eligible for Medicare, you need to understand what it covers. This is vital, particularly when determining whether you need supplemental coverage. Most people will need to supplement their plans due to benefits gaps in Medicare.

Part A covers hospital stays, visits, and hospice care. For extended hospital stays, you'll need coinsurance. Keep in mind that there is also a deductible.

Part B covers preventive services, physician visits, outpatient services, and some home health visits. Many Part B benefits have a deductible ($185 per year in 2019) and coinsurance of 20 percent. But there's no coinsurance or deductible for annual wellness visits.

Original Medicare does not pay for some services. These include long-term care, cosmetic surgery, most chiropractic services, dental exams and most dental care, and eye exams and eyeglasses, and others.

Eligible for Medicare - Final Thoughts

As long as you're an American citizen or you've been living in the country for more than five years, you're automatically eligible for MedicarePart A once you hit 65 years old. You'll get a mail three months before your 65th birthday to notify you about the coverage.

Basically, eligibility requirements are more comfortable to meet for most Americans. For those who don't meet some of the requirements, such as work credits, you can still qualify for Part A, but you'll pay a premium.

Do you want to learn more? Here is how you can replace your Medicare card.

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.