Medicare Eligibility: How to Qualify for Medicare Benefits

 

There are different ways to qualify for Original Medicare, Part A and Part B. Most people become eligible for Medicare by aging into the system when they turn 65. However, you can also qualify for Medicare before 65 if you have certain disabilities.

When it comes to other parts of Medicare, such as Medicare Part C (Medicare Advantage plans), Medicare Part D (prescription drug coverage), and Medicare Supplement insurance (Medigap), there’s another set of eligibility requirements.

Here are some situations where you may be eligible for Medicare Part A and Part B, Medicare Advantage plans, Medicare prescription drug coverage, and Medigap.

You’re 65 and a United States citizen

Typically, you’re eligible for Medicare if you’re 65 or older and either a United States citizen or a legal permanent resident of at least five continuous years. For purposes of Medicare, the U.S. includes the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

If you’ve worked at least 10 years (40 quarters) and paid Medicare taxes, you’ll usually get Medicare Part A for free. You may also get Medicare Part A without a premium if your spouse has worked long enough in Medicare-covered employment. If you haven’t worked long enough to get premium-free Medicare Part A, you’re still eligible for Part A, but you may have to pay a monthly premium. You’ll also typically pay a premium for Medicare Part B.

If you’re already receiving your retirement benefits from Social Security or the Railroad Retirement Board, you’ll be automatically enrolled in Medicare Part A and Part B on the first day of the month you turn age 65. This applies to Medicare-eligible beneficiaries living in the United States, District of Columbia, U.S. Virgin Islands, Guam, Northern Mariana Islands, and the American Samoa.

Please note: If you live in Puerto Rico and are receiving retirement benefits when you turn 65, you’ll be automatically enrolled in Part A but will need to manually sign up for Part B. If you qualify for automatic enrollment, you should receive your Medicare card in the mail showing your Medicare eligibility and coverage about three months before your 65th birthday.

If you aren’t yet receiving retirement benefits when you turn 65, you’ll need to manually enroll in Medicare. You can sign up for Medicare during your Initial Enrollment Period, the seven-month period that starts three months before you turn 65, includes the month you turn 65, and ends three months later.

If you miss your Initial Enrollment Period, your next chance to enroll in Medicare is the General Enrollment Period, which runs from January 1 to March 31 of every year. However, if you didn’t sign up for Part A and Part B when you were first eligible, you may owe a late-enrollment penalty.

You are allowed to delay your enrollment in Medicare Part B when you’re first eligible if you or your spouse is still working and have health insurance through a current employer or union (retiree coverage and COBRA don’t count as insurance based on current employment). In this situation, you may qualify for a Special Enrollment Period to enroll in Part B when that employment or health coverage ends. However, if you delay enrollment in Part B and you don’t qualify for a Special Enrollment Period, you may have to pay a penalty for late enrollment.

You receive disability benefits

You’re eligible for Medicare if you’re not 65 yet but have been receiving disability benefits from Social Security or the Railroad Retirement Board for at least two years. You’re automatically enrolled in Medicare Part A and Part B on the first day of the 25th month of disability benefits.

You have Lou Gehrig’s disease

If you have amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease), you’ll be eligible for Medicare and automatically enrolled in Medicare Part A and Part B on the first day of the month that you start receiving disability benefits. Unlike other disabilities, you don’t have to wait 24 months to be eligible for Medicare benefits.

You have end-stage renal disease

For people with end-stage renal disease (ESRD), you’re eligible for Medicare if your condition requires a kidney transplant or regular dialysis treatment. In order to qualify for Medicare, you also need to be eligible for or already receiving Social Security or Railroad Retirement Board benefits, or you need to have worked long enough under Social Security, the Railroad Retirement Board, or as a government worker. You can also qualify for Medicare if you’re the spouse or dependent of someone who is eligible for Social Security or Railroad Retirement benefits.

If you meet eligibility requirements for end-stage renal disease, your Medicare coverage begins after three months of kidney dialysis (on the first day of the fourth month of dialysis). For example, if you began treatment in September, you wouldn’t be eligible for Medicare until December.

If your condition requires a kidney transplant, Medicare coverage can start the month that a Medicare-approved hospital admits you for a kidney transplant as long as the transplant happens that same month or within the next two months.

If you’re admitted to the hospital for the transplant or other medical services, but your transplant is delayed for more than two months, your Medicare coverage could start two months before your transplant. For example, if you’re admitted into the hospital in January for pre-transplant medical services, but your transplant is delayed until May, your Medicare coverage would begin in March (two months prior to the transplant).

Please note that if you’re eligible for Medicare solely based on end-stage renal disease, your Medicare benefits will end at either of these times:

  • 12 months after you discontinue dialysis treatment
  • 36 months after you have had a kidney transplant and no longer need dialysis

For more information about qualifying for Medicare when you have ESRD, you can do any of the following:

  • See the Medicare publication “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services.”
  • Go to the Social Security Administration (SSA) website.
  • Call the SSA at 1-800-772-1213 (TTY users call 1-800-325-0778) Monday through Friday, from 7AM to 7PM.
  • Go to your local Social Security office; office hours may vary by location, so contact your nearest office directly.
  • If you worked for the Railroad Retirement Board, you can visit the website or call 1-877-772-5772 (TTY users: 1-312-751-4701). Railroad Retirement Board representatives are available Monday through Friday, from 9AM to 3:30PM.

You’re enrolled in Original Medicare and are looking for additional coverage

If you’re enrolled in Original Medicare, Part A and Part B, and you’re interested in other types of Medicare coverage, your eligibility will depend on the “part” of Medicare.

Medicare Advantage (Medicare Part C) plans are another way to receive your Medicare benefits, delivered through Medicare-contracted private insurance companies. These plans offer, at minimum, the same benefits as Original Medicare, but may include additional coverage, such as routine vision and dental, prescription drug benefits, or wellness programs. You must continue paying your Part B premium, in addition to any premium the Medicare Advantage plan charges. To be eligible to enroll in a Medicare Advantage plan, you must:

  • Have Medicare Part A and Part B.
  • Not have end-stage renal disease (with some exceptions).
  • Live in the service area of the Medicare Advantage plan you’re considering.

Medicare Part D is prescription drug coverage. This is optional coverage that doesn’t come with Original Medicare and must be obtained through a Medicare-approved private insurance company. You can get this coverage through a stand-alone Medicare Prescription Drug Plan (if you have Original Medicare) or a Medicare Advantage plan that comes with prescription drug benefits (also known as a Medicare Advantage Prescription Drug plan). To be eligible for Medicare Part D, you must:

  • Have Medicare Part A and/or Part B.
  • Live in the service area of the plan you’re considering.
  • Not have end-stage renal disease, with some exceptions (if the plan is a Medicare Advantage Prescription Drug plan).

Medicare Supplement (Medigap) plans are also sold through private insurance companies. These plans pay for certain out-of-pocket expenses in Original Medicare and may offer some additional benefits, like emergency foreign travel coverage. To be eligible for Medigap, you must:

  • Have Medicare Part A and Part B.
  • Be enrolled in Original Medicare (Medigap doesn’t work with Medicare Advantage plans).
  • Live in the service area of the Medigap plan you’re considering.

Most states require you to be at least 65 to be eligible for Medigap, but there are some exceptions. To find out what the eligibility rules are in your state, contact your State Health Insurance Assistance Program (SHIP).

If you’re interested in comparing Medicare Part D, Medicare Advantage, or Medigap plan options in your area, eHealth’s plan comparison tool makes it easy to do so; just enter your zip code into the plan finder tool on this page to view plan options in your area. Prefer to speak with a live person? Just pick up the phone to get personalized assistance with an eHealth licensed insurance agent.

To learn about Medicare plans you may be eligible for, you can:

  • Contact the Medicare plan directly.
  • Call 1-800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048; 24 hours a day, 7 days a week.
  • Contact a licensed insurance agency such as Medicare Consumer Guide’s parent company, eHealth.
    • Call eHealth's licensed insurance agents at 888-391-2659, TTY users 711. We are available Mon - Fri, 8am - 8pm ET. You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day.
    • Or enter your zip code where requested on this page to see quote.

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