Medicare health insurance helps millions of people over 65 cover medical expenses, but you don’t have to be a senior to be eligible. Similarly, reaching age 65 doesn’t guarantee you’ll qualify. If only it were that simple, huh?
Even though Medicare’s eligibility rules are complex, this is no time to take a backseat approach to your coverage. Knowing when you’re eligible is critical for enrolling at the right time.
The Social Security Administration (SSA), not the Centers for Medicare and Medicaid (CMS), decides who qualifies for Medicare. That means you’ll need to apply for Medicare through the Social Security website, by calling the SSA, or during an in-person visit to your local SSA office.
Each part of Medicare has its own rules to determine eligibility, but in general, the SSA designates two main ways people with the necessary citizenship status (we cover this below) can qualify for Medicare benefits: by age or disability status.
Medicare’s age and disability eligibility rules
Generally speaking, people who are eligible for Medicare health insurance meet at least one of these requirements:
- Are age 65 or older
- Have been on disability for two years
- Have end-stage renal disease (ESRD)
- Have amyotrophic lateral sclerosis (ALS)
That said, Medicare’s age and disability eligibility rules regarding who can get coverage and for how much depend on a person’s unique situation. On top of that, how you qualify could affect your coverage choices, your health care costs, and when your insurance kicks in.
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Can I apply for Medicare at age 62 or do I have to be 65?
If you are under the typical Medicare qualifications age of 65, you qualify for free Part A benefits if you meet any of the following criteria.
- You have been receiving Social Security disability benefits for at least 24 months.
- You receive a disability pension from the Railroad Retirement Board and meet certain criteria.
- You have Lou Gehrig’s disease (ALS).
- You have ESRD requiring regular dialysis or a kidney transplant, and you or your spouse has paid Social Security taxes for a length of time that depends on your age.
If you are eligible for Part A at no cost, you can enroll in Part B (medical insurance) by paying a monthly premium. If you don’t receive Part A for free, but instead purchase it, you must also enroll in Part B. However, you can also enroll in Part B without buying Part A if you meet the following two qualifications:
- You are 65 or older.
- You are a US citizen or permanent resident who has been here lawfully for a minimum of five years.
Qualifying by age
Turning 65 is the way most beneficiaries qualify for Medicare.
If you qualify for Medicare based on age, you can enroll beginning three months before your birthday month, during your birthday month, or at any time during the following three months. These seven months are called your Initial Enrollment Period (IEP), and chances are, this is the best time to sign up for Medicare.
If you enroll during the first three months (before you turn 65), your coverage kicks in the first day of your 65th birth month. If you register during your birth month or after, your coverage begins the following month. 1
Qualifying by disability status
If you’re under the age of 65, you may still meet the requirements for Medicare disability eligibility.2
In most cases, people who have received Social Security Disability Insurance (SSDI) or Railroad Retirement Board disability benefits for two years (that’s a full 24 months) are eligible for Medicare beginning their 25th month on disability. This is commonly known as the 24-month rule.
These 24 months don’t have to be consecutive to gain eligibility. Once you do, you’ll stay eligible for up to 93 months (that’s a whopping eight-and-a-half years) after your disability benefits end, assuming they ever do. If your SSDI payments don’t stop, you’ll be eligible for the rest of your life.
Like those who qualify for Medicare based on age, people with disabilities get an Initial Enrollment Period that begins three months before they become eligible for Medicare and runs for seven consecutive months.
Enrolling during the first three months means coverage will kick in your 25th month on disability. Enrolling after you’re eligible means coverage will begin the following month.
The 24-month rule means you’ll have your disability for two full years before you can get Medicare. If you’re like many people, you may have increased health care costs related to a disability or a limited income if your disability prevents you from working.
That would be a tough situation for just about anyone. And it could be financially devastating for people with conditions that require a lot of medical or long-term care.
That’s why the above rules apply to most people on disability, but not all.
End-stage renal disease is a condition in which a person’s kidneys are in the final stages of failure. Most people with ESRD need regular dialysis or a kidney transplant to live, which can result in extremely high medical costs.
Because of that, people with ESRD don’t have to wait two years for Medicare to kick in after getting disability benefits. They can get covered just four months after their first dialysis treatment.3
To be fully insured, ESRD patients still need to have earned 40 work credits and fulfill citizenship or residency requirements (we explain both in the “Eligibility requirements for Part A” section below).
CMS places some limits on what kinds of plans people with ESRD can sign up for. Generally speaking, these beneficiaries can sign up only for Medicare Advantage if they enroll in a Special Needs Plan (SNP) designed explicitly for ESRD patients.
Amyotrophic lateral sclerosis is more commonly known as Lou Gehrig’s disease because the famous New York Yankees baseball player had it. ALS damages the brain and spinal cord in ways that result in an inability to move one’s muscles.
People diagnosed with ALS can get Medicare the same month their SSDI or Railroad Retirement Board disability benefits begin.4
Age and disability overlap
For most people, it’s pretty clear whether they qualify for Medicare based on age or disability. But some people meet the requirements for both, so which rules will they follow?
If you satisfy the Medicare age qualification, this takes precedence over qualifying by disability. In other words, if you are over age 65 and meet disability requirements, your benefits will follow the regulations that apply to age-qualified Medicare, not those that apply to disability-qualified Medicare.
But what if you initially qualify for Medicare based on disability, and you’re turning 65 soon?
Receiving a Medicare card in the mail can be a rite of passage like retiring or getting your first Social Security check. But for people who already have Medicare due to their disability status, turning 65 may not seem like a significant milestone.
The truth is, people with disabilities may requalify for Medicare benefits at 65. When they do, they may get a lot of the perks that newly age-qualifying people get.
- A second IEP
- A Medigap Enrollment Period, complete with all its protections and guarantees.
- Waved Late Enrollment Penalties moving forward, if they’ve racked any up.
As a federal program that subsidizes health insurance for some of the Americans who need it most, Medicare eligibility criteria includes citizenship requirements. If you’re a US citizen or have a green card and have lived in the United States for at least the last five years, you could be eligible for Medicare, provided you meet all other requirements.5
If you don’t meet citizenship status on your own, but you’re married to a US citizen or legal resident, you may still be able to get full coverage before the five-year mark if you meet all the following requirements.
- You’re 65 or older.
- Your spouse is 62 or over and has earned four work credits (see “Eligibility requirements for Part A” below).
- You’ve celebrated your first-year wedding anniversary.
Qualifying for Medicare’s various parts
The above requirements are the basis for general Medicare eligibility. We wish we could end this article here, but then you’d miss this hard truth: each of Medicare’s five parts has its own eligibility requirements in addition to those above.
But don’t worry. We’ll break those down for you too.
Eligibility requirements for Part A
At first, qualifying for Part A might seem pretty straightforward. After all, the right legal status, along with a qualifying age or disability status, are all it takes to be able to buy in to Part A. It’s qualifying for premium-free Part A that gets a little more complicated.
Whether you’ll get free Medicare Part A depends on how much you’ve paid into Medicare taxes throughout your working life. If you’ve been paying Medicare taxes for long enough (usually about ten years), you won’t have to pay a Part A premium. The trouble is, Uncle Sam doesn’t congratulate you or so much as mention it when you’ve reached this milestone.
That makes knowing if you qualify for free Part A hard. And to be honest, the system Uncle Sam uses to measure eligibility is a little complicated, so it’s not always easy to decipher on your own either.
CMS measures eligibility for premium-free Medicare Part A in “work credits,” and you’ll need at least 40 of them to avoid paying a premium. These credits don’t exactly measure how much money you’ve paid into Medicare. In fact, many people below the federal poverty level qualify for free Part A premiums.
Instead, work credits measure how long you’ve been paying into Medicare taxes.6 Each credit corresponds to one quarter-year (think winter, spring, summer or fall) in which you paid Medicare taxes.
To earn a credit, you must have a minimum level of income that quarter. To have earned one credit in 2018, for example, you needed to have made at least $1,320 of taxable income and paid into Medicare on the income during one quarter of the year. You do not have to have been employed for the entire quarter.7
Doing so for the entire year earns you four credits. Ten complete years equals 40 quarters. That’s not to say you have to work ten years straight to get your credits. You can collect these credits one quarter at a time as you work through life. You can even earn them while being self-employed, provided you keep paying into Medicare while you are.
Most people qualify for premium-free Part A.
But what if you’ve paid into Medicare for less than ten years? You could qualify for discounted Part A premiums. The following chart shows that breakdown in 2019.8
|0 – 29||$437.00|
|30 – 39||$240.00|
If you don’t have enough work credits, you may still qualify for premium-free Part A in some situations.
- You’re self-employed and deduct your premiums from your taxes.
- You’re in the military.
- You work for a church or other organization that doesn’t pay Social Security taxes.
- You are or were employed by a local or state government agency that doesn’t participate in Social Security.
- You were a domestic or farm worker.
- Your 62 or older spouse earned enough credits
If any of these circumstances apply to you, contact Social Security to see if you can get your Part A premiums waived.
Eligibility requirements for Part B
In general, people over age 65 and those with certain disabilities can get Medicare Part B. Also, you or your spouse need to have been a US citizen or permanent resident for at least five years. If qualifying based on your spouse’s citizenship, you must be 65 or older, and your spouse must be 62 or older.
Beyond that, all you need to do to stay eligible for Part B coverage is pay your premiums. It’s possible to get Part A for free, but most people pay premiums for Medicare Parts B, C, D, and Medigap. Of course, if you qualify for your state’s Medicare program or Extra Help, you may get free or reduced premiums.
Part B premiums are calculated based on your income. Unlike Part A, Part B’s premiums have nothing to do with how much you’ve paid into Medicare taxes.
The standard Part B premium for enrollees that make $85,000 or less in 2019 is $135.50 per month.9
If you make more than that, check out our Medicare Premiums and Deductibles page to find out what your Part B premium may be.
Eligibility requirements for Part C
Medicare sign-up requirements for Part C, also known as Medicare Advantage, are a bit more complicated than for Parts A and B. For starters, you’ll need to have both Part A and B to get a Medicare Advantage plan, and there must be a plan available where you live. Finally, people with ESRD may be limited to certain kinds of policies.
Like other parts of Medicare, Medicare Part C eligibility also depends on paying your monthly premiums. Medicare Advantage premiums include three components:
- Your Part A premium (if applicable)
- Your Part B premium
- Any additional amount the Medicare Advantage insurance company charges
Sounds expensive, right? Usually, it’s not too bad. Most people pay no Medicare Part A premium at all, and Part B is cheaper than many employer-offered health insurance plans.
The average monthly premium for Medicare Advantage is expected to be $28.00 in 2019.10
Even better: some plans add nothing at all to your Medicare premiums or give you a Part B rebate.
On top of that, most Medicare Advantage plans offer more than what you’d get with Original Medicare, like dental, vision, and hearing coverage. Plenty of Part C plans include prescription drug coverage too, which means you may not have to worry about a separate Part D premium to boot.
ESRD and Medicare Advantage
Unfortunately, eligibility for Part C is more restricted if you have ESRD. ESRD patients can’t join a Medicare Advantage Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-For-Service (PFFS), or Medical Savings Account (MSA) plan. If they join a Special Needs Plan (SNP), it must be one specifically designed for people with ESRD.
If you already have one of these plans when diagnosed with ESRD, don’t worry. You won’t get kicked out of your plan. If you ever decide to switch coverage, however, you’ll have to choose an SNP for people with ESRD or enroll in Original Medicare instead.
While this may seem like ESRD patients get the short end of the stick, most Part C plans aren’t ideal for covering regular dialysis treatments. HMOs and PPOs don’t cover out-of-area costs as well as Original Medicare, which means you may have trouble covering treatment if you travel out of your service area.
Meanwhile, PFFS plans may not provide consistent, dependable service from health care providers, and high-deductible MSA plans can leave you with depleted savings and a pile of bills.
Eligibility requirements for Part D
Medicare qualifications for Part D include those for Original Medicare (Parts A and B).
In fact, to qualify for Part D, you need to have Part A, Part B, or both.
There are a few cases where you can enroll in a Part D plan if you have Part C, such as having a Medicare Advantage PFFS plan that doesn’t offer prescription drug coverage.
Like Uncle Sam, insurance companies offering Medicare Part D coverage expect to be paid a monthly premium for their services. You (or the Extra Help program if you qualify) need to keep up with these payments to get coverage.
The average basic premium for Medicare Part D is expected to be $32.50 in 2019.11
Eligibility requirements for Medigap
Medigap, also known as Medicare Supplement insurance, is designed to help cover out-of-pocket costs of Parts A and B.
You’ll need to enroll in Parts A and B to be eligible for Medigap.
If you’ve signed up for a Medicare Advantage plan instead of Original Medicare, you aren’t eligible for a Medicare Supplement plan.
Medigap is offered by private insurance companies that charge a monthly premium in addition to any Part A and B premiums. If you don’t pay your Medigap premiums, the insurance company may cancel your coverage.
Medicare supplement premiums vary widely by plan, provider, area, and when you enroll. The best way to find out what your premiums might be is to use our Suggest-a-Plan tool.
Medigap coverage guarantees
If you qualify for Medicare by age, the federal government prevents Medigap insurance companies from charging you a higher premium, denying you coverage, or making you wait for coverage due to a preexisting condition. Unfortunately, you get these protections only if you enroll in Medigap when you’re first eligible (just after you sign up for Part B for the first time) and under a few other rare circumstances.
Check out our Medicare Supplement plans page for full details, but let’s just say we strongly recommend enrolling in Medigap as soon as possible, even if you don’t think you’ll need it right away.
If you qualify for Medicare based on disability status, we have some bad news: you won’t get these same guarantees until you reach 65 and requalify for Medicare based on age.
Am I eligible for Medicare?
Whew, that’s a lot of information to process, isn’t it? But the million-dollar question is this: how do you know for sure if you’re eligible for Medicare?
The simplest way to find out if you’re currently eligible for Medicare is to use the Check Your Enrollment tool at Medicare.gov. Alternatively, contact Social Security directly. The SSA automatically enrolls some people in Original Medicare, so you might find out you’re eligible when your Medicare card shows up in the mail.
But not everyone’s enrollment process is so easy. If you’d prefer the comprehensive coverage of Medicare Advantage, for example, the government won’t enroll you in one of those plans. And in most cases, you’ll have to join a Part D or Medigap plan on your own too.
Hoping your Medicare card shows up in the mail before you turn 65 or hit your 24th month on disability isn’t a great start to becoming a Medicare beneficiary. We find it’s best to have a more proactive role with Medicare to avoid any pitfalls such as missing enrollment periods or getting slapped with Late Enrollment Penalties. After all, “I didn’t know” won’t be enough to get yourself out of most Medicare mishaps.
Medicare is complicated, but we have your back. MedicareHealthPlans can help with the heavy lifting in three ways.
- Learn more about how and when to enroll in Medicare Advantage, Part D, and Medigap on our Medicare Enrollment page.
- Compare plans in minutes with our Suggest-a-Plan tool.
- Or just give us a call at 855-802-1206, and we’ll help you find and enroll in the right plan for you.
- Medicare.gov, “Part A & Part B Sign Up Periods”
- Medicare.gov, “Getting Medicare If You Have a Disability”
- Medicare.gov, “Signing Up for Medicare if You Have ESRD”
- Medicare.gov, “Getting Medicare If You Have a Disability”
- Medicare.gov, “Enrolling in Medicare Part A & Part B”
- Medicare.gov, “Part A Costs”
- SSA.gov, “How You Earn Credits”
- CMS.gov, “CMS announces 2019 Medicare Parts A & B premiums and deductibles”
- CMS.gov, “CMS announces 2019 Medicare Parts A & B premiums and deductibles”
- CMS.gov, “Medicare Advantage Premiums Continue to Decline While Plan Choices and Benefits Increase in 2019”
- CMS.gov, “Medicare Part D Premiums Continue to Decline in 2019”
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