Summary: Knowing when you become eligible for Medicare will help ensure you don’t miss your initial enrollment period or have a lapse in health coverage. In this article, we’ll cover the various eligibility requirements for getting Medicare coverage. Estimated Read Time: 5 min
Who is Eligible for Medicare?
Medicare is a federal health insurance program for people over 65 or those who have certain disabilities or conditions. Medicare is for individuals who:
- Are legal residents of the U.S. for a minimum of 5 years
- Are age 65 or older
- Under the age of 65 with certain disabilities or receive social security disability benefits for at least 24 months
- Have End-Stage Renal Disease (all ages)
When you first become eligible for Medicare, you enter your Initial Enrollment Period. Enrolling during this time is important for ensuring you don’t have a lapse in health coverage and avoid late enrollment penalties. In some cases, you may automatically be enrolled in Original Medicare as soon as you become eligible. Otherwise, you will need to sign up for Medicare through the Social Security Administration.
Medicare Part D Prescription drug plans, Medicare Supplement plans, and Medicare Advantage plans are all optional coverage you can sign up for outside of Original Medicare. In most cases, once you enroll in Original Medicare, you become eligible to enroll in a Medicare Supplement (Medigap) Plan or Medicare Advantage plan. To be eligible for Medicare Part D, a prescription drug plan, you are only required to be enrolled in one part of Original Medicare (Medicare Part A and/or Medicare Part B).
Age for Medicare Eligibility
Most people become eligible for Medicare when they turn 65. If you are not receiving disability benefits or don’t qualify for Medicare under the age of 65, then you will first become eligible for Medicare three months before you turn 65. You will have three months prior to your birthday, your birthday month, and three months after to enroll in Medicare without a late enrollment penalty.
If you have End-Stage Renal Disease, ALS, or have been receiving disability benefits for more than 24 months, you may be eligible for Medicare under the age of 65. In these cases, there is no age requirement for receiving Medicare coverage.
Medicare Eligibility Under Age 65
There are circumstances in which you may be eligible for Medicare under the age of 65.
Disability Medicare Eligibility
If you have received Social Security Disability Insurance (SSDI) or Railroad Retirement Board (RRB) benefits for 24 months, you qualify for Medicare and will automatically be enrolled in Medicare Part A and Medicare Part B. You will receive this coverage regardless of your age. For individuals who have ALS, also called Lou Gehrig’s disease, you will automatically enroll in Medicare the month your SSDI benefits begin.
Medicare Eligibility Under ESRD
Individuals with End-stage Renal Disease (ESRD) are eligible for Medicare at any age. ESRD is a medical condition in which a person has permanent kidney failure and requires regular dialysis treatments or a kidney transplant. If have ESRD, you will have to sign up for Medicare through the Social Security Administration. Your Medicare coverage will begin on the 4th month of dialysis treatment.
Are There Work Requirements for Medicare?
There are no work requirements to be eligible for Medicare. However, if you have not paid Medicare taxes while working for at least 40 quarters (or 10 years), you may be required to pay a monthly premium for your Medicare Part A. If you qualify for Medicare prior to age 65 due to a disability or condition, you will not have to pay a Medicare Part A premium.
Even if you are working past age 65, you are still eligible for Medicare. If you do not have to pay a premium for Medicare Part A, you can choose to enroll even if you are still employed.
You can also choose to delay Medicare Part B coverage if you are still working and receiving health insurance through your employer. However, before you delay coverage, it is essential to compare your employer benefits and costs with Original Medicare to ensure your coverage is creditable and you have the best plan to fit your needs. Remember, if you do not enroll in Medicare Part B when you are first eligible, you could be subject to a late enrollment penalty.
Who is Eligible for Both Medicare and Medicaid?
Medicare and Medicaid are two different healthcare programs that have different eligibility requirements.
Medicare is federal health insurance for individuals over the age of 65 or with certain disabilities or conditions.
Medicaid is a joint federal and state program that helps pay the healthcare costs for individuals with limited income and resources. Medicaid eligibility requirements vary from state to state. To qualify for Medicaid, you must meet your state’s income and resource requirements. You can contact your state’s Medicaid office for more information and to see if you qualify.
If you are eligible for both Medicare and full Medicaid coverage, you will receive prescription drug coverage through Medicare. You will also automatically qualify for Medicare Extra Help for assistance with paying for your prescriptions.
Individuals who qualify for Medicare and Medicaid may be eligible to enroll in a Dual Eligible Special Needs Plan. This type of Medicare Advantage plan can help coordinate your Medicare and Medicaid benefits. Plan coverage and availability varies by location and carrier.
When am I Eligible for Medicare?
Most individuals will qualify for Medicare when they turn 65. The timeframe in which someone first becomes eligible for Medicare is known as the Initial Enrollment Period. This enrollment period spans over seven months. It begins three months before an individual turns 65, includes their birthday month, and lasts three months after. Let’s look at an example.
John is turning 65 on September 5th. He is a citizen of the U.S. and has paid Medicare taxes through working for over 10 years. He can enroll in Medicare as early as June 5th and will qualify for premium-free Part A. If John needs more time to explore coverage options with Medicare, he has until December 31st to enroll without incurring a late enrollment penalty.
If you are eligible for Medicare due to a disability, your Initial Enrollment Period will still be a seven-month period. It will begin three months before your 25th month of disability payments, includes the 25th month, and ends three months after.
Medicare Eligibility Calculator
Follow the steps prompted by the tool to understand your Medicare Eligibility date.
How to Get Help with Medicare Eligibility Requirements
Knowing when you will become eligible for Medicare is important for ensuring you don’t face late enrollment penalties or a lapse in healthcare coverage. If you need help figuring out when you will become eligible for Medicare coverage, give us a call at the number above. Our licensed insurance agents can answer your questions and help you plan for enrollment.
Sources
Original Medicare (Part A and B) Eligibility and Enrollment, CMS.gov. Accessed July 2023
https://www.cms.gov/medicare/eligibility-and-enrollment/origmedicarepartabeligenrol
End-Stage Renal Disease (ESRD), Medicare.gov. Accessed July 2023
https://www.medicare.gov/basics/end-stage-renal-disease
Medicare, SSA.gov. Accessed July 2023
https://www.ssa.gov/pubs/EN-05-10043.pdf
Learn More About Medicare:
New to Medicare? Learn more about the four parts of Medicare: Part a, Part B, Part C, and Part D.
Ready to enroll in Medicare? Learn more about signing up.
Have you recently become eligible for Medicare? Learn more about the Initial Enrollment Period.
