Signing up for Medicare starts with finding out if you are eligible to join. If you haven’t joined, you’re probably wondering what the requirements are and whether you qualify.
In this article, we’ll go over Medicare eligibility and tell you what you need to know about eligibility for Original Medicare and Medicare Advantage.
The federal government Medicare program offers health insurance coverage to eligible people who live in the U.S.
Once you enroll as a Medicare beneficiary, you can get Original Medicare (government-run), or you can join a Medicare Advantage plan (private health cover).
Both options will provide you with medical insurance. However, Medicare Advantage plans usually have added benefits and more Medicare coverage options.
Medicare Part A is hospital insurance and deals with inpatient or hospital costs. For example, if you are admitted to the hospital because of an illness. Part A is usually free for enrollees who have paid Medicare taxes for at least 40 financial quarters (or ten years).
Medicare Part B relates to outpatient or out of hospital costs. For example, if you go to your doctor because you aren’t feeling well. Part B is voluntary, and there is a monthly premium to enroll in Part B coverage. In 2022, the average monthly premium is $170.10.
Medicare Part C is now known as Medicare Advantage. These are private health insurance plans that cover Part A, B, and D expenses.
Medicare Part D deals with the costs of self-administered prescription drugs. For example, if you have back problems and need drugs for pain, your pills will be a Part D expense.
Most people think that Medicare is only for those over 65s, but that’s not always the case. Medicare is available for certain people who are not 65 or older.
You can become eligible for Original Medicare (Part A hospital insurance) and Part B (general medical insurance) in two ways:
Age: You are 65 or turning 65 in the next three months.
Disease or disability: You are of any age and have ESRD (End-Stage Renal Disease) or ALS (Lou Gehrig’s), or you have been receiving SSDI for 24 months.
Here's a checklist you can use to see if you are eligible for Medicare.
If you answered yes to both questions, you can sign up for Medicare Part A and B. Let’s take a look at eligibility for different Medicare health insurance options.
Finding out if you’re eligible for Medicare benefits can be confusing. Here are the eligibility requirements for different kinds of Medicare coverage.
Original Medicare is the government’s basic Medicare option that covers Part A and Part B expenses.
If you do not suffer from a disability, ESRD, or ALS, you will become eligible to join Original Medicare three months before your 65th birthday.
You can get Medicare at any age if a doctor has diagnosed you with permanent kidney failure, you need regular dialysis, or if you’ve had a kidney transplant, and if one of the following applies to you:
You are getting or eligible for Social Security retirement benefits or Railroad Retirement Board benefits.
You have worked long enough in a Medicare-covered government job.
You are the spouse or dependent child of a person who meets one of the requirements above.
Medicare eligibility for ESRD also depends on treatment.
If you receive dialysis in a treatment facility, you can apply on the first day of the fourth month of your treatment.
If you receive dialysis at home, you can apply for Medicare when you start your treatment.
You can get Medicare benefits as soon as you are diagnosed with ALS and start getting Social Security disability benefits.
You become eligible for Medicare at any age if you have been receiving Social Security disability benefits. There is a 24-month standard waiting period before you become eligible.
SSDI covers many diseases and disabilities. Take a look at the Social Security Agency’s website to find out more.
The same rules and criteria for Original Medicare eligibility apply to:
Medicare Advantage Plans
Medicare Prescription Drug Plans
Medicare Supplemental Insurance Plans
This means if you are eligible for these plans if you are:
A US citizen OR a legal resident (for at least five years)
Over the age of 65, OR you suffer from ESRD or ALS before you turn 65.
People often think that their application to join a private Medicare plan won’t be rejected because they are eligible for Medicare.
However, this isn’t true. Private health insurance providers can reject your application:
If your Medicare coverage can’t be confirmed. For example, if you cannot provide a Medicare approval letter.
If you live outside the plan's service area.
If you apply outside of the standard periods (Your Initial Enrollment Period or the Annual Open Enrollment Period).
If the private Medicare plan you want to join is full and is not accepting new members.
They will also reject your application if you currently have another type of private health insurance. For example, if you have a Medicare Advantage plan you will not be able to purchase a Medicare Supplement Plan or a stand-alone Prescription Drug plan (Part D).
Medicare Advantage (Medicare Part C) plans are offered by private insurance companies and cover Medicare Part A and B expenses. They usually offer dental, vision, and hearing coverage and sometimes cover Part D expenses.
You are eligible for Medicare Advantage if:
You are eligible for Medicare.
You are enrolled in Medicare (Both Medicare Part A and B).
You are not a member of a Medicare Supplement Plan or a Part D (PDP) plan.
If you have another type of Medicare insurance plan, you’ll need to end your contract to be eligible to join a Medicare Advantage plan.
It’s important to know that health insurance providers will not reject your application if you have a disability or chronic illness.
Most private health insurance companies offer specialized health insurance plans, known as SNPs (Special Needs Plans), to help members with certain illnesses and conditions.
To find out more about your different options, look at our Guide to Medicare Advantage.
Medicare Supplement (Medigap) plans help Medicare enrollees pay for additional Medicare costs such as coinsurance and deductibles.
You are eligible for a Medicare Supplement plan if:
You are eligible for Medicare.
You are enrolled in Original Medicare (Both Part A and B).
You are not a member of a Medicare Advantage plan or a Part D plan.
Coinsurance amounts are portions of costs that Medicare beneficiaries have to pay for medical services, tests, and items.
Deductibles are fixed amounts of money that you will have to pay before your medical insurance begins.
However, Medicare Supplement plans in 46 states (except in Connecticut, Maine, Massachusetts, and New York) aren’t required by law to accept your application if you don’t enroll during:
Your Initial Enrollment Period (three months before and three months after your 65th birthday month).
A Special Enrollment Period.
Medicare Supplement Insurance plans can also reject your membership application if you are under the age of 65.
To learn more about this, check out our article on Medicare Supplement Insurance enrollment periods.
Prescription Drug Plans (Part D Plans) are health insurance plans offered by private insurance companies that help pay for prescription drugs.
You are eligible for Part D cover if:
You are eligible for Medicare
You are enrolled in Medicare (Both Part A and B)
You are not a member of a Medicare Advantage plan or a Medicare Supplement Plan
If you’d like to learn more about Medicare prescription drug coverage, we’d recommend you check out our article on Medicare Part D.
You are still eligible for Medicare even if you’ve never worked or paid Medicare taxes.
This also applies to Medicare Part C (Medicare Advantage) and Medicare Part D (Prescription Drug Cover). As long as you can pay for your private health insurance plan, you can get coverage.
However, you may then have to pay a monthly premium for Medicare Part A insurance (which is free for people who pay Medicare taxes for at least 40 quarters (around 10 years)).
|Number of contributions||Standard Part A Premium|
|40 quarters or more||$0.00 per month|
|30 - 39 quarters||$274.00 per month|
|Less than 30 quarters||$499.00 per month|
There are also options available for people who cannot afford to pay for Original Medicare. For example, if you cannot pay your monthly premiums or other Medicare costs, you can apply for a Medicare Savings Program in your state.
You can also apply for Extra Help, Social Security’s financial assistance program for Medicare Part D (Prescription Drug) coverage.
If you have not worked, have ESRD or ALS, or get disability benefits, you may be able to get your Medicare premiums covered by your state or the Social Security Agency.
There are many reasons why a person might not be eligible for Medicare. For example, if you moved to the United States and haven’t been a permanent resident for five years, you will not be able to join Medicare or buy a private Medicare health plan.
In cases like this, you can get private health insurance until you qualify for Medicare. If you need assistance finding private health care plans in your area, send an email to Help@PolicyScout.com or call 1-888-912-2132 to speak with one of our consultants.
Yes, Medicare exclusions are when a person is not allowed to join or rejoin Medicare. However, exclusions are not the same as not being eligible.
If you are excluded from Medicare, you are eligible but cannot legally join the program.
Some reasons for Medicare exclusion include:
Medicare or Medicaid fraud
Felony convictions relating to health care fraud
Felony convictions relating to controlled substances
Convictions for health program-related crimes
Most people will never have to worry about being excluded from Medicare, and there are avenues to get Medicare coverage reinstated.
Our Medicare Hub has the latest information on Medicare and health care options. You’ll be able to find everything you need if you want to find out more about the different Medicare parts, enrollments, costs, and coverage.
If you'd like to discuss the different health coverage options available in your area, reach out to PolicyScout’s experienced consultants.