For the vast majority of Americans who look forward to receiving Original Medicare health benefits, eligibility is as uncomplicated as celebrating your 65th birthday. But your eligibility to receive Medicare coverage without having to pay a premium – and your eligibility for other Medicare plans – depends on such factors as your work history and your health status.Here’s what you need to know:
Medicare Part A eligibility
Generally, you’re eligible for Medicare Part A if you’re 65 years old and have been a legal resident of the U.S. for at least five years. In fact, the government will automatically enroll you in Medicare Part A at no cost when you reach 65.
If you’re already receiving Social Security or Railroad Retirement benefits, all you need to do is check your mail for your Medicare card, which should automatically arrive in the mail three months prior to your 65th birthday (or the 25th month of a disability).
If you’re not already receiving Social Security or Railroad Retirement benefits, you’ll need to enroll in Medicare during a seven-month open enrollment window that includes the three months before the month you turn 65, the month you turn 65, and the three following months.
Sound good? It’s even better if you don’t have to pay a premium for Part A coverage, which is the case for most people. You’re eligible to receive Part A coverage premium-free if:
- You are 65 and you or your spouse has paid Medicare taxes for at least 10 years.
- You’re not yet 65, but you’re disabled and you’ve been receiving Social Security benefits or Railroad Retirement Board disability benefits for two years.
- You have end-stage renal disease (ESRD) and are receiving dialysis.
- You have amylotrophic lateral sclerosis (ALS) and are eligible for Social Security Disability Insurance.
If you (or your spouse) have not been paying Medicare taxes for at least 10 years, you’ll still be eligible for Part A coverage, but you’ll need to pay a premium – and your premium will depend on your work history. If you worked and paid into Medicare for between 7.5 and 10 years, you’ll pay $224 a month. Your premium will be $407 a month if you’ve paid into Medicare less than 7.5 years.
Medicare Part B eligibility
When you receive notification that you’re eligible for Medicare Part A, you’ll also be notified that you’re eligible for Part B coverage, which is optional and has a premium for all enrollees ($104.90 for most enrollees in 2015, although the price is higher if your income is more than $85,000 or $170,000 for a married couple).
Medicare A covers hospital charges, and Medicare B picks up where that leaves off, covering most outpatient expenses. If you enroll during an initial invitation period (the three months prior to the month you turn 65), Part B will kick in on the first of the month you turn 65. You’ll also have an opportunity to enroll during the month you turn 65, and in the three following months, although your effective date will be delayed.
If you don’t enroll during that period, you won’t lose eligibility for Part B, but you will be penalized with an increased premium when you eventually enroll, which climbs 10 percent for each year that you’re eligible but don’t enroll in Part B. General open enrollment for Medicare A and B runs from January 1 to March 31 each year, for coverage effective July 1 (with an increased premium if the late enrollment penalty applies).
Medicare Advantage eligibility
Your eligibility for Medicare Advantage is determined by some of the same criteria that apply to Original Medicare. To be eligible, you must:
- Be at least 65 or – if you’re not yet 65 – you’ll have to prove that you’ve received Social Security benefits or Railroad Retirement Board benefits for at least two years.
- Disclose whether you have have end-stage renal disease. If you have ERSD, you usually can’t join a Medicare Advantage Plan, but definitely do your research, as you may be eligible under special circumstances. (You may, for instance be eligible if you’ve had a successful kidney transplant.)
- Live in an area that offers Medicare Advantage plans.
- Confirm that you’re a U.S. citizen or permanent resident – or that you’re a legally admitted non-citizen who has lived here for at least five years.
- Prove that you’ve paid FICA taxes for 10 or more years.
Medicare Part D eligibility
To be eligible for Medicare Part D prescription drug coverage, you must be entitled to Medicare Part A benefits and/or enrolled in Medicare Part B. You must also live within your Part D plan’s service area and you must not be enrolled in more than one Part D plan.
If you’re enrolled in a private fee-for-service (PFFS) Medicare Advantage plan that doesn’t include prescription drug coverage, you can enroll in a stand-alone prescription drug plan, but with most types of Medicare Advantage coverage, separate stand-alone prescription drug coverage is not permitted (and not usually necessary, since most Medicare Advantage plans include prescription coverage).
Like Part B, you are still eligible for Part D prescription drug coverage if you don’t enroll when you’re first eligible, but you may pay higher premiums if you enroll later on.
If you’re enrolled in both Medicare Part A and Part B, you’re eligible to purchase a Medigap policy. The primary factor that will affect your ability to purchase the policy – regardless of your health – will be whether you enroll during your Medigap Open Enrollment Period.
If you don’t enroll during the six months that starts with the month you turn 65, carriers are allowed to use your medical history to determine eligibility for coverage and to set your premium if you apply for coverage later on.