Who Is Eligible for Medicare? | Find Requirements for All Plans

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Who Is Eligible for Medicare?

Figuring out whether you are eligible for Medicare can feel complex—there are several parts, and while many of the basic rules are the same, some of the details differ between the individual plans. That’s where we come in. We’ll break down the basic requirements for all of the different parts, and then go into detail on each one and its specific rules and enrollment regulations to help you understand which Medicare plan you qualify for.

Who is Eligible for Original Medicare?

To be eligible for Original Medicare—Parts A and B—you must be either a US citizen or a permanent resident for at least five years. In addition, you must meet at least one of these conditions:

  • Be age 65 or older
  • Have a disability
  • Have End-Stage Renal Disease (ESRD)

You do not need to meet all three qualifications to be eligible. For example, if you are over 65, you don’t need to have a disability to receive benefits; on the flip side, if you have a disability, you may be eligible for benefits at any age.

Now let’s look at the specifics of Part A and Part B

Who is Eligible for Medicare Part A?

Most people are automatically enrolled in Part A when they turn 65. There won’t be any paperwork to fill out; your card will arrive roughly three months before your 65th birthday. If you (or your current spouse) paid Social Security for at least 40 quarters—that’s 10 years of work—you won’t have to pay a premium for Part A coverage, either. In the event that neither you nor your spouse paid into the program for 40 quarters, you may have to pay a premium for coverage.

If you’re eligible for because of a disability, you’ll be automatically enrolled after you’ve been receiving disability benefits for 24 months. Expect to receive your card three months before the 25th month of your disability benefits. There is one exception to this rule: if you are eligible because you have ALS, (Lou Gehrig’s disease), your benefits begin the first month you receive disability benefits, rather than the 25th.

Some people must manually enroll in Part A. This generally happens if you turn 65 but aren’t receiving Social Security benefits (because you haven’t yet retired) or if you qualify because you have ESRD. In these cases, you must stick to certain enrollment periods: three months before and after your birthday, known as the Initial Enrollment Period (IEP), or the General Enrollment Period (GEP), between January 1 and March 31 every year. You may also have the option to sign up during a Special Enrollment Period (SEP) if you have coverage through an employer-sponsored health plan.1

In the event that you aren’t eligible for premium-free coverage and you miss the IEP, you may have to pay a penalty of a 10% higher premium for a set number of years.2

Who is Eligible for Medicare Part B?

Part B follows the same basic eligibility rules as Part A. If you meet the requirements, you’ll be automatically enrolled three months before you turn 65 or reach your 25th month of disability benefits.

The main difference between Part A and Part B is that Part B includes a monthly premium. This can be deducted from your Social Security benefits each month, or you can request to have a bill sent to you. You may also have to pay a higher premium than the standard, depending on your past yearly income.

As with Part A, there is a late enrollment penalty for Part B. If you aren’t automatically enrolled and you don’t sign up during your IEP, your premium may go up 10% for each full 12-month period that you could have had coverage but didn’t sign up. You pay this penalty as long as you have Part B.3

Who is Eligible for Medicare Part C?

Part C, sometimes known as Medicare Advantage, refers to plans provided by private insurers. An Advantage Plan will bundle your Part A, Part B, and sometimes Part D coverage into a single plan. These plans take the place of your basic coverage.

To be eligible for a plan, you must meet all of the following requirements:

  • Have Part A and Part B (or be newly eligible for them)
  • Live in the area covered by your chosen plan
  • Not have ESRD

Because Part C plans come from private insurers, you must manually enroll in a plan—you won’t be automatically enrolled. You can sign up for an Advantage Plan during the IEP, which is the same as the period for Part A and Part B. There is also an annual Open Enrollment Period from October 15 to December 7, during which you can enroll in new plan or adjust your coverage.4

Learn more about Advantage Plans here.

Who is Eligible for Medicare Part D?

To be eligible for Part D, sometimes called a Prescription Drug Plan, you must meet the standard requirements for Part A and Part B outlined above. You’ll also need to have—or be newly eligible for—Original Medicare.

These plans are provided and administered by private insurers, so enrollment is not automatic. You need to select a plan and enroll yourself during either the IEP or the Part D Open Enrollment Period, which is from October 15 to December 7 each year. If you got your Part B coverage during the General Enrollment Period, you may be eligible to sign up for a Prescription Drug Plan between April 1 and June 30. Note that if you don’t sign up for a Part D plan within 63 days after your IEP ends, you may have to pay a penalty for late enrollment.5

What about Medicaid?

Medicaid is a separate program intended to help people with limited resources and income cover their medical expenses. It is possible to qualify for both Medicare and Medicaid benefits at the same time. This is referred to as being “dual eligible.”

Medicaid covers some things that Medicare does not, such as nursing home care. As a result, people who qualify for both programs are likely to have a good portion of their medical expenses covered. To apply for Medicaid, you must contact your state’s Medicaid program.

If you have more questions around eligibility and enrollment requirements, we can help.  Check out our Eligibility Guide here.


Sources

1 Medicare.gov, “Part A & Part B Sign Up Periods
2 Medicare.gov, “Part A Late Enrollment Penalty
3 Medicare.gov, “Part B Late Enrollment Penalty
4 Medicare.gov, “Joining a Health or Drug Plan
5 Medicare.gov, “Part D Late Enrollment Penalty

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