Medicare Eligibility Requirements: Who Qualifies?
Over 60 million Americans are eligible for Medicare, the federal medical insurance program for older adults. Most people become eligible by turning 65, but others may be eligible due to having a disability.
While not perfect, most people are excited to become eligible for Medicare because it provides high-quality insurance that is cheaper than COBRA and often provides better value than employer health insurance.
In this guide, we’ll explain the Medicare eligibility requirements to give you a clear understanding of who qualifies for Medicare. We’ll cover more unique situations, like how to qualify due to disability and what the eligibility requirements are for permanent residents.
If you ever need help determining your eligibility for Medicare or choosing between your employer coverage and Medicare, we’re here to help! Just schedule a consultation or give us a call at (855) 900-2427 to get all of your Medicare questions answered.
Key Takeaways:
If you’re a US citizen over the age of 65, you’re eligible for Medicare.
If you have certain disabilities, you may be eligible to get Medicare before you turn 65.
How long you’ve worked and paid Medicare taxes helps determine if you’re eligible for premium-free Part A.
Medicare eligibility basics: Who qualifies for Medicare?
There are two ways you can qualify for Medicare: by turning 65 or due to having certain disabilities. For both types of eligibility, you must be a US citizen or permanent resident to qualify for Medicare.
Qualifying for Medicare due to age
You become eligible for Medicare when you turn 65 and can enroll during your Initial Enrollment Period.
Your Initial Enrollment Period is a seven-month period that starts three months before the month you turn 65 and ends three months after. You’ll be automatically enrolled in both Medicare Part A and Medicare Part B when you turn 65 if you are already drawing from Social Security.
Some people choose to delay Part B enrollment because they’re eligible for the Part B Special Enrollment Period, which you can learn more about here.
Qualifying for Medicare due to disability
Having certain disabilities, like End-Stage Renal Disease (ESRD) and ALS, can grant you Medicare eligibility. If you’re entitled to Medicare due to disability, you’ll be eligible on the 25th month that you receive Social Security Disability Insurance (SSDI) benefits.
Your Initial Enrollment Period starts three months before your 25th month of receiving disability benefits and ends three months after. Typically, you’d be automatically enrolled in both Part A and Part B after receiving Social Security disability benefits for 24 months.
Medicare eligibility for permanent residents
If you qualify due to age or disability and have held permanent residence status for five years or more, then you qualify for Medicare. Your Initial Enrollment Period is determined by your birth month or length of disability status. Both of these scenarios are explained in the sections above.
How to qualify for premium-free Medicare Part A
Most Americans get Medicare Part A for free because they (or their spouses, including former spouses) have worked and paid Medicare taxes for ten years or more.
You also won’t pay the Part A premium if you:
Qualify to get or are already receiving Social Security retirement or disability benefits from Social Security or the Railroad Retirement Board.
Get Medicare before you turn 65.
Eligibility for additional Medicare insurance options
When you first enroll in Medicare, you get Original Medicare, which includes Part A and Part B. Once you’re enrolled in Original Medicare, you can choose to switch to a Medicare Advantage plan or stay on Original Medicare. If you stay on Original Medicare, you may also sign up for a Medicare Supplement plan and/or a Part D (prescription drug) plan.
Medicare Advantage eligibility
Medicare Advantage plans (also known as Medicare Part C plans) replace your Original Medicare coverage. These plans provide a bundled approach to Medicare, often covering prescriptions, dental, vision, and hearing needs in addition to the same services as Part A and Part B.
You’re eligible to switch to Medicare Advantage once you’ve enrolled in Original Medicare: both Part A and Part B. You can enroll in Medicare Advantage during your Initial coverage election period or the Medicare Open Enrollment Period.
Your initial coverage election period is a seven-month window that aligns with your Initial Enrollment Period—unless you enroll in Medicare Part B after you turn 65. If you enroll in Part B after turning 65, then you can enroll in Medicare Advantage starting three months before your Part B effective date.
You can also switch from Original Medicare to Medicare Advantage during the annual Medicare Open Enrollment Period, which occurs every year from October 15 to December 7.
Medicare Supplement eligibility
Medicare Supplement plans (also known as Medigap plans) stack on top of your Original Medicare coverage to help cover the 20% of costs that Original Medicare doesn’t cover. You’re eligible to enroll in a Medigap plan if you’re enrolled in Medicare Part A and Part B and are not enrolled in a Medicare Advantage plan.
The best time to enroll in a Medigap plan is during your Medigap Open Enrollment Period, which lasts for six months after your Part B effective date. During this time, you can enroll in any Medigap plan without answering questions about your health history—these are called underwriting questions. Outside of this period, you may need to answer Medicare underwriting questions, and your answers could affect your premium or cause insurance carriers to deny you coverage.
Medicare Supplement enrollment for beneficiaries under 65
If you qualify for Medicare before turning 65, you may be unable to sign up for a Medigap policy. This is because federal law does not require insurance companies to offer Medigap policies for Medicare beneficiaries under 65.
While federal law doesn’t require insurance companies to offer Medigap to individuals under 65, the states listed below require insurance companies that offer Medigap policies to offer at least one type of plan (e.g., Medigap Plan D) to Medicare beneficiaries under 65.
Usually, the Medigap plan available to Medicare beneficiaries under age 65 is more expensive. This is because if you qualify for Medicare due to having a disability, you’re more likely to need frequent and costly care.
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
New Hampshire
New Jersey
New York
North Carolina
Oklahoma
Oregon
Pennsylvania
South Dakota
Tennessee
Texas
Vermont
Wisconsin
Medicare Part D eligibility
Original Medicare doesn’t cover prescription drugs. For this reason, Medicare beneficiaries can enroll in separate Medicare Part D (prescription drug) plans. You’re eligible to enroll in a standalone Part D plan if you’re enrolled in Part A and/or Part B.
Note: most Medicare Advantage plans include Medicare Part D coverage, so there’s no need to enroll in a separate Part D plan.
Get help determining when you should enroll in Medicare
Figuring out when you should enroll in Medicare isn’t always easy, especially if you have unique circumstances, like you’re still working after turning 65. Furthermore, deciding on which type(s) of Medicare coverage is best for you can feel incredibly overwhelming.
That’s why we’re here! Our licensed Medicare insurance agents can help you understand, choose, and use your Medicare coverage to ensure your healthcare needs are met and you’re receiving the best value. Get help by scheduling a free consultation or calling us at (855) 900-2427.