Health insurance, also known as healthcare coverage, is a type of insurance that covers for a portion, or the entire cost of health services you get, such as doctor’s appointments, hospital stays, and visits to the emergency department. It contributes to the predictability and affordability of your healthcare expenses. It is possible that you will be required to pay multiple different amounts for health insurance:
- In most cases, you will be required to pay a premium, which is a fixed monthly payment to the insurance company.
- It is possible that you will be required to pay a deductible. This is a set sum that you must pay out-of-pocket before your health insurance begins to reimburse you for your medical expenses.
- You and your insurance carrier will normally share the cost of covered healthcare services after you have met your deductible. The majority of the cost is covered by insurance, and the remaining portion is covered by you. The amount you pay is either a copayment, which is a fixed amount, or a coinsurance, which is a variable amount and a percentage of the cost of the service.
Table of Contents
- 1 What is Medicare?
- 2 Medicare eligibility age
- 2.1 Medicare eligibility for those under 65
- 2.2 Medicare eligibility due to a disability
- 2.3 Medicare Eligibility for End-Stage Renal Disease(ESRD)
- 2.4 Medicare eligibility for those 65+
- 2.5 Medicare eligibility for disabled youths
- 2.6 Medicare Part D drug benefit eligibility
- 2.7 Medicare Part B eligibility for those ineligible for premium-free Part A
- 2.8 Medicare eligibility for non-U.S. citizens
- 3 Am I eligible for Medicare Part A?
- 4 Am I eligible for Medicare Part B?
- 5 How do I become eligible for Part C (Medicare Advantage)?
- 6 When can I enroll in Medicare Part D (prescription drug coverage)?
- 7 Who’s eligible for Medigap (Medicare Supplement Plan)?
- 8 Medicare eligibility for providers
- 9 Medicare eligibility phone number
- 10 Bottom line
What is Medicare?
When you are 65 or older, or if you are under 65 and have been receiving Social Security Disability Insurance (SSDI) for a specified period of time, or if you are under 65 and have End-Stage Renal Disease, Medicare is a federal government program that provides health care coverage. The Centers for Medicare & Medicaid Services (CMS) is a government organization that is in charge of the administration of Medicare. The program is partially funded by the Social Security and Medicare taxes that you pay on your earnings, partially by the premiums that people who have Medicare pay, and partially by the federal government’s budget.
Once you have become Medicare-eligible and enrolled, you have the option of receiving your Medicare benefits through Original Medicare, which is a traditional fee-for-service program offered directly by the federal government, or through a Medicare Advantage Plan, which is a type of private insurance offered by companies that have a contract with the federal government (the federal government). Original Medicare consists of the following benefits:
- Part A (coverage for inpatient/hospitalization)
- Part B (outpatient/medical coverage) is a supplemental insurance plan.
Most of the time, if you want Medicare prescription drug coverage (Part D) with Original Medicare, you will have to actively choose and join a stand-alone Medicare private drug plan (PDP).
If you choose to participate in a Medicare Advantage Plan, your Medicare coverage remains intact. This implies that you will continue to be responsible for your monthly Part B fee (and your Part A premium, if you have one). Each Medicare Advantage Plan is required to provide all Part A and Part B services covered by Original Medicare, but each Medicare Advantage Plan may do so under a different set of rules, prices, and restrictions, which may influence the way and when you receive care.
Part D coverage is available through Medicare Advantage Plans as well. Take note that if you have health coverage through a union, current or past employer, or another group when you become eligible for Medicare, you may be automatically enrolled in one of their Medicare Advantage Plans if you meet the eligibility requirements. Keep your current Medicare Advantage Plan, switch to Original Medicare, or enroll in a different Medicare Advantage Plan; however, before making any changes, you should consult with your employer or union.
It is critical to understand your Medicare coverage options and to make an informed decision about your coverage. The way you choose to receive your benefits and from whom you receive them might have an impact on your out-of-pocket payments as well as where you can receive your care.
To give you an example, Original Medicare provides coverage for visits to practically all doctors and hospitals in the United States. Medicare Advantage Plans, on the other hand, are typically subject to network constraints, which means that you will have a more limited choice of doctors and hospitals to choose from. The Medicare Advantage Plans, on the other hand, may be able to provide extra services that are not covered by Original Medicare, such as routine vision or dental treatment.
Difference between Medicare and Medicaid
A distinction between Medicare and Medicaid is that the former is a government-sponsored health insurance program and the latter is not. Medicaid is a federally financed and administered program that works in conjunction with states to provide health insurance to those with low financial resources.
Depending on the state, Medicaid can be made available to people who earn less than a particular amount but meet other requirements (such as being over the age of 65, being disabled, or being pregnant), or it can be made available to everyone who earns less than a certain amount. It’s important to remember that, unlike Medicaid, Medicare eligibility is not based on income. In addition, persons who are eligible for both Medicare and Medicaid are referred to as dual-eligibles because they qualify for both programs.
Everyone who has Medicare is issued an Original Medicare card, which is colored red, white, and blue. If you choose to obtain your coverage through Original Medicare, you will be required to present this card whenever you seek medical attention or services. In the event that you elect to receive your Medicare benefits through a Medicare Advantage Plan, you will continue to get an Original Medicare card, but you will be required to provide your Medicare Advantage Plan card while receiving services. No matter how you obtain your Medicare health coverage, only your Medicare number should be shared with your doctors and other healthcare providers.
Medicare eligibility age
For the vast majority of Americans who are looking forward to receiving Medicare health benefits, being eligible is as simple as turning 65 years old and registering with the Social Security Administration.
Qualification for Original Medicare, Part A, and Part B can be accomplished in a variety of ways. The majority of people become eligible for Medicare when they reach the age of 65 when they become part of the system. However, if you have a disability that qualifies you for Medicare before the age of 65, you may be eligible.
If you’re considering other aspects of Medicare, such as Medicare Part C (Medicare Advantage plans), Medicare Part D (prescription drug coverage), or Medicare Supplement insurance (Medigap), there are additional qualifying requirements that must be met.
However, your ability to obtain Medicare coverage without having to pay a premium – as well as your eligibility for other Medicare plans – is determined by a variety of variables, including your job history and your health status. You may be eligible for Medicare Part A and Part B, Medicare Advantage plans, Medicare prescription medication coverage, and Medigap coverage under the following conditions.
Medicare eligibility for those under 65
When you reach the age of 65, you become eligible for Medicare if you meet the following criteria:
- You have received at least 24 months of Social Security Disability Insurance (SSDI) benefits.
- Alternatively, you have been diagnosed with End-Stage Renal Disease (ESRD) (ESRD)
Medicare eligibility due to a disability
If you have been receiving SSDI benefits for more than 24 months, often known as the two-year waiting period, you may be eligible for Medicare as a result of your disability. The two-year waiting period begins the month you receive your first SSDI payment. At the start of the 25th month, following the receipt of an SSDI check, you will be automatically enrolled in Medicare.
If you receive SSDI as a result of Amyotrophic Lateral Sclerosis or ALS, Medicare coverage begins the month automatically after your SSDI benefits begin. You do not have to wait two years.
Not Medicare, but Social Security determines whether you qualify for SSDI benefits and runs the program that distributes them. It is recommended that you contact your local Social Security Administration (SSA) office for additional information about the Social Security Disability Insurance program.
Railroad employees should contact the Railroad Retirement Board for information on disability annuities and eligibility for Medicare.
Medicare Eligibility for End-Stage Renal Disease(ESRD)
You may be eligible for ESRD Medicare if you have been diagnosed with renal failure and you meet the following criteria:
- Are you on dialysis or have you undergone a kidney transplant?
- You are eligible for SSDI.
- You qualify for Railroad Retirement benefits.
- Alternatively, you, a spouse, or a parent have paid Medicare taxes for a period of time that meets the Social Security Administration’s requirements.
If you are under the age of 65 and have ESRD, the date on which you begin receiving Medicare benefits is determined by your unique circumstances, including when you register for Medicare, whether you receive dialysis at home or in a facility, and if you obtain a kidney transplant. If you qualify for ESRD Medicare, you may enroll in Parts A and B concurrently. Part A is retroactive for up to 12 months but cannot begin prior to the month in which you become eligible for ESRD Medicare.
If you are a railroad employee who has ESRD, you must contact Social Security, not the Railroad Retirement Board, to determine your Medicare eligibility.
Medicare eligibility for those 65+
When you reach the age of 65, you become eligible for Medicare if you meet the following criteria:
- Social Security retirement cash benefits are available to those who receive or qualify for them.
- Alternatively, you now reside in the United States and are one of the following:
- A citizen of the United States,
- or a permanent resident of the United States who has been in the United States for a continuous period of five years previous to applying
If you are currently receiving Social Security retirement benefits or Railroad Retirement benefits at the age of 65, the method by which you enroll will be determined by this factor. Additionally, there are scenarios in which someone may become Medicare-eligible at age 65 but may choose to defer enrollment in Medicare without incurring any future fines, such as if the individual receives qualifying health insurance via his or her workplace.
The amount of money you have to pay toward your Medicare coverage is determined by your job history (i.e., if and how long you have paid Medicare taxes). Everyone is required to pay a monthly payment for their medical insurance coverage (Part B). The majority of Medicare beneficiaries do not have to pay a premium for their hospital insurance (Part A).
Medicare eligibility for disabled youths
If you have a child under the age of 20 who has End-Stage Renal Disease, they will only be eligible for Medicare if they also have End-Stage Renal Disease (ESRD). Additionally, in order to be eligible for Medicare coverage, the kid must meet the following requirements:
- Requires dialysis on a regular basis or a kidney transplant in order to survive.
- In addition, you must have at least one parent who receives or is eligible to receive Social Security retirement payments.
Children over the age of 20 who have been receiving Social Security Disability Insurance (SSDI) benefits for at least two years are eligible to enroll in Medicare (24 months). Your child may be eligible for SSDI benefits, even if they have no prior work experience if they meet the following criteria:
- Began experiencing a handicap before the age of 22.
- Secondly, you must have at least one parent who is a recipient of Social Security retirement payments.
- In addition, they are unmarried.
In the event that your child is 18 years old or younger and does not qualify for Medicare, he or she may be eligible for the Children’s Health Insurance Program in your state (S-CHIP). S-CHIP is a federally funded program for low-income families. If your child is 19 years old or older, he or she may be eligible for Medicaid.
Medicare Part D drug benefit eligibility
In the event that you are qualified for Medicare coverage, you may also be eligible for the Medicare drug benefit program (Part D). To enroll in Medicare Part D, you must first be enrolled in Medicare Part A and/or Part B.
Drug coverage for Medicare beneficiaries is only provided through private health insurance policies. It is recommended that you enroll in a Medicare Part D plan if you are a beneficiary of Medicare Part A and/or Part B and do not have other prescription drug coverage (creditable coverage). This is true even if you are not currently taking any prescription medications. A premium penalty will be imposed if you fail to enroll in Part D for any period of time and then discover that you require medication coverage at a later point.
Generally speaking, if you are enrolled in Medicaid and later become eligible for the Medicare drug benefit, you will be automatically enrolled in a Medicare Part D plan and will not be required to pay a premium for the plan. If you are enrolled in Medicaid and do not wish to receive the Medicare drug benefit, contact the Medicaid office in your area.
If you do not have the qualifying employment history of being eligible for premium-free Part A, you may decide not to pay for hospital insurance because of the expensive monthly payment.
While it is typically recommended to have Part A, you can purchase Medicare Part B (medical insurance) without also purchasing Medicare Part A (hospital insurance) if you meet the following requirements:
- Age 65 and up
- Additionally, a citizen or legal resident of the United States who has resided in the country for a minimum of five years is eligible.
However, keep in mind that if you do not enroll in Part A when you become eligible for Medicare and you are required to pay a premium for Part A, you will only be able to enroll later if you are eligible for a Special Enrollment Period or if you are eligible for Medicare during the general enrollment period.
In order to participate in Medicare, you must pay the Part A fee and enroll in the program; you cannot purchase Part A without enrolling in the program’s Supplemental Insurance Program (Part B). If you are eligible for no premiums for Part A, you have the option of enrolling or not enrolling in Part B.
Finally, state-specific programs are available to assist beneficiaries with low incomes and assets which are not qualified for premium-free Medicare Part A in paying their Medicare premiums and other costs.
The premium for Part A will be paid by some state programs. In addition, some state programs will allow enrollment in premium-free Part A outside of the General Enrollment Period.
Medicare eligibility for non-U.S. citizens
If you are not a citizen of the United States but are lawfully present in the country, you may still be eligible for Medicare benefits, depending on your circumstances.
In particular, if you qualify for or are presently receiving Social Security retirement benefits, Railroad Retirement Benefits (RRB), or Social Security Disability Insurance, you will be eligible for Medicare even if you are not a citizen of the United States. Specifically (SSDI).
If you fall into any of these categories, you will be eligible for premium-free Part A.
You will be required to pay a premium for Part B.
Am I eligible for Medicare Part A?
In general, if you are 65 years old and have lived in the US for five years, you are eligible for Medicare Part A. By the time you reach the age of 65, the government will have automatically enrolled you in Medicare Part A at no cost.
It’s easy to get Medicare if you currently get Social Security or Railroad Retirement. Your Medicare card should arrive in the mail around three months before your 65th birthday or after 25 months of disability if you are qualified for Medicare due to a disability rather than age. Opting out is only worthwhile if you are still employed and have comparable or better coverage via your job or if your spouse is still employed and you are covered under their plan.
Not collecting Social Security or Railroad Retirement benefits, you must enroll in Medicare during a seven-month open enrollment period that encompasses the three months before, during, and following your 65th birthday. You do not need to enroll in Medicare if you currently get Social Security or Railroad Retirement payments. Benefits start the month you turn 65 or the month before if your birthday is on the first of the month. Enrolling in health insurance within three months of turning 65 may delay coverage by three months.
Aside from turning 65, persons can qualify for Medicare if they have a disability, end-stage renal illness, or amyotrophic lateral sclerosis (ALS).
When someone with ESRD starts dialysis for the fourth month or earlier, they are eligible for Medicare coverage. Patients with ALS are eligible for Medicare in the same month they start receiving disability benefits. When diagnosed with AL, there is no longer a five-month waiting period before receiving disability compensation.
Most people don’t have to pay a premium for Medicare Part A. You can acquire Part A coverage without paying a premium if you meet the following criteria:
You must be at least 65 years old and have paid Medicare taxes for ten years, whether married or divorced.
You qualify if you are disabled before turning 65 and you or your spouse have paid Medicare taxes for ten years. After two years of collecting Social Security or Railroad Retirement Board disability benefits, you’ll be eligible for Medicare with no Part A premiums. After two years of earning Social Security or Railroad Retirement Board disability benefits, you’ll be eligible for Medicare (the two-year waiting period does not apply for people with ESRD or ALS). In some circumstances, a disabled child’s Medicare eligibility is determined by their parents’ work history.
If you or your spouse hasn’t paid Medicare (FICA) taxes in ten years, you can still buy Part A coverage, but you’ll have to pay a premium based on your employment history and income. In 2022, if you’ve paid into Medicare (FICA taxes) for less than 7.5 years, your monthly premium will be $499, and $274 if you’ve paid into Medicare (FICA taxes) for 7.5 to 10 years.
Am I eligible for Medicare Part B?
As soon as you’re eligible for Medicare Part A, you’ll also be advised of your eligibility for Part B, which is voluntary and charges a fee to all participants.
To qualify for Part B in 2022, your income must be at least $91,000 (or $182,000 for a married couple; these amounts were updated for inflation starting in 2020; therefore, the determination for 2022 is made based on your tax return from 2020).
Enroll in both Parts A and B. In most situations, your enrollment window lasts seven months, starting three months before your 65th birthday and ending three months after. While you can join in Part B three months after turning 65, it’s advisable to do so early to avoid coverage gaps. Remaining ineligible for Part B may mean waiting until the next general Medicare enrollment session.
If you don’t enroll during your initial window, you won’t lose eligibility for Part B, but your premium will go up 10% each year you’re eligible but don’t enroll. Part B can be postponed if you or your spouse is already covered by a current employer’s plan. The General Enrollment Period (GEP) for Medicare A and B runs from January 1 to March 31 each year, with a late enrollment penalty if applicable.
How do I become eligible for Part C (Medicare Advantage)?
If you qualify for Medicare, you must pick between the government-run Original Medicare and Medicare Advantage. However, more than four in ten are enrolled in Medicare Advantage plans, and enrollment in these plans has risen significantly faster than overall Medicare enrollment.
For Medicare Advantage, you must have both Medicare Part A and Part B, and you can choose a plan during your first enrollment period, which is the seven months after the month you qualify for Medicare.
Most Medicare Advantage plans provide Part D prescription drug coverage; however, the maximum out-of-pocket limitations for Medicare Advantage (up to $7,550) do not include prescription drug costs.
End-stage renal disease (ESRD) patients are eligible for Medicare, but not most Medicare Advantage plans. The 21st Century Cures Act modified this in 2021. By 2021, ESRD patients can choose from the same Medicare Advantage plans as other seniors.
When can I enroll in Medicare Part D (prescription drug coverage)?
Prescription drug coverage under Medicare Part D requires either Medicare Part A or B or both. You can enroll in Medicare Part D at the same time as Parts A and B.
As stated previously, most beneficiaries of Medicare Advantage must also have Part D pharmaceutical coverage (89 percent of all Medicare Advantage plans include Part D coverage in 2022). Some MSA plans, and some PFFS Medicare plans do not cover Part D. If your MSA or PFFS doesn’t offer Part D coverage, you can buy a stand-alone plan to augment it.
Enrolling later may result in higher rates unless you had creditable coverage from another plan during the period in which you delayed Part D enrollment.
Who’s eligible for Medigap (Medicare Supplement Plan)?
Medicare supplemental insurance, also known as Medigap insurance due to the fact that it fills in the gaps in out-of-pocket coverage in Medicare Parts A and B, is acquired from private insurance companies.
Medigap insurance helps to cover the costs of copayments, coinsurance, and deductibles associated with Medicare Part A and Part B.
- You must meet one of the following requirements in order to be eligible for Medigap coverage:
- You must be at least 65 years old.
- The diagnosis of Lou Gehrig’s disease has been diagnosed for you.
- During the previous 24 months, you have been receiving Social Security or Railroad Board disability payments.
A diagnosis of end-stage renal disease, needing regular dialysis or kidney transplantationmust have been made for you before you may apply.
It is not possible to enroll in both a Medicare Advantage plan and a Medigap plan at the same time under Medicare. You have to decide between the two options.
Medicare eligibility for providers
Centers of Medicare and Medicaid Services provides an X12 270/271 Eligibility System (HETS 270/271) for determining eligibility. In order to prepare an accurate Medicare claim, determine Beneficiary liability, or determine eligibility for specific services, the HIPAA Eligibility Transaction System (HETS) is intended to make eligibility data available to Medicare Providers and Suppliers or their authorized billing agents under the HIPAA Privacy and Security Act.
Medicare eligibility phone number
Due to the complexity of Social Security and Medicare eligibility regulations, it is recommended that you contact Social Security at 800-772-1213 for the most up-to-date information about your specific circumstances.
An individual must be 65 years old or older in order to be eligible for premium Part A, and they must also be registered in Part B in order to qualify. People who have been receiving Social Security or Railroad Retirement Board benefits for at least four months prior to becoming eligible for Medicare and who reside in the United States (apart from residents of Puerto Rico) are automatically enrolled in both premium-free Parts A and B of Medicare. Individuals residing in Puerto Rico who are eligible for automatic enrollment are only enrolled in Part A, which is free of premiums. Part B is not free of premiums. People who do not get a Social Security or Railroad Retirement Board benefit are not automatically enrolled. These individuals should submit an application by contacting the Social Security Administration.
Individuals with end-stage renal disease (ESRD), Alzheimer’s disease (ALS), and certain disabilities may be eligible for Medicare at an earlier age. Those with end-stage renal disease (ESRD) qualify after two months of dialysis or after completing a home dialysis training course. Individuals who live with disabilities can apply for Social Security benefits after two years of receiving assistance from the Social Security Administration. People with ALS, on the other hand, become eligible for Medicare as soon as they are able to begin receiving Medicare coverage. Getting in touch with Medicare directly is the best way for people to find out if they meet the qualifying requirements for their conditions.