If you’re approaching your 65th birthday then it is likely that you’ve already started thinking about enrolling in Medicare for the first time. In fact, your mailbox is probably overflowing with offers from various Medicare brokers and health insurance companies that would love to earn your business.
It is fairly common knowledge that most Americans qualify for Medicare coverage once they reach this milestone birthday. However, this isn’t a given for every individual. In fact, there are a number of Medicare qualifications that one must meet in order to enroll in the program.
Who qualifies for Medicare?
There are two basic groups of Medicare-eligible individuals:
- People who age into the Medicare program at 65 based on their work history
- People under age 65 who are receiving social security benefits due to a disability which prevents them from working
I’ve reached the Medicare eligibility age of 65. Do I qualify for Medicare?
After turning 65 you will qualify for Medicare benefits, including premium-free Part A, if you meet all of the following qualifications:
- You are a citizen of the United States
- While you don’t necessarily need to be a natural-born citizen of the United States to qualify for Medicare, you do need to be a legal permanent resident who has lived in the country for at least five years
- You or your spouse has earned enough work credits to qualify for Social Security or Railroad Retirement Benefits
- If you or your spouse has worked and paid into social security in the United States for more than 10 years, then it is likely that you have earned the requisite 40 work credits required for Medicare eligibility
- You or your spouse is a government employee that paid Medicare payroll taxes
- In this case, you (or your spouse) earned your Medicare eligibility through the Medicare payroll taxes that were deducted from your income while working
What if I don’t meet all of the Medicare qualifications after turning 65?
Even if you do not qualify for premium-free Part A, you may still be able to purchase Medicare coverage if you meet one of the following criteria:
- You’re a U.S. citizen
- You have been a permanent legal resident for at least five years
- You’ve been married to someone who meets one of the above criteria for at least one year
I haven’t turned 65 yet. Do I qualify for Medicare
Before turning 65, you may qualify for full Medicare benefits if you meet any of the following criteria:
- You’ve been receiving social security benefits for more than 24 months due to a disability
- You collect a disability pension from the Railroad Retirement Board, and your disability meets the eligibility requirements they’ve defined
- You’ve been diagnosed with ALS (Lou Gehrig’s disease)
- You’ve been diagnosed with kidney failure (end-stage renal disease) and have had a kidney transplant or are receiving dialysis treatments
What Medicare coverage options are available?
While Original Medicare (Parts A and B) will cover many of your health care costs, it doesn’t cover everything. In fact, some of the most common health care needs for older patients — like prescription drug coverage, hearing, and vision care — are not included with Medicare Parts A or B. Fortunately, there are additional coverage options available to fill in many of these gaps.
When it comes to selecting your Medicare coverage, your strategy should be based on your unique health situation. You should take all of your needs, as well as your personal budget, into account as you consider your options. But don’t worry: whether you’re in tip-top shape or take multiple medications each day, there is a combination of plans that can work for you.
Original Medicare – Part A
Most Americans will qualify for premium-free Part A at age 65 if they or their spouse worked and paid into Social Security for 10 years or more.
If you haven’t met this requirement, you may still be able to purchase Part A coverage if you or your spouse is a U.S. citizen or has been a permanent legal resident for at least five years.
Do I need Medicare Part A?
If you are not automatically enrolled for Medicare Part A, you should sign up for this coverage during your seven-month Initial Enrollment Period. This period begins three months prior to your 65th birthday.
While many people elect to delay their enrollment in Medicare Part B until after they retire and lose coverage under their group health insurance plan, there is no downside to enrolling in Part A as soon as you become eligible.
Original Medicare – Part B
Medicare Part B covers outpatient care, some medical services, preventive services, and medical supplies. It is important to note that enrolling in Medicare Part B is optional and that you will need to pay a monthly premium in order to take advantage of this coverage.
Am I eligible for Medicare Part B?
If you’re eligible for premium-free Medicare Part A, then you’re also eligible to purchase coverage under Medicare Part B. If your work history doesn’t qualify you for premium-free Part A, but you or your spouse is a U.S. citizen or has been a legal permanent resident for more than five years, then you can purchase Part B coverage in addition to Part A coverage.
Do I need Medicare Part B?
The likelihood of finding comparable coverage at an affordable price through a private insurer is low for people in this age group. For this reason, most seniors would be wise to purchase Part B coverage. However, whether you should enroll as soon as you become eligible at 65 will depend upon your unique situation.
If you are still receiving creditable coverage through your employer’s group insurance plan when you turn 65, you may elect to delay your enrollment in Medicare Part B. Those who delay their enrollment without creditable coverage will be subject to permanent late enrollment fees.
Not sure whether your health insurance qualifies as creditable coverage? If you work for an employer with more than 20 full-time employees, then your coverage most likely qualifies as creditable. However, you should confirm this with your company’s human resources department before making any decisions.
Medicare Advantage – Part C
Medicare Part C plans are sold by private insurance companies as an optional alternative to Original Medicare Parts A and B.
While the government requires these plans to provide the same standard coverage that is included with Parts A and B, Medicare Part C plans often include additional benefits, like hearing, vision, and dental care.
Many Part C plans, known as Medicare Advantage Prescription Drug (MAPD) plans, also include Part D prescription drug coverage.
Am I eligible for Medicare Part C?
Before you can enroll in a Medicare Part C plan, you must be enrolled in Original Medicare Parts A and B. It is important to note that you will still pay a monthly Part B premium in addition to any monthly premiums you pay for your Medicare Part C plan. Your costs will vary depending on which plan you purchase.
Do I need Medicare Part C?
While Medicare Part C plans do offer more coverage than Medicare Parts A and B, they also come with additional costs. At the same time, Medicare Part C plans do place an annual cap on their members’ out-of-pocket costs (not including prescription drug costs). In some cases, this could help you better forecast your health care costs, or even cut down your total cost of care, for the year.
Prescription Drug Plans – Part D
Medicare Part D prescription drug plans are optional plans that can be purchased in addition to Original Medicare Parts A and B.
These plans help enrollees pay for the prescription medications they need to survive. Like Medicare Advantage plans, Medicare Part D plans are sold by private insurance companies. While they are regulated by the federal government, the specific drugs covered, as well as the costs associated with this coverage, will vary depending on which plan you choose.
Am I eligible for Medicare Part D?
You must be enrolled in Medicare Parts A and B to qualify for Part D coverage. You also need to live within the plan’s defined service area.
Do I need Medicare Part D?
Even if you are not currently taking any prescription medications, it is highly likely that you will at some point in the future. Without Part D coverage, paying out of pocket for even a single drug could cost you hundreds of dollars each month.
Since delaying your enrollment will result in permanent late-enrollment penalties, many Medicare experts advise purchasing a Part D plan when you first become eligible.
Medicare Supplement (or Medigap) Plans
Medicare Supplement plans help cover some of the costs not covered by Original Medicare, such as copayments, coinsurance, and deductibles.
Depending on which type of Medicare Supplement plan you purchase, they can also cover additional services or benefits.
Like Medicare Advantage plans, Medicare Supplement plans are sold by private insurance companies.
Am I eligible for a Medicare Supplement plan?
You must be enrolled in Medicare Parts A and B to enroll in a Medicare Supplement plan. The ideal time to enroll in a Medicare Supplement plan is during your Initial Enrollment Period. During this seven-month window, a plan cannot use medical underwriting to deny you coverage or charge higher premiums based on pre-existing health conditions.
Do I need a Medicare Supplement plan?
Because Medicare Supplement plans can help cover some of the costs associated with Original Medicare, these plans can be good options for individuals who are likely to incur a significant amount of out-of-pocket costs throughout the year. If you expect to visit the doctor frequently or to have more than one hospital stay over the course of the next 12 months, then a Medicare Supplement plan can help offset a lot of the expenses associated with your care.
Ready to find a Medicare plan that works for you?
While there is no one-size-fits-all Medicare coverage solution, being aware of the various options you are eligible for, as well as how well they will meet your unique needs, is an important exercise that could impact your health and your budget for many years to come.
