Are you eligible for Medicare?Updated September 18, 2017
Are you eligible for Medicare?
Medicare is the federal health insurance program for people who are 65 or older and are citizens or permanent residents of the United States, certain younger people with disabilities, Amyotrophic Lateral Sclerosis (ALS) and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). People can get Medicare benefits two ways: 1) Original Medicare; or 2) a Medicare Advantage Plan.
This detailed guide on the Medicare program 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. The Medicare Eligibility phone number is 1-877-485-2048.
Types of Medicare
The main ways to get Medicare coverage are through:
- Original Medicare (Part A and Part B)
- A Medicare Advantage Plan (Part C)
- Prescription Drug Coverage (Part D)
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 is hospital insurance that covers medically necessary inpatient hospital stays, care in skilled nursing facilities, hospice care and some home health care.
- Medicare Part B is Medicare insurance that covers certain doctors’ services, durable medical equipment (i.e. wheelchairs), preventative care, outpatient services, lab tests and x-rays, and ambulance services.
- Medicare Part C (Medicare Advantage) is a type of Medicare health plan that is offered by private insurance companies approved by Medicare to provide Part A (hospital insurance) and Part B (medicare insurance) benefits under one plan. Medicare Advantage plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS), Special Needs Plans (SNPs) and Medicare Medical Savings Account Plans (MSA). Some people choose to get Medicare coverage through a Medicare Advantage Plan instead of through Original Medicare. Medicare Advantage plans must offer the same level of coverage as Original Medicare Parts A and B. Most Medicare Advantage plans offer prescription drug coverage and may also offer extra benefits such as routine dental, vision and wellness programs. Please keep in mind that individuals may be required to pay a monthly premium for a Medicare Advantage plan which is in addition to the monthly Part B premium. Also, the SilverSneakers fitness program is typically covered by Medicare Advantage plans.
- Medicare Part D (Prescription Drug Plans) provides stand-alone prescription drug coverage that works alongside Original Medicare (Parts A and N). It is offered through private insurance companies that have contracts with 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.
Check Your Eligibility
Who is eligible for Medicare? At what age do I enroll in Medicare? When is the Medicare enrollment period?
Many people begin their search for Medicare eligibility information asking about Medicare age requirements. At what age are you eligible for Medicare?
Well, the age for Medicare eligibility depends on a few factors. 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. Call the Medicare eligibility phone number at 1-877-485-2048 for audio help.
You can sign up for Medicare three months before you turn 65 years old. Overall, you will have a seven-month window to apply for Medicare benefits so that you do not experience a lapse in medical insurance coverage or have to pay any penalties.
What are the Medicare eligibility requirements?
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.
How do I check my Medicare eligibility? Where do I check Medicare eligibility?
A Medicare eligibility check can be conducted by speaking with the CMS directly. To explain, Medicare is managed by the Centers for Medicare and Medicaid Services (CMS). CMS works with Social Security to enroll people in Medicare.
Who can verify Medicare eligibility? The official U.S. government website for Medicare has an online enrollment calculator that can be used to verify your current and future enrollment in Medicare. To access it, go here. You can also find out if you’re eligible and calculate your premium for Medicare services by going here.
You can also talk to a live customer service representative 24 hours a day, 7 days a week by calling 1-800-MEDICARE to verify Medicare eligibility.
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.
Check Your Eligibility
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.
Part A Eligibility
You are eligible for Part A Medicare at no cost, if:
- You are 65 or older AND
- You currently receive or are eligible to receive Social Security benefits (See eligibility information below). OR
- You currently receive or you are eligible to receive railroad retirement benefits. OR
- 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. OR
- You or your spouse worked long enough in a government job where Medicare taxes were paid. OR
- You are a dependent parent of a deceased child who is fully insured.
SOCIAL SECURITY CREDITS AND SOCIAL SECURITY MEDICARE ELIGIBILITY
Most people become eligible for Medicare Part A free of charge by working and paying taxes long enough to earn enough Social Security credits. Social Security credits count toward social security Medicare eligibility for Medicare. Credits are earned by paying Social Security and Medicare payroll taxes while working. Generally, 40 credits, generally equal ten years of work, from employment are required to receive Social Security benefits and qualify for Medicare. As of 2017, you earn one Social Security or Medicare work credit for every $1,300 you make. You can only earn a maximum of four credits each year, which means you need to earn $5,200 to earn the maximum four credits in 2017.
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. 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 2017 you must pay $413 each month, and $227 each month if you have earned between 30 and 39 credits
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 of 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 2017, it costs $413 each month for Medicare Part A for those who have earned fewer than 30 credits, and $227 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 in 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, 1952, then you get coverage on June 1, 2017. If your birthday is on the first day of the month (June 1, 1952), then Part A (and Part B) will start the first day of the prior month—May 1, 2017.
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
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.
Part B eligibility
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 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.
Cost of Part B Plans
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 $134 each month in 2017. (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 2017 was between $85,000 and up to $107,000 and you filed an individual tax return, then Part B costs $187.50 each month of 2017. The IRMAA varies based upon income, but the most one would have to pay for Part B in 2017 is $428.60 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 2017.
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 2017, the Part B deductible is $134 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 in 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.
Check Your Eligibility
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.
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 C eligibility
If you have Medicare Part A and Part B coverage, then you can join Part C coverage. 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 of Part C Plans
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 in 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
Medicare 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.
Part D eligibility
If you are eligible for Part A and Part B Medicare coverage, then you are eligible for Medicare Part D coverage. You must also live in the service area of the Medicare drug plan you want to join. 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.
Cost of Part D Plans
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 $400 in 2017), 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 2017, you're in the coverage gap once you and your plan have spent $3,700 on covered drugs.
Health care reform law is gradually narrowing the coverage gap. For example, in 2017, you pay 40% for brand-name drugs and 49% 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 ($4,950 for 2017), 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 in 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 1stof 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).
- need help with SSI Medicare eligibility and answers to SSI Medicare eligibility questions.
Other people must apply to receive assistance under this program. As of 2017, if you earn less than $18,090 per year as an individual ($24,360 for a married couple living together) and you have financial resources that are less than $13,820 ($27,600 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.
Check Your Eligibility
Medicaid and Medicare Supplement Insurance (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.
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.
How can I apply for Medicaid?
You must first see www.HealthCare.gov where you will find access to an online application as well as lots of information regarding Medicaid benefits.
What are the differences between Medicare and Medicaid?
The main difference is that Medicare is an insurance program and Medicaid is an assistance program.
Medicare helps people who are covered pay medical bills from funds they have paid into over the course of their working life. For the most part, Medicare serves people 65 and over, with some exceptions for younger disabled and dialysis patients. Premiums are many times required for certain parts of Medicare. It is a federal program and is uniformly administered across the United States.
Medicaid has no age restrictions and serves people of all ages based on income. Generally, patients are not required to pay any costs for medical services, except in a few limited circumstances. Although Medicaid adheres to federal guidelines, it is administered by state and local governments.
Medicare Supplement Insurance (Medigap)
Medigap is a supplemental 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 notably, 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.
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.
Cost of Medigap Plans
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.
Enrollment in Medigap
You can enroll in a Medigap policy during the six-month open enrollment period, which begins the month you areboth65 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 is Medicare Advantage?
Medicare Advantage is another name for Part C coverage and is insurance designed to supplement Medicare Part A and Part B coverage. It is offered by private insurance companies who provide enhanced benefits that kick in when Part A and Part B benefits are maxxed out. Participants pay a premium for this service which includes HMOs, PPOs, PFFS Plans, Special Needs Plans and Medicare Medical Savings Account Plans.
Companies agree to follow rules about what care and procedures are covered, but have different out-of-pocket costs and rules on how those services are administered. One of the biggest benefits of Medicare Advantage plans is that they may offer more coverage that can include vision, hearing, dental and other related programs, as well as prescription drug coverage which is normally covered under Medicare Part D.
See Medicare Part C for more information.
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 do I verify that I am eligible for free Medicare?
You are eligible for free Part A Medicare if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. If you are under 65 years old you can also get free Part A benefits if you’re entitled to Social Security or Railroad Retirement Board disability benefit for 24 months, or you are a kidney dialysis or kidney transplant patient.
Most people do not have to pay for Part A benefits, but everyone who wants Part B coverage must pay for it. You must also pay a premium for Part C and Part D coverage.
How do I check Medicare eligibility online to see if you qualify for free coverage?
To check and see if you are eligible for free Part A coverage, you can use the Medicare eligibility calculator here.
How do I check Medicare provider eligibility online? How to check Medicare eligibility for providers?
Medicare maintains a comprehensive list of providers on it’s website. Users can find out about what services are offered, make side-by-side comparisons on what care they provide and get tips and information to help make the best possible informed decision.
Providers are broken out by categories. Click on the links below to find the specific provider information you are looking for:
- Nursing homes
- Home health services
What is a Medicare eligibility letter?
A Medicare eligibility letter is a document that advises a provider of the date you and any qualifying family members became eligible for Medicare benefits.
To obtain an eligibility letter, visit any Medicare branch office and they will give you a letter while you wait, or you can call Medicare at 1-800-MEDICARE and request a letter to be sent to you.
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.
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 towww.medicare.gov or call 1-800-MEDICARE.
Check Your Eligibility