As of 2023, Medicare insures about 64 million Americans; however, enrollment is not necessarily automatic. Because of this, it's essential to understand when you become eligible for Medicare and how to enroll.
American citizens of 65 and older are eligible for Medicare, as are legal residents of five years or more. You can also qualify for Medicare if you're collecting Social Security benefits or if you're a spouse of a federal employee who has paid Medicare payroll taxes while working.
Medicare Eligibility for Those Under 65
If you are younger than 65, you may qualify for Medicare if you:
Have been entitled to Social Security disability benefits for 24 (non-consecutive) months.
Receive disability benefits from the Railroad Retirement Board and meet certain conditions.
Suffer from Amyotrophic Lateral Sclerosis (ALS).
ALS is also known as Lou Gehrig's disease.
You have been diagnosed with end-stage renal disease (ESRD).
Alternative Means of Eligibility
If you are not in one of the above categories, there are multiple ways to “buy into” Medicare. First, by Part A premiums, or hospital insurance. How much you pay varies by how long you have worked. You earn more work credits the longer you work, and credits are based on income.
If you worked less than 40 quarters or 10 years, you might have to pay a premium for Part A to enroll in Medicare. The costs for Medicare Part A will vary depending on how many quarters you've worked and paid into Original Medicare.
Suppose you can't afford the Premium for Medicare Part A. In that case, you can apply for a Medicare Savings Program that may assist you with paying the Medicare premiums.
The price of Medicare can be affected by an income-related monthly adjusted amount or IRMAA. The more you make, the more your premium will be.
Medicare Advantage Eligibility
Suppose you qualify for Original Medicare (Parts A and B). In that case, you can enroll in Medicare Part C or Medicare Advantage. Private companies offer Medicare Advantage plans, which must cover the same benefits as Medicare Part A and Part B.
These plans usually include drug coverage and additional benefits not covered under Original Medicare. These plan extras include routine dental, vision, and hearing coverage and items like gym memberships and over-the-counter allowances.
There are 3 requirements for Medicare Advantage eligibility:
You are a US citizen or a permanent legal resident.
You are already enrolled in Original Medicare.
You live in your MA provider's area of service.
Medicare Supplement Insurance Eligibility
Medicare Supplement Insurance, also known as Medigap, is insurance designed to fill in the “gaps” in Original Medicare. Private companies sell Medigap to help cover out-of-pocket costs like deductibles, coinsurance, and copayments. Medigap plans also allow you to see any doctor who accepts Medicare or a specialist without a referral.
These Medigap plans have their own enrollment periods and don't include drug coverage. You must enroll in a stand-alone Part D prescription drug plan to add drug coverage unless you have other creditable coverage.
You can enroll in a Medicare Supplement plan if you have Medicare Part A and Part B. You'll need to pass medical underwriting to be accepted into the program. The exceptions to medically qualifying are during your one-time Open Enrollment or a Guaranteed Issue situation. In that case, you'll need to pass medical underwriting to be accepted into the plan.
Medicare Enrollment Periods
Suppose you are an American citizen or permanent legal resident currently receiving Social Security Benefits. In that case, you will be automatically enrolled in Original Medicare (Parts A and B). Otherwise, you will have to enroll during one of several specific windows during the year.
Initial Enrollment Period
Your Initial Enrollment Period begins three months before your 65th birthday and lasts seven months. Social Security will mail you instructions when this period starts; you can enroll online, by phone, or in person.
Annual Enrollment Period
The Annual Enrollment period is a seven-week period during which you can change or modify your coverage. Medicare Annual Enrollment happens annually from October 15 to December 7. Common reasons for changing your coverage include increasing premiums and copayments, fluctuating drug prices, or changes in one's permanent health.
Medicare Advantage Open Enrollment
The Medicare Advantage Open Enrollment lasts for three months. It begins on January 1 and continues through March 31. The MAOEP allows Medicare beneficiaries enrolled in a Medicare Advantage plan to make one change. The change will take effect on the first of the following month.
Special Enrollment Periods
Specific events or life changes trigger Special Enrollment Periods (SEPs). There are more than twenty recognized qualifiers, so research your situation online. Examples include:
Losing employer health insurance.
Moving outside your plan's area.
Being released from or leaving prison.
Returning to the US after working/living abroad.
Late Enrollment Penalties
If you do not enroll during the Initial or Open Enrollment windows, you may face a Late Enrollment Penalty. The Part B penalty rises 10% for every year you delay enrollment. Part D multiplies the average drug plan premium amount by every month delayed. The easiest way to avoid Penalties is to enroll during your Initial Enrollment Period.
Given Medicare's complexity and shifting nature, enrolling during your Initial Enrollment Period provides you the most time and widest range of options. To begin, visit the Social Security Administration's website, call 1(800)-633-4427, or visit an office in person. If you are unsure about what plans or assistance you may qualify for, be sure to utilize tools such as Medicare.gov's Eligibility Premium Calculator.
Amie has been writing about senior care products and services for the last decade. She is particularly passionate about new technologies that help improve the quality of life for seniors and their families. Seeing her parents and grandparents age made Amie ask herself, “Would this be good enough for my loved ones?” In her spare time, Amie enjoys outdoor adventures and spontaneous road trips. Learn more about Amie here