Many people think Medicare is only for people turning 65. Age 65 is the most common way to qualify, but it is not the only way. Some people can become eligible earlier because of a disability or certain serious health conditions.
Knowing when you are eligible can help you avoid enrollment delays and make better decisions about your health coverage. Medicare eligibility and Medicare enrollment are related, but they are not exactly the same. You may be eligible for Medicare before you need to sign up, especially if you are still working and have health insurance through an employer.
Who is eligible for Medicare at age 65?
Most people become eligible for Medicare when they turn 65. In general, you must also be a U.S. citizen or a lawful permanent resident who has lived in the United States for at least five continuous years.
If you qualify based on age, your Medicare eligibility usually begins on the first day of the month you turn 65. If your birthday falls on the first day of a month, eligibility generally begins on the first day of the month before your birthday.
For example, someone with a birthday in July will generally become eligible on July 1. Someone born on July 1 will generally become eligible on June 1.
Being eligible does not always mean you are automatically enrolled. Many people receiving Social Security retirement benefits are enrolled automatically in Medicare Part A and Part B. Others may need to take action to enroll.
Can you qualify for Medicare before age 65?
Yes. Some people qualify for Medicare before age 65 because of a disability, kidney failure, or ALS.
You may qualify for Medicare before 65 if you have received Social Security Disability Insurance, often called SSDI, for 24 months. Medicare coverage generally starts after that waiting period. The timing can vary based on your individual situation, so it may help to review your Social Security information well before coverage is expected to start.
People with end-stage renal disease, or ESRD, may also qualify for Medicare at any age. ESRD means permanent kidney failure that requires regular dialysis or a kidney transplant. The start date for Medicare in this situation can depend on when dialysis begins, when you complete training for home dialysis, or when you receive a transplant.
People diagnosed with ALS, also known as Lou Gehrig’s disease, may qualify for Medicare when their Social Security disability benefits begin. They generally do not have the usual 24-month waiting period.
Do you need to have worked to get Medicare?
You do not always need your own work history to enroll in Medicare, but work history can affect what you pay for Part A.
Medicare Part A helps cover inpatient hospital care, skilled nursing facility care in certain situations, hospice care, and some home health services. Many people qualify for premium-free Part A because they, or sometimes their spouse, paid Medicare taxes while working.
In general, people need about 40 work credits, which is usually equal to about 10 years of work, to qualify for premium-free Part A. You may be able to use a current, former, or deceased spouse’s work record if you meet certain requirements.
If you do not have enough work credits, you may still be able to enroll in Part A. You may need to pay a monthly premium for it. Medicare Part B has a monthly premium for most people, whether or not they have enough work credits for premium-free Part A.
Your work history does not determine whether you can get Medicare Part B. It mainly affects whether you can receive Part A without a premium.
What if you are still working when you become eligible?
Turning 65 does not always mean you must enroll in every part of Medicare right away. If you or your spouse is actively working and you have group health coverage through that employer, you may be able to delay Part B without a late enrollment penalty.
The employer’s size and the type of health plan can matter. Coverage from a current employer is treated differently from retiree coverage, COBRA coverage, or an individual health plan. Those other types of coverage may not allow you to safely delay Part B.
Part A can also deserve a closer look if you contribute to a health savings account, or HSA. Medicare enrollment can affect your ability to contribute to an HSA. This is one reason it is wise to plan ahead rather than simply enrolling as soon as you turn 65.
If you have coverage through work, consider asking the benefits department how the plan works with Medicare. You may also want to compare the coverage, provider access, and out-of-pocket costs before deciding what to do.
Does Medicare eligibility mean all health care is free?
No. Medicare can help pay for many covered health care services, but it generally does not pay every cost. Original Medicare includes Part A and Part B, and it may leave deductibles, copayments, and coinsurance for you to pay.
Many people choose additional coverage to help manage those costs. Options may include a Medicare Supplement insurance plan, also called Medigap, a Medicare Advantage plan, or other coverage available through an employer, union, or Medicaid program.
Medicare Supplement plans work with Original Medicare and can help pay certain out-of-pocket costs. Medicare Advantage plans are another way to receive Medicare-covered benefits through private insurance companies. Plan choices, provider networks, drug coverage, benefits, and premiums can vary by plan, carrier, and state.
What should you do before you become eligible?
A good first step is to confirm your expected eligibility date. If you are already receiving Social Security benefits, watch for information about automatic enrollment. If you are not receiving Social Security, you may need to apply for Medicare yourself.
As your eligibility date gets closer, review a few important questions:
- Will you be retired, working, or covered under a spouse’s employer plan?
- Will you qualify for premium-free Part A based on your work record or a spouse’s record?
- Do you take prescription medications that may require Part D drug coverage?
- Do you prefer the flexibility of Original Medicare with a Medicare Supplement plan, or are you considering a Medicare Advantage plan?
- Will you need help paying Medicare premiums or other health care costs?
Starting this process a few months early can give you more time to understand your choices. Medicare rules can be confusing at first, but you do not have to figure them out alone. If you would like free, no-pressure help understanding your Medicare eligibility and Medicare Supplement options, reach out to Eric for guidance based on your situation.