Who is eligible for Medicare?

Like many milestone decisions, enrolling in Medicare comes with a lot of uncertainties, questions... and fine print. If you’re close to turning 65 or believe you meet other Medicare eligibility requirements, we want you to be certain you know exactly what you’re signing up for — and how to do it. Ahead, we’ve answered some of the most common Medicare eligibility and enrollment questions, so you can be clear on all the important choices to come.

Medicare eligibility age, qualifications, and requirements

Who is eligible for Medicare?

Generally speaking, Medicare is healthcare for people who are 65 years of age or older, people who have certain disabilities, and people with end-stage renal disease or amyotrophic lateral sclerosis (also known as ALS).

When you turn 65 (happy birthday, if that’s you!), you become automatically eligible for Medicare if you:

• Receive or qualify for Social Security benefits.

• Or currently reside in the United State and are either a U.S. citizen or a permanent U.S. resident who has lived in the U.S. continuously for five years before applying.

There’s also a chance you might be automatically enrolled into Medicare (specifically Medicare Part A) on your 65th birthday — think of it as a gift from the United States government! But if you’re not, you’ll have the opportunity to sign up during your Initial Enrollment Period (or IEP). Hang tight — we’ll come back to the when’s, how’s, and why’s of your IEP soon.

Can you enroll in Medicare if you’re under 65 years old?

If you’re under age 65, there are two circumstances in which you are eligible for Medicare.

You have received Social Security Disability Insurance (SSDI) checks for at least 24 months.

But there are a few rules to be aware of. If you start receiving SSDI checks, the 24-month waiting period begins the first month you receive a check. On your 25th month, you will be automatically enrolled in Medicare.

If you receive SSDI because you have amyotrophic lateral sclerosis (commonly known as ALS), you do not have a waiting period, and you’ll automatically be enrolled in Medicare the first month that your SSDI benefits start.

You have been diagnosed with end-stage renal disease.

If you have been diagnosed with end-stage renal disease (also known as ESRD or kidney failure), you may qualify for ESRD Medicare if you:

• Are getting dialysis treatment or have had a kidney transplant.

• Are eligible to receive SSDI, Railroad Retirement benefits, or you, your spouse, or parent have paid Medicare taxes for a sufficient amount of time (as determined by the Social Security Administration).

If you are under age 65 and have end-stage renal disease, your Medicare benefits will begin based on a few factors, including when you apply for Medicare, whether or not you receive dialysis at home or a facility, and if you get a kidney transplant. If you are eligible for ESRD Medicare, you can enroll in Part A and Part B at any time.

To determine if you qualify for Medicare if you’re under 65, contact your local Social Security Administration office. If you’re a railroad worker, you should contact the Railroad Retirement Board for this information instead. (However, if you’re a railroad worker with end-stage renal disease, you should contact Social Security.)

Who is eligible for premium-free Medicare Part A?

Medicare Part A is hospital insurance. These benefits include inpatient hospital stays, care in a nursing facility, hospice care, and some home health care. These benefits do not cover regular doctor visits or prescription drugs. To enroll, you can get Part A directly from the government — in many cases, without a monthly premium.

To be eligible for premium-free Part A, you must have paid Medicare taxes for a sufficient period of time as determined by Social Security or the Railroad Retirement Board, if you were a railroad worker.

Who is eligible for Medicare Part B?

Medicare Part B is medical insurance. These benefits include certain doctors’ services, outpatient care, labs, medical supplies, and preventive services. It is voluntary coverage, because it requires a monthly premium. (Which will depend on what your income was while you were working.)

Individuals who are eligible for premium-free Part A are also eligible to enroll in Part B, but enrollment in Part B can only happen at certain times — like your IEP, and other enrollment periods. And if you were automatically enrolled in Part A, you have the choice to keep or refuse Part B coverage.

Also, here’s something to keep in mind while you prep and budget for your senior years: if you choose not to enroll in Part B coverage but decide later that you’d like that benefit, you will have to pay a late enrollment penalty.

How can you become eligible for Medicare Part C, Part D, and Medicare Supplement?

You are eligible for Medicare Part C, Part D, and Medicare Supplement after you have signed up for Original Medicare (or, Parts A and B).

Medicare Part C, or Medicare Advantage, is a privatized, all-in-one health plan. These benefits are the alternative to Original Medicare, bundled together with Parts A, B, and usually D. These benefits also sometimes cover dental care, vision care, over-the-counter items, and other specialized health needs. You must be in a plan’s service area though, because Medicare Advantage plans have much smaller doctor networks.

Medicare Part D is prescription drug coverage. These benefits include your prescription drugs, which are not covered in Parts A and B.

Medigap, or Medicare Supplement, is extra health coverage you can buy from a private company to pay for health costs that are not covered by Original Medicare. You’ll need to be enrolled in Original Medicare in order to enroll in this type of supplemental coverage. While this cost varies depending on your plan, it is designed to help fill the “gaps” in Original Medicare, since an Original Medicare plan covers most — but not all — healthcare costs, like copays, coinsurance, and deductibles. Some policies even cover medical care when you travel outside of the U.S., as long as it is a type of care covered by Original Medicare.

These plans are considered additional coverage options. You can choose these plans to help pay for prescription drugs, your Original Medicare expenses, and other care needs, but they are not required.

Enrolling in Medicare

When can you enroll in Medicare?

Your 65th birthday gift is automatic enrollment into Original Medicare (Part A and Part B) if you’re receiving Social Security retirement or Railroad Retirement benefits. If for some reason you have not received your red, white, and blue Medicare card in the mail, contact Social Security for your membership information.

Additionally, if you’re not automatically enrolled, you have the opportunity to sign up during your Initial Enrollment Period (IEP). This is a seven-month period of time when you can enroll in Medicare Parts A and B for the first time, and it begins three months before your birthday, lasts throughout your birth month, and ends three months after your birthday.

When can you enroll in Medicare Part C and Part D?

If you’d like to enroll in a Medicare Advantage plan, or Medicare Part C, make sure you:

• Already have Medicare Parts A and B.

• Have checked to make sure you live in the Medicare Advantage plan’s service area.

• Do not have end-stage renal disease.

You can enroll in Medicare Advantage during your IEP. But you can also enroll during:

• The Annual Election Period. This is the time in which you can change your plan or enroll in Medicare Advantage. Your benefits will go into effect on January 1 of the upcoming year.

• A Special Enrollment Period, which is when certain qualifying life events occur, like retirement, losing employer-covered insurance, or even if you move out of your plan’s service area.

• The Open Enrollment Period. This is the time in which those that are already enrolled in a Medicare Advantage plan have the opportunity to change plans.

To enroll in a Medicare Part D plan, you can enroll during the above times, including your IEP. If you think you’ll need prescription drug coverage at any point, consider enrolling in a Part D plan or a Medicare Advantage plan with prescription drug coverage upon initial Medicare eligibility. You are liable for penalties (which are added to your Part D drug premiums) based on how many months you went without this type of coverage since turning 65.

Can you have both Medicare Part C and Part D?

The short answer is no, you can’t have both Parts C and D. If you’d like prescription drug coverage, your best bet is to first decide whether you want Original Medicare with Part D added, or a Medicare Advantage plan that includes prescription drug coverage. If you enroll in a Medicare Advantage plan that includes prescription drug coverage and also join a Medicare prescription drug plan, you’ll be unenrolled in your Advantage plan and be sent back to Original Medicare.

Working past 65? Here’s what you should do.  

 
If you or your spouse are still working when you turn 65, Medicare works a little differently. It all depends on how you get your health insurance now and how many employees are at the company you (or your spouse) work for. Let’s break it down:  

• If your employer has less than 20 employees: you might need to sign up for Medicare during your IEP so you don’t have gaps in health coverage — just to be safe. (Check with your employer, though.) 
  

• If your employer has more than 20 employees: As long as you have health insurance from your employer in which you are actively working, you can delay enrolling in Medicare until retirement or when coverage stops (whichever happens first) without late penalties. When your employer-sponsored health coverage ends, you can enroll in Medicare during a Special Enrollment Period. Note: if you receive health coverage from retiree benefits or COBRA, this does not count as actively working and means you must sign up for Medicare during your IEP.  

Some people enroll in Medicare Parts A and B in addition to keeping their employer-sponsored plan — and that’s totally okay! But if you’re at a company with more than 20 employees, keep in mind that the employer plan is primary. So if you have great coverage, you might be paying monthly premiums for Medicare with little return.  

You can also sign up for Medicare Part D when you enroll in Parts A and B — and many people do this at the same time to avoid the late enrollment penalty. But there are a few other ways to avoid paying this:

• If you don’t have drug coverage: Enroll in Medicare Part D or a Medicare Advantage Plan with drug coverage within 3 months of enrolling in Original Medicare. 
  

• If you have drug coverage that’s credible: You can wait to get a Medicare Part D plan until you lose health coverage from your employer. When that happens, just make sure to enroll in a Part D plan within 63 days to avoid a penalty. (Tip: to determine if your drug coverage is credible, just ask your health insurance company.) 
  

• If you have drug coverage that’s not credible: Enroll in Medicare Part D or a Medicare Advantage Plan with drug coverage within 3 months of enrolling in Original Medicare.