Eligibility For Medicare

Enrolling in Medicare is not as simple as turning 65. There are certain other eligibility criteria as well as separate Medicare plans to choose from, and there are some conditions where people under 65 may be eligible for Medicare as well. 

Read on as we break down the different parts of Medicare and who is eligible for what.

What are the Parts of Medicare?

Medicare is split into several parts. Parts A and B are Original Medicare (and connected to Social Security) while Supplemental and Parts C and D are run by private insurance companies. 

Original Medicare

Medicare Part A is known as hospital insurance and covers in-patient hospital bills, skilled nursing facility charges, home health care and hospice care.

For those who meet the following requirements, Part A is available at no monthly premium:

• You are 65 or older. 
• You or your spouse worked and paid Medicare taxes for at least 10 years.
• You receive Social Security benefits.

If you or your spouse did not pay Medicare taxes while working, you may may still be eligible for premium-free Part A if:

• You are 65 or older and a US citizen or permanent resident.
• You have been entitled to Social Security benefits for 24 months.
• You are a kidney dialysis or transplant patient.

The other part of Original Medicare is Part B—medical insurance. Medicare Part B is a voluntary program and covers medical expenses not included in Part A, such as out-patient surgery, visits to the doctor, medical equipment, and blood work.

Eligibility for Part B depends on a person’s eligibility for premium-free Part A. Individuals who must pay a premium for Part A must also satisfy these requirements to enroll in Part B: 

• 65 or older
• US resident AND 
• US citizen or permanent resident who has been residing in the US for five continuous years.

For those eligible for Part A at no monthly premium, you are automatically eligible for Part B. 

Individuals already receiving Social Security for at least four months before becoming eligible for Medicare will be automatically enrolled in the premium-free Part A and Part B and will be given the choice to keep or refuse Part B. The monthly premium for Part B is deducted from Social Security or Civil Service Retirement checks or it can be paid directly. 

You cannot decline Part A if you are automatically enrolled unless you also withdraw your original Social Security application and pay back all cash benefits received. 

Now we move to the parts of Medicare that are handled by federally approved private insurance companies—Parts C, D and Medigap.

Medicare Parts C and D and Medigap

Part C is also known as the Medicare Advantage Plan, and provides all Part A and B coverage as well as additional coverage such as vision and hearing. It also typically includes prescription drug coverage.

Medicare pays a fixed amount each month for your care provided by Medicare Advantage Plans though they can have different out-of-pocket costs similar to standard health insurance plans. 

Prescription drug coverage—Part D—is available to anyone enrolled in any part of Medicare. It is provided through private companies approved by the federal government. You can enroll in a stand-alone prescription drug plan to supplement Original Medicare or through your Medicare Advantage Plan. 

Medicare Supplement Insurance, or Medigap, helps defray remaining healthcare costs (such as copayments and deductibles) and is also sold by private companies. Medigap is only available to those enrolled in Medicare Part A and B, not a Medicare Advantage Plan. Medigap does not include any prescription drug coverage, but you are still eligible for Medicare Part D.

Medicare Eligibility If You Are Under 65

Medicare is available for certain people with disabilities under 65 who have been receiving Social Security Disability benefits for 24 months.

People with End Stage Renal Disease become eligible for Medicare three months after a regular dialysis course begins or after a kidney transplant. Those with ALS (also known as Lou Gehrig’s disease) are eligible immediately upon collecting Social Security Disability benefits. 

People who meet the Social Security Disability requirements are typically automatically enrolled in Parts A and B, and people with other long-term conditions such as mental illness, dementia, and Parkinson’s disease can also qualify for Medicare coverage after an individual assessment of whether they meet the criteria.

Questions About Medicare? 

We can help!

While it might seem as though Medicare was designed to be deliberately confusing, it is possible (and crucial!) to understand this program so that you can make informed decisions about your healthcare.

If you have any questions about Medicare, including your eligibility or which plan is right for you, give me a call to schedule your consultation. All services are offered free of charge.