Are you eligible for Medicare?Updated February 27, 2017
Many people begin their search for Medicare eligibility information asking about age requirements. At what age are you eligible for Medicare? Well, it depends. Medicare is a federal government health insurance program primarily for those who are 65 years or older. Some people with certain disabilities younger than 65 can also qualify for Medicare. It assists with the cost of health care, but does not cover all medical expenses.
Medicare has four parts:
- Part A is hospital insurance that covers medically necessary inpatient hospital, skilled nursing, hospice and home health care.
- Part B covers doctors’ services, durable medical equipment (i.e. wheelchairs), preventative care, outpatient services, lab tests and x-rays, ambulance services and some home health services.
- Part C allows private health insurance companies to provide Medicare benefits to patients. This includes providers such as HMOs and PPOs. They are known as Medicare Advantage Plans. Some people choose to get Medicare benefit coverage through a Medicare Advantage Plan instead of through original Medicare coverage.
- Part D provides outpatient prescription drug insurance. It is provided only through private insurance companies that have contracts with the government.
Who is eligible for Medicare? When are you eligible for Medicare?
In broad terms, there are two groups of people who are eligible for Medicare:
- People age 65 or older who are citizens or permanent residents of the United States
- People under 65 years old with qualifying medical conditions.
Each of these has certain criteria that must be met.
Part A eligibility, if you are 65 or older
You are eligible for Part A Medicare at no cost, if:
- You currently receive or are eligible to receive Social Security benefits. To be eligible to receive Part A at now cost, you must have 40 credits accumulated through the payment of payroll taxes. You earn one credit for each quarter year you have worked, as long as you meet minimum income guidelines. In other words, 40 credits equals ten years of a work history. If you do not have 40 credits, you can pay a monthly premium to be covered. If you have earned less than 30 credits, as of 2015 you must pay $426 each month, and $234 each month if you have earned between 30 and 39 credits.
- You currently receive or you are eligible to receive railroad retirement benefits.
- Your spouse receives or is eligible to receive Social Security or railroad retirement benefits. This applies to spouses who are living, deceased or divorced from the person seeking coverage.
- You or your spouse worked long enough in a government job where Medicare taxes were paid.
- You are a dependent parent of a deceased child who is fully insured.
Part A eligibility, if you are under 65 years old
You are eligible for Part A Medicare at no cost, if:
- You have received or you are entitled to receive Social Security disability benefits for 24 months.
- You are getting a railroad retirement board disability pension and you meet certain conditions.
- You get Social Security disability benefits because you have amyotrophic lateral sclerosis (Lou Gehrig’s disease).
- You worked in a government job long enough where you paid Medicare taxes, and you have been entitled to receive Social Security disability benefits for at least 24 months.
- You have kidney failure and you receive dialysis or a kidney transplant, and you meet other certain requirements.
- You’re the child or the widow(er) and you are age 50 or older of someone who worked in a government job long enough where they paid Medicare taxes, and you meet Social Security disability program requirements.
Part B eligibility
When are you eligible for Medicare Part B? If you are eligible for Part A coverage at no cost, you are eligible to enroll in Medicare Part B coverage by paying a monthly premium. The amount of premium you pay may depend on what your income level is.
If you are not eligible for Part A at no cost, you can still sign up for Part B if you are 65 years or older and you are a United States citizen or a lawfully admitted noncitizen who has live in the country for a minimum of five years.
Part C eligibility
When are you eligible for Medicare Part C? Part C coverage is offered by private companies, with benefits that are similar to those offered by Medicare. If you have Medicare Part A and Part B coverage, then you can join Part C coverage. The main reason to utilize Part C coverage, also known as Medicare Advantage plans, is because they offer additional benefits over and above the level of coverage provided by Part A and Part B. Once you have reached the coverage limits that Medicare covers, you will be entitled to enhanced benefits under a Medicare Advantage Plan. Because of these enhanced benefits, you’ll be required to pay an additional monthly premium.
Part D eligibility
If you have Part A and Part B Medicare coverage, then you are eligible for Medicare Part D coverage which is for prescription drug coverage. Enrollment in Part D is optional, and you will be required to pay a monthly premium. Depending your income level, this premium may be higher for some people.
What’s covered under Medicare?
Many times, coverage for tests, services and medical care items depends on where you live. However, there are some of these things that are universally covered, no matter where you live. The following chart is a list of those items. If you do not see an item listed here, talk to your healthcare provider to see why certain items are needed, and ask if they can be covered under Medicare.
NOTE: The following chart was reproduced from Medicare.gov
|Abdominal aortic aneurysm screeningAcupuncture|
Air-fluidized beds & other support surfaces
Alcohol misuse screening & counseling
Ambulatory surgical centers
Artificial eyes & limbs
Blood processing & handling
Blood sugar (glucose) monitors
Blood sugar (glucose) test strips
Bone mass measurement (bone density)
Braces (arm, leg, back, and neck)
Cardiac rehabilitation programs
Cardiovascular disease (behavioral therapy)
Cardiovascular disease screenings
Cervical & vaginal cancer screenings
Clinical research studies
Colorectal cancer screenings
Continuous passive motion (CPM) machine
Defibrillator (implantable automatic)
Diabetes self-management training
Diabetes supplies & services
Dialysis (kidney) services & supplies
Doctor & other health care provider services
Durable medical equipment (DME) coverage
EKG (electrocardiogram) screening
Emergency department services
|Enteral nutrition supplies & equipment (feeding pump)|
Federally qualified health center services
Glucose control solutions
Gym membership & fitness programs
Health education & wellness programs
Hearing & balance exams & hearing aids
Hepatitis B shots
Hepatitis C screening test
Home health services
Hospice & respite care
Hyperbaric oxygen (HBO) therapy
Incontinence supplies & adult diapers
Infusion pumps & supplies
Inpatient hospital care
Kidney disease education
Kidney transplants (adults)
Kidney transplants (children)
Laboratory services (clinical)
Lancet devices & lancets
Long-term care hospitals
Lung cancer screening
Manual wheelchairs & power mobility devices
Mental health care (inpatient)
Mental health care (outpatient)
Mental health care (partial hospitalization)
Nebulizers & nebulizer medications
Nursing home care
Nutrition therapy services (medical)
Obesity screening & counseling
Orthotics, artificial limbs, & eyes
|Outpatient hospital services|
Oxygen equipment & accessoriesPancreas transplants (adults)
Physical therapy/occupational therapy/speech-language pathology services
Prescription drugs (outpatient)
Preventive & screening services
Preventive visit & yearly wellness exams
Prostate cancer screenings
Pulmonary rehabilitation program
Religious non-medical health care institution (RNHCI) items & services
Rural health clinic services
Second surgical opinions
Sexually transmitted infections (STI) screening & counseling
Skilled nursing facility (SNF) care
Sleep apnea & Continuous Positive Airway Pressure (CPAP) devices & accessories
Smoking & tobacco use cessation (counseling to stop smoking or using tobacco products)
Supplies (you use at home)
Surgery (estimating costs)
Surgical dressing services
Tdap shot (tetanus, diphtheria, & pertussis shot)
Therapeutic shoes or inserts
Travel (when you need health care outside the U.S.)
Urgently needed care
Yearly eye exam
At what age do I enroll in Medicare? When is the Medicare enrollment period?
How and when to enroll in Medicare is an important aspect of coverage. The annual open Medicare enrollment period begins each year in October, but there are other timeframes that also work for certain qualifying Medicare applicants. Remember, it is to your advantage to pay attention to deadlines and Medicare enrollment periods for all parts and situations that affect you. Here are some deadlines and situations that apply to enrolling in Medicare.
If you are already getting Social Security or railroad retirement benefits, you will be contacted about three months before your 65th birthday. If you live in one of the 50 states, Washington, D.C., the Northern Mariana Islands, American Samoa, Guam or the U.S. Virgin Islands, you will automatically be enrolled in Medicare Parts A and B. Because a premium is required for Part B coverage, you will be given the opportunity to opt out of that coverage.
If you are not already getting Social Security or railroad retirement benefits, you can enroll in Medicare during the Initial Coverage Election Period to avoid any penalties or a gap in your health care coverage. The Initial Coverage Election Period is a seven-month period beginning three months before the month you turn 65, and ending three months after your 65th birthday. The good news is that you can sign up and get Medicare coverage even if you don’t plan on retiring when you turn 65.
There are also special situations that allow you to apply for Medicare before age 65:
- You’re a disabled widow(er) between 50 and 65.
- You work for the government and became disabled before turning 65
- You or an immediate family have permanent kidney failure
- You had Medicare Part B coverage in the past but dropped coverage
- You turned down Medicare Part B coverage when you first got Medicare Part A coverage.
- You or your spouse worked for the railroad industry.
Don't Miss These Important Medicare Enrollment Periods
If you don’t enroll in Medicare Part B during your initial enrollment period, you can still sign up during an annual enrollment period from January 1 through March 31, but you may need to pay a late enrollment penalty. You coverage will begin on the following July 1 of the year in which you sign up. If you are in a Medicare Part C plan and want to switch to an original Medicare plan (Part A and Part B), you can do so between January 1 and February 14. If you do so, you will also have until February 14 to join a Part D plan as well. Your coverage begins the first day of the month after your enrollment form is received.
For more information on how and when to enroll, contact the Social Security Administration, or visit a local Social Security office. Those who have been receiving social security disability benefits for at least two years can qualify for Medicare automatically. You can also learn more about Medicare enrollment forms and related information online through the Medicare.gov website.
The role of Medicaid and Medigap Plans
Medicare does not provide full coverage for healthcare in all instances, leaving some gaps in coverage. Fortunately, there are several ways to pay for medical services through supplemental coverage. These can include employment-based health insurance if a spouse is still working and has coverage, Medicare Advantage Plans, retiree insurance, or Veterans’ Administration benefits. There are two other primary ways that many people use to fill in coverage holes that Medicare does not provide.
Medicaid helps low-income families pay for costs of long-term medical and custodial care. It is a joint program of the federal government and state governments. The federal government largely funds the program, but Medicaid is administered by state governments, and coverage may vary from state to state.
Medigap is a supplmemental insurance policy sold by private companies that helps to pay for some health care costs not covered by Original Medicare. This can include copayments, coinsurance, and deductibles. Most noteably, unlike Medicare, Medigap policies cover medical care when you travel outside the United States. To qualify for a Medigap policy, you must already be enrolled in Medicare Part A and Part B.
Our Deep Guide to Medicare
There are several resources available to help you understand the benefits you are entitled to through Medicare. Our Ultimate Guide to Medicare continues on below.
Our detailed guide on the Medicare program which should answer a vast a majority of your questions. You can also email or call us and one of our representatives will assist you on a one-to-one basis.
Call the Medicare toll-free number at 1-800-MEDICARE (1-800-633-4227). If you are hard of hearing or deaf, call Medicare’s TTY number at 1-877-485-2048.
Medicare is a federal health insurance program that covers most individuals (and current or former spouses) who are age 65 or older, as well as younger individuals who have a certain health condition or are disabled.
Medicare has four parts.
Part A (hospital insurance): Part A covers the cost of staying in a hospital, along with certain follow-up costs. It also covers hospice care and home health care if certain conditions are met.
Part B (medical insurance): Part B pays certain doctor and outpatient costs for medical care. (Part A and B are commonly referred to jointly as “Original Medicare.”)
Part C (Medicare Advantage): Medicare Advantage Plans are health care plans that are run by Medicare-approved private insurance companies. Part C plans provide Part A (hospital) and Part B (medical) benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.
Part D (Medicare prescription drug coverage): Medicare Part D adds prescription drug coverage to Original Medicare. (Most Medicare Advantage Plans and other health plans offer prescription drug coverage. In some types of plans that don’t offer drug coverage, it may be possible to join a Medicare prescription drug plan.)
The two main ways to get Medicare coverage are through:
- Original Medicare or
- a Medicare Advantage Plan.
In addition to these options, you may be able to join other types of Medicare health plans. Medicare health plans are plans offered by private companies that contract with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan.
For example, Medicare Cost Plans (available in certain areas of the country) and Demonstration/Pilot Programs (also called “research studies”) are Medicare health plans. (All Medicare Advantage Plans are also considered Medicare health plans.) Programs of All-inclusive Care for the Elderly (PACE) organizations are special types of Medicare health plans that can be offered by public or private entities and provide Part D and other benefits in addition to Part A and Part B benefits.
Medicare Part A
Medicare Part A is hospital insurance that provides coverage for inpatient hospital care, as well as coverage for critical access hospitals and skilled nursing facilities (though not custodial or long-term care). It also covers hospice care and home health care so long as certain conditions are met.
Eligibility (Medicare Part A Plans)
To qualify for Medicare Part A, you must be a U.S. citizen or legal resident who is 65 years of age or older. Some people under age 65 with certain disabilities, Amyotrophic Lateral Sclerosis (ALS), or end-stage renal disease (those with permanent kidney failure requiring dialysis or a kidney transplant) are also eligible.
Eligibility Based on Work/Tax History
Most people become eligible for Medicare Part A free of charge by working and paying taxes long enough.
You qualify for Medicare Part A as soon as you reach age 65 if you or your spouse (living or deceased, including divorced spouses) has worked long enough so that you’re entitled to Social Security or Railroad Retirement benefits, even if not receiving them.
Social Security Credits
Social Security credits count toward eligibility for Medicare. Credits are earned by paying Social Security and Medicare payroll taxes while working. Generally, 40 credits—ten years of work—from employment are required to receive Social Security benefits and qualify for Medicare. As of 2015, you earn one Social Security or Medicare work credit for every $1,220 you make. You can only earn a maximum of four credits each year, which means you need to earn $4,880 to earn the maximum four credits in 2015. If more than 40 credits are earned over the years, the additional credits do not provide any added benefit. You may also qualify for Medicare if you are, or have been, a government employee who has paid Medicare payroll taxes during employment.
What does Medicare Part A Cover?
Depending on your medical situation, answering at what age are you eligible for Medicare benefits changes. Those under the age of 65 are eligible for Medicare in any one of the following circumstances.
- You have received disability benefits from Social Security or the Railroad Retirement Board for 24 months. (You're automatically enrolled in Part A and Part B after you get Social Security or Railroad Retirement benefits for 24 months. The 24 months do not need to be consecutive.)
- You receive disability benefits because you have Amyotrophic Lateral Sclerosis (ALS), also called Lou Gehrig’s disease.
- You have end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant) and one of the following applies to your situation: you've worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee; you’re already receiving or are eligible to receive Social Security or Railroad Retirement benefits; or you’re the spouse or dependent child of a person who meets one of the requirements listed above.
Cost (Part A Plans)
Those who qualify for Part A don’t have to pay premiums for coverage—it’s free. (Though there is a deductible for hospital stays.)
If you don’t qualify for premium-free Part A, but are 65 or older, and you have (or are enrolling in) Part B as well as meet citizenship and residency requirements, you can pay a monthly fee for the same coverage. The monthly cost will depend on how long you have worked and how close you are to meeting the 40-credit requirement. In 2015, it costs $407 each month for Medicare Part A for those who have earned fewer than 30 credits, and $224 each month for those who earned between 30 to 39 credits.
In most cases, those who pay for Part A (hospital insurance), must also enroll in Part B (medical insurance), and pay an additional monthly premium for Part B.
Enrollment (Part A)
Some people are automatically enrolled in Part A (and Part B), while others must sign up.
Who Is Automatically Enrolled in Parts A (and Part B)?
- Those already receiving benefits from Social Security or the Railroad Retirement Board automatically get Part A (and Part B) starting on the first day of the month they turn 65 years old.
- Those who are under 65 and have received disability benefits from Social Security or certain disability benefits from the Railroad Retirement Board will be automatically enrolled in Parts A and B after 24 months of disability benefits.
- Those who have Amyotrophic Lateral Sclerosis (or ALS, which is also called Lou Gehrig’s disease) get Parts A and B the month that Social Security disability benefits start.
Who Needs to Sign Up for Part A and/or Part B?
- Those who are within three months of age 65, but not receiving Social Security or Railroad Retirement Board benefits, must sign up for Medicare. (For example, this applies to those who are still working.)
- Those with end-stage renal disease must sign up for Medicare.
- Residents of Puerto Rico who receive Social Security benefits or Railroad Retirement benefits automatically get Part A the first day of the month they turn 65 (or after receiving disability benefits for 24 months). However, to get Part B, they must sign up for it.
Initial Enrollment Period Details for Medicare
The initial enrollment period consists of a seven-month period starting three months before the month you turn 65, including the month you turn 65, and extending three months after the month you turn 65.
Warning: Those who are not automatically enrolled and fail to sign up during the initial enrollment period may face late enrollment penalties and/or have a gap in coverage.
Coverage for Medicare Part A (and Part B) begins on the first day of your birthday month when you become 65 (so long as enrollment is automatic or you sign up during the first three months of the initial enrollment period), unless your birthday falls on the first day of the month. Then coverage begins on the first day of the previous month.
For example, if your birthday is June 6, 1950, then you get coverage on June 1, 2015. If your birthday is on the first day of the month (June 1, 1950), then Part A (and Part B) will start the first day of the prior month—May 1, 2015.
It’s not necessary to sign up for Medicare each year. Once you’re enrolled, you don’t have to sign up again.
Medicare Enrollment Period Each Year: January 1 through March 31
Those who don’t sign up for Part A and/or Part B when first eligible (and who do not qualify for a Special Enrollment Period) can sign up between January 1 to March 31 each year, which is the general enrollment period. Coverage then begins July 1. Those who do this might have to pay higher premiums for late enrollment in Part A and/or Part B.
When is Medicare's Special Enrollment Period?
For those who are covered under an employer’s group health plan, there is a Special Enrollment Period to sign up for Part A and/or Part B. (However, COBRA and retiree health plans aren't considered coverage based on current employment.)
If you are covered under a group health plan based on current employment, you can sign up for Part A and/or Part B:
- any time you (or your spouse, or family member if you’re disabled) are still covered by the group health plan or
- during the eight-month period that starts the month after the employment ends or the group health plan insurance ends, whichever occurs first.
If you are still working at 65 and you have health insurance through employment, it may make sense to delay enrollment until your employment ends because you must pay a monthly premium for Part B coverage.
There is typically no late enrollment penalty for signing up during a Special Enrollment Period.
People with end-stage renal disease generally don’t get this special enrollment period.
Medicare Part B Plan
Medicare Part B covers doctor services, outpatient care, and other medical services provided by clinics and laboratories. This includes lab tests, preventative services, surgeries, and doctor visits, as well as supplies (including wheelchairs and walkers) that are considered medically necessary to treat a disease or condition.
Eligibility (Medicare Part B Plans)
Anyone who is eligible for free Medicare Part A is eligible for Medicare Part B by enrolling and paying a monthly premium.
If you are not eligible for premium-free Medicare Part A, you can qualify for Medicare Part B if you are:
- age 65 or older and
- either a United States citizen or an alien lawfully admitted for permanent residence who has resided in the United States continuously during the five years immediately preceding the month before applying for enrollment in Part B.
What is the Cost of Medicare Part B?
Unlike Part A, which is usually free, Part B requires a monthly premium.
Most people who sign up for Medicare Part B when first eligible pay $104.90 each month in 2015. (If you don't sign up for Part B when first eligible, you may have to pay a late enrollment penalty.)
Certain individuals must pay a higher premium each month for Part B if their modified adjusted gross income falls above a certain amount. The Income Related Monthly Adjustment Amount (IRMAA) is the additional amount added to monthly Part B premiums. The Social Security Administration looks at your income from two years ago to determine if an IRMAA should be added to your monthly premium.
For example, if your yearly income in 2013 was between $85,000 and up to $107,000 and you filed an individual tax return, then Part B costs $146.90 each month of 2015. The IRMAA varies based upon income, but the most one would have to pay for Part B in 2015 is $335.70 per month, which applies to individuals who earned more than $214,000, or a couple who filed jointly and earned more than $428,000 in 2013.
The Part B premium is ordinarily taken directly out of a Social Security, Railroad Retirement, or Office of Personnel Management retirement check, which means most people will not receive a bill.
Medicare Late Enrollment Penalty, Explained
Part B coverage is not required. However, those who choose not to enroll in Part B, but later decide they want coverage, may have to pay a higher monthly premium for as long as they have Medicare (unless they qualify for a Special Enrollment Period).
The Part B monthly premium may increase by 10% for each twelve-month period of eligibility for Part B that was not elected. The penalty does not go away–you must it for as long as you have Part B.
Also, if you miss the initial enrollment period, you may have to wait to enroll at a specific, later time unless you qualify for a Special Enrollment Period. (For example, you may have to wait until the general enrollment period, which runs from January 1 to March 31, with coverage starting on July 1 of that year).
Deductible and Copay
In 2015, the Part B deductible is $147 per year. After the deductible is met, you usually pay 20% for all approved Medicare services. For example, if you visit the doctor or have medical testing done, you will receive a bill for your 20% share.
There is no out of pocket limit for Medicare Part B and not all procedures are covered. If you need more information about whether a medical service or procedure is covered, contact Medicare or ask your doctor to find out more.
Enrollment (Part B)
As with Part A, the enrollment period for Part B typically takes place during the seven-month period that begins three months before the month you turn 65, including the month you turn 65, and ending three months after the month you turn 65. For example if your birthday is July 15th, the initial enrollment period includes the months of April, May, June, July, August, September, and October. (Certain people are automatically enrolled in Part B. See the “Enrollment [Part A]” section above to find out who is automatically enrolled and who needs to sign up.)
General Enrollment Period Each Year: January 1 through March 31
If you fail to enroll during the initial enrollment period (and you don’t qualify for a special enrollment period), then you will have to wait to enroll in Medicare during the general enrollment period, which runs from January 1 through March 31 each year. Coverage then begins July 1st.
Special Enrollment Periods
For those who are covered under a group health plan through an employer, there is a Special Enrollment Period to sign up for Part A and/or Part B. (See “Special Enrollment Periods” under “Part A” above for more information.)
People with end-stage renal disease generally don’t get this special enrollment period.
Medicare Part C
Medicare Part C provides the option of enrolling in a Medicare Advantage Plan, which are plans offered by private companies and approved by Medicare. The most common types are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Private-Fee-for-Service (PFFS) plans.
Medicare Advantage Plans include coverage for all Part A and B services (except hospice care and some care in qualifying clinical research studies). The companies offering the plans agree to follow rules about what care and procedures are covered, but have different out-of-pocket costs and rules about how services are provided. (For example, a copayment may be required for a doctor’s visit.) With a Medicare Advantage Plan, you are still enrolled in Medicare, but you are in a private health insurance plan that may have different restrictions and costs.
Depending on your health and any ongoing conditions you have, a Medicare Advantage Plan may make more sense than Original Medicare. One benefit of some Medicare Advantage Plans is that they may offer more coverage than Original Medicare, including vision, hearing, dental, and other health and wellness programs.
Most Medicare Advantage Plans include prescription drug coverage.
Also, Medicare Advantage Plans include a yearly out-of-pocket maximum whereas Original Medicare does not. After the limit is reached, there is no charge for covered services.
Eligibility (Medicare Part C Plans)
To enroll in an optional Medicare Advantage (Part C) Plan, you must first enroll in both Medicare Part A and Part B. Generally, if you have Medicare Parts A and B and you live in the area of coverage you will be eligible to join.
In most cases, those with end-stage renal disease can’t join a Medicare Advantage Plan, though there are certain exceptions.
Cost (Part C)
Most people will continue to pay a Medicare Part B premium and pay an additional monthly premium to be enrolled in a Medicare Advantage Plan. There may also be a copayment or coinsurance for services.
Plans establish the amounts they charge for premiums, services, co-payments, and deductibles. For example, you may pay more per month for a smaller deductible or for cheaper doctor visit copayments.
The cost of the plan can only change once a year, on January 1.
Enrollment (Part C)
It’s possible to enroll in a Medicare Advantage Plan or Medicare prescription drug coverage (or make changes to coverage you already have) during certain enrollment periods that happen each year. Those period are as follows.
- During your initial enrollment period.
- Between October 15 through December 7, there is an open enrollment period for joining, switching, or dropping a Medicare Advantage Plan. (This open enrollment period applies to health plans and drug plans.)
- If you have Part A, and you get Part B for the first time during the general enrollment period (January 1 through February 14), you can join a Medicare Advantage Plan between April 1 to June 30.
- You can also enroll during certain special enrollment periods, if you qualify. (The qualifications include moving out of your plan’s service area or if your plan changes its contract with Medicare, among others).
- If you’re in a Medicare Advantage Plan, you can switch to Original Medicare between January 1 to February 14. (See “Special Disenrollment Period” below.)
- You can switch to a 5-star Medicare Advantage Plan (or Medicare Cost Plan, or Medicare Prescription Drug Plan) once, between December 8 and November 30.
Special Disenrollment Period
If you enroll in a Medicare Advantage Plan and are unhappy with the coverage or do not want to be enrolled in the plan any longer, you can leave the plan during a special disenrollment period. This period occurs from January 1 until February 14 each year.
However, if you leave a Medicare Advantage Plan during this period, you must switch to Original Medicare. You cannot change to a new Medicare Advantage Plan.
Medicare Part D
Part D offers optional Medicare prescription drug plans that cover brand-name and generic drugs if you are enrolled in Medicare Part A and/or B, and some other plans such as Medicare Cost Plans and Private-Fee-for-Service-Plans. (Many Medicare Advantage Plans include prescription drug plans as part of their options, though not all do.)
Medicare Part D is only available through an insurance company or other private company that has been approved by Medicare.
Plans vary in cost and drugs covered. For example, you may need prior authorization from the insurance company to obtain certain drugs and many plans have limits on the amount of drugs you can purchase at one time. Some plans may also require you to try cheaper drugs before the plan will pay for the drug prescribed by your doctor.
Part D also covers certain vaccines that are not already covered under Part B.
Eligibility (Part D)
To enroll in an optional Part D prescription drug plan, you must be entitled to benefits under Part A (it doesn’t matter if you’re enrolled or not) or enrolled under Part B. You must also live in the service area of the Medicare drug plan you want to join. (This is different than Medicare Advantage Plans. To enroll in a Medicare Advantage Plan, you must have Part A and Part B, as well as live in the service area.)
Cost (Part D)
Monthly premiums for Medicare Part D coverage vary from plan to plan. The actual cost depends on:
- the monthly premium (which is in addition to the Part B premium) (certain individuals with higher incomes pay a higher premium)
- the yearly deductible, if there is one (no more than $320 in 2015 and no more than $360 in 2016), and
- copayments/coinsurance (these differ according to the plan chosen and are paid after meeting the deductible)
- the coverage gap (which is called the “donut hole”), and
- catastrophic coverage.
What is the Medicare Coverage Gap (Donut Hole)?
The Medicare coverage gap (which is called the “donut hole”) is when you and your plan have paid a certain dollar amount during the year (a limit) for covered drugs. After you hit this limit, you then pay more out of pocket for drugs until you qualify for catastrophic coverage.
In 2015, you're in the coverage gap once you and your plan have spent $2,960 on covered drugs. For 2016, the amount is $3,310.
Health care reform law is gradually narrowing the coverage gap. For example, in 2015, you pay 45% for brand-name drugs and 65% for generic drugs when you’re in the coverage gap. However, by 2020, you’ll only have to pay 25% for covered brand-name and generic drugs during the gap.
Once your out-of-pocket costs (deductible, copays, and coinsurance, plus anything you paid for drugs in the gap) reach a certain amount ($4,700 in 2015 and $4,850 for 2016), catastrophic drug coverage kicks in automatically and you only pay a small coinsurance or copayment for the remainder of the year. The discount you receive on drugs and amounts you pay count towards the out-of-pocket limit.
If you don’t join a Medicare drug plan when becoming eligible for Medicare and you don’t have other drug coverage that’s expected to pay at least as much as standard Medicare prescription drug coverage on average (“creditable prescription drug coverage”), you may have to pay a late enrollment penalty if you later join (in addition to your premium each month) for as long as you have a Medicare drug plan.
The amount of the penalty depends on how long you went without Part D or creditable prescription drug coverage.
Enrollment (Part D)
You can enroll in a Part D prescription drug plan through the private company offering the coverage. You can enroll at the following times.
- During your initial enrollment period.
- If you get Part B for the first time during the general enrollment period, you can then join a Medicare drug plan (from April 1 to June 30).
- During the open enrollment period between October 15 to December 7 each year, with your coverage beginning January 1st of the following year.
- At any time if you qualify for Extra Help. (“Extra Help” is a program under Medicare that helps people with limited income and resources pay for Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.)
Extra Help is a program that offers assistance paying for a Medicare drug plan to those who qualify. Certain people qualify automatically, including those who:
- have both Medicare and Medicaid
- get help from Medicaid paying Medicare Part B premiums (in a Medicare Savings Program), or
- get both Medicare and Supplemental Security Income (SSI).
Other people must apply to receive assistance under this program. As of 2015, if you earn less than $17,655 per year as an individual ($23,895 for a married couple living together) and you have financial resources that are less than $13,641 ($27,250 for a married couple living together) you may be eligible to receive assistance. The income limits are higher in certain circumstances, such as if you or your spouse:
- support other family members who live with you
- have earnings from work, or
- live in Alaska or Hawaii.
Note: Financial resources include the amount of cash you have in your savings account, any assets you may own like stocks and bonds and whether you own multiple properties.
If you qualify for assistance, the Part D premium may be lowered and you will pay less for prescription drugs.
Also, many states provide State Pharmacy Assistance Programs, or SPAPs, that help those with low-income or individuals with a disability or medical condition with the cost of pharmaceutical drugs.
Special Enrollment Periods
In some cases, you can join, switch, or drop Medicare drug plans at other times of the year, such as when you move out of your plan’s service area or you lose other drug coverage, among other circumstances.
5-Star Special Enrollment Period
As with Part C, you can switch to a Medicare prescription drug plan that has a 5-star overall rating from December 8 to November 30, one time.
Warning: If you are part of a Medicare Advantage Plan that includes prescription drug coverage and you later join a Medicare prescription drug plan, you’ll be disenrolled from your Medicare Advantage Plan and switched to Original Medicare.
Those who do not enroll in Part D when first eligible will likely pay a late enrollment penalty if they decide to join a plan later, and continue to pay the penalty for as long as they have prescription drug coverage.
Medicare Savings Programs
Many states provide financial assistance (Medicare Savings Programs, or MSPs) for those who qualify and have a difficult time paying their Medicare premiums, deductibles, coinsurance, and copayments.
There are four kinds of MSPs: the Qualified Medicare Beneficiary (QMB) Program, Specified Low-Income Medicare Beneficiary (SLMB) Program, Qualifying Individual (QI) Program, and the Qualified Disabled and Working Individuals (QDWI) Program.
Generally, you must earn less than a certain amount per month and not own personal assets that exceed a particular threshold to qualify. (Personal assets include cash, stocks and bonds. Not included in the personal asset calculation are one house, car, and personal belongings such as clothing and furniture.) The limits vary from program to program and between states.
Ask your state’s Medicaid office if you meet eligibility requirements.
Medicare Supplement Insurance (Medigap Plans)
A Medicare Supplement Insurance (Medigap) policy is an optional policy offered by a private company to fill in some of the gaps in coverage of Original Medicare (Part A and Part B). Because there is no out-of-pocket limit on spending for Original Medicare, obtaining a Medigap policy is a good idea for certain individuals.
Medigap can be used to pay for services not covered by Original Medicare including deductibles, coinsurance, and copayments. Also, some Medigap policies offer coverage for services that are not provided by Original Medicare. For example, a Medigap policy may provide coverage if you become sick while traveling internationally.
Policies sold on or after January 1, 2006, do not include prescription drug coverage. (Earlier policies may cover prescription drugs.)
A Medigap policy is only available to those who have Medicare Part A and Part B. If you have a Medicare Part C Advantage Plan, then you cannot purchase a Medigap policy.
A monthly premium for a Medigap policy is required in addition to the monthly Part B premium.
The cost varies widely based upon the benefits of the plan and the age and gender of the individual enrolled. There can even be differences in premiums charged by various companies for exactly the same coverage.
You can enroll in a Medigap policy during the six-month open enrollment period, which begins the month you are both 65 and enrolled in Medicare Part B.
If you apply for a policy during the open enrollment period, the medical information that you provide can’t be used against you to deny coverage or increase the monthly price of the policy.
There are no guarantees that you can buy a Medigap policy after the open enrollment period ends if you don’t meet the medical underwriting requirements, unless you're eligible due to certain limited circumstances. And, if you are able to obtain coverage outside of the open enrollment period, the Medigap policy may cost more.
What does "Dual Eligible" for Medicare mean?
An individual is considered "dual eligible" when they qualify for benefits of both Medicare and Medicaid. This is also commonly referred to as "dual eligible beneficiaries" or "duals", in the insurance industry. Qualifying for Medicaid varies state-by-state and depends on your annual income. Read more about Medicaid qualification and eligibility here in our Medicaid section.
How to Get More Information About Medicare
To learn the specific steps you need to take to enroll in the various Medicare programs, go to www.medicare.gov.
To get further information about Medicare, go to www.medicare.gov or call 1-800-MEDICARE.