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When Do You Qualify for Medicare?

Most Americans automatically qualify for Medicare once they turn 65. In a few special cases, Americans under 65 can get Medicare coverage.

September 29, 2017 - By Hal Levy - read

Medicare is a national health insurance program offered by the federal government. It provides health coverage for those over the age of 65 as well as for certain disabled individuals. Nearly all Americans who qualify for Original Medicare decide to enroll, since Medicare gets fantastic grades for patient satisfaction.

When Do You Qualify for Medicare? | flowchart | HealthCare.com

Basic Facts About Medicare

Medicare Part A: Covers inpatient hospital care. You must enroll if you receive Social Security and are over the age of 65. Some people call Part A “hospital insurance.”

Medicare Part B: Covers outpatient doctor care. You can apply by contacting your local Social Security office. Some people call Part B “medical insurance.”

Original Medicare (Part A & Part B): Together, Part A & Part B are the combined health insurance product known as Original Medicare. Original Medicare also serves as the foundation for private Medicare Advantage and Medicare Supplement plans.

Social Security: A government program that gives assistance to retired persons. Social Security also provides for disabled persons through Social Security Disability Insurance. Local Social Security offices take care of your Original Medicare enrollment.

Once you’re eligible to enroll in Medicare, the penalties for late enrollment increase the longer you wait. You may be able to sign up sooner than you think.

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How to Become Eligible for Medicare

There are just two ways to become eligible for Medicare:

1.) Most people will automatically qualify when they reach their 65th birthday, or

2.) People can qualify for Medicare if they receive Social Security Disability Insurance benefits (SSDI) or have end-stage renal disease (ESRD).

1. Automatically Qualify for Medicare Once You’re 65 Years Old

On your 65th birthday, you can celebrate your Medicare eligibility! You’ll qualify for Medicare enrollment upon turning 65, as long as:

  1. You have been a U.S. citizen or permanent resident for more than 5 years, AND
  2. You have paid Medicare taxes for at least 10 years.

Automatic Enrollment: If you’ve received Social Security or Railroad Retirement benefits for the 4 months before your 65th, then you’ll be automatically enrolled. Your Medicare information will arrive in the mail.

Manual Enrollment: If you’re not receiving Social Security benefits already upon turning 65, you’ll need to manually sign up for Medicare by contacting your local Social Security office.

When Does Original Medicare (Part A and Part B) Start?

If you qualify for Original Medicare by turning 65 years old, then the first day of the month that you turn 65 is the earliest you can begin coverage.

Can Begin as Soon as You Turn 65: For your coverage to start as soon as possible, you have to sign up at your local Social Security office during one of the 3 months prior to your birthday month. Remember: even if you automatically qualify for enrollment in Medicare Part A, you’ll still need to manually enroll in Medicare Part B.

  • Initial Enrollment Period: You first become eligible when you turn 65, but you have a 7-month initial enrollment period during which you can sign up for Medicare Part A and/or Medicare Part B.  This 7-month period includes: the 3 months before the month of your 65th birthday, the month of your 65th birthday, and the 3 months after that birthday month.

Group 15

Delays in Coverage Can Occur: Coverage will start later if you wait until the month of your 65th birthday (or if you wait until the months following your 65th birthday).

  • If you enroll during your birthday month: Original Medicare coverage will be postponed for 1 month.
  • If you enroll in the month following your birthday month: Original Medicare coverage will be postponed for 2 months.
  • If you enroll 2-3 months after your birthday month: Original Medicare coverage will be postponed for 3 months.

Special Cases: Depending on your situation, your Original Medicare coverage might follow a special timeline.

  • If your birthday is on the 1st of the month, Original Medicare will start on the 1st of the previous month.
  • If you already received Social Security or Railroad Retirement Board (RRB) benefits for 4 months before turning 65 years old, then you’ll automatically be enrolled in Medicare Parts A and B on your 65th birthday.

I Missed the Initial Enrollment Period – Now What Can I Do?

If you miss all of these opportunities to sign up for Original Medicare, then you’ll need to qualify for a Special Enrollment Period. You can also wait until the General Enrollment Period of January 1 – March 30 to enroll. Either option can be difficult; they can also burden you with an additional payment for the lifetime of your plan. It’s best to sign up during the 3 months before your birthday month.

When Can You Collect Original Medicare?

If you’re automatically enrolled in Medicare, then your official Medicare card will arrive in the mail 2 to 3 months before you’re eligible. Otherwise, your card will arrive about 3 weeks after you apply for Medicare coverage. The sooner you apply, the sooner your card will be ready.

You can access benefits as soon as your coverage begins.

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2. Qualify for Medicare When You’re Under 65 Years Old Due to Your Disability

About 16 percent of Medicare enrollees have a disability that qualifies them for Medicare, no matter their age. You could be one of the 9 million Americans who enroll in Medicare before their 65th birthday.

SSDI: If you’ve received 24 months of Social Security Disability Insurance payments, then you qualify for Medicare. It’s not easy to earn SSDI, but once you do, you can access Medicare regardless of your age.

ESRD: If you’ve received a diagnosis of end-stage renal disease, you can enroll in Medicare by contacting your local Social Security office.

  • To qualify, you must receive Social Security benefits or have worked for 40 quarters of Social Security (or the equivalent Railroad Retirement Board or government employee benefit).
  • If you have ESRD but don’t meet those requirements, you qualify if you are the spouse or dependent child of a person who meets those requirements.

ALS: If you’ve been diagnosed with amyotrophic lateral sclerosis (ALS), then you will automatically be enrolled in Medicare upon receiving your first SSDI payment.

When Does Original Medicare (Part A and Part B) Start?

In all cases that you receive Original Medicare, your official Medicare card will arrive in the mail 2 to 3 months before you’re eligible. Otherwise, your card will arrive about 3 weeks after you apply for Medicare coverage. The sooner you apply, the sooner your card will be ready.

SSDI: Your enrollment begins automatically on the 25th month that you receive SSDI benefits. You’ll get your Medicare information and the official card in the mail soon after your 23rd month of receiving SSDI.

The 24-month requirement is cumulative, not consecutive. You don’t need to have received all 24 months during a 24-month period to qualify.

ESRD: Your ESRD Medicare coverage can begin:

  • During the first month of dialysis, if you take part in a home dialysis training program;
  • During the first month that you are admitted to the hospital for a kidney transplant or transplant-related health services;
  • Two months before your transplant, if it is delayed for more than two months after you’re admitted to the hospital; or
  • After your fourth month of dialysis, if you receive treatment at a dialysis facility.

Note that ESRD Medicare enrollees receive complete Medicare coverage, not just coverage for ESRD-related issues.

ALS: Your Medicare benefits will begin as soon as you receive your first SSDI payment. There’s usually a 5-month waiting period to receive this payment if you have ALS.

When Can You Collect Original Medicare?

You can access benefits as soon as your coverage begins.

SSDI: If your SSDI payments end, you may be able to stay enrolled in Medicare. In that circumstance, your end date depends on the specifics of your case. You’ll want to speak with your doctor for more information.

ESRD: Your Medicare will end 12 months after dialysis ends, or 36 months after your kidney transplant.

ALS: ALS patients typically stay on Medicare without interruption.

Railroad Medicare Eligibility:

Former railroad employees may collect their pensions from the Railroad Retirement Board (RRB) instead of Social Security. Railroad employees will also need to contact the RRB instead of the Social Security Administration to apply for Medicare. However, your benefits and requirements for Medicare will be the same as any other enrollee.

If you are a railroad worker who receives railroad disability annuity or a railroad retirement benefits check, then you’ll be enrolled in Original Medicare automatically once you turn 65. If you plan to turn 65 before you receive retirement benefits, you’ll need to contact your local RRB to sign up.

Is Medicare Free?

Original Medicare isn’t free, but compared to alternatives it’s a more affordable option.

You don’t have to pay for Medicare Part A under most circumstances (the monthly premium for Part A is $0 for those who have worked long enough to quality for Social Security benefits). You’ll still need to pay a deductible for each hospital stay, though, before Medicare covers some of your hospital costs.

The premium for Medicare Part B is generally $134 per month, although the exact cost will depend on your tax returns from two years ago. Additionally, there’s a deductible of $183 every year, plus you’ll need to pay a 20 percent coinsurance on your medical costs after reaching that deductible.

Consider Supplementary Insurance

It’s strongly recommended that you sign up for additional coverage to save money on healthcare costs. Although you can rely on Original Medicare alone, 86 percent of Medicare enrollees also join a privately-run supplementary plan.

With Original Medicare, you’ll still have to pay for prescription drugs, emergency care in foreign countries and your first three pints of medically-necessary blood per year. You’re also still on the hook for deductibles and co-payments of up 20 percent on Part B costs. Supplementary plans can cover these costs.

Medigap Plans: Medicare Supplement plans, also known as Medigap insurance, fill the “gaps” in coverage that you would otherwise be charged by Original Medicare. All plans cover your Part A coinsurance and hospital costs. Most plans cover your full Part B coinsurance, and some plans even cover your Original Medicare deductibles and excess charges.

Medicare Part D: Prescription drug payments generally aren’t covered by Original Medicare. Instead of paying for drugs out-of-pocket, you can purchase Medicare Part D to add prescription drug coverage to your existing Original Medicare benefits. Depending on your medication needs, a Part D plan may be a vital extension of your coverage.

If you were born in 1953 or later, being prepared for Medicare will save you a lot of hassle. Check out our eBook and guides to learn more. We’d love to help you compare plans for when you’re ready to buy supplemental coverage!

Taking the Next Steps

If you’re nearing the age of 65, then it’s important you start considering your Medicare coverage.

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