Who Is Eligible For Medicare?

More than 18 percent of Americans depend on Medicare for their health coverage. Here is a direct guide to Medicare eligibility.

For more than 55 years, Medicare has given health insurance to Americans who are 65 years old and more, as well as to individuals with disabilities. However, qualifying for the program is not automatic. So, who is eligible for Medicare? Here is how you can find out if you are.

Who is eligible for Medicare?

What qualifies you to receive Medicare? Typically, Medicare is available for individuals who are 65 years old or more, younger people with disabilities and individuals with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). Medicare includes two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). You will be qualified for premium-free Part A if you are 65 years old or more and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without paying premiums if you:

  • are getting retirement benefits from Social Security or the Railroad Retirement Board.
  • are qualified to get Social Security or Railroad benefits but have not yet filed for them.
  • or your spouse had Medicare-covered government employment.

You can find your expected premium and whether or not you are qualified, through the Medicare.gov eligibility tool.

If you (or your husband/wife) did not pay Medicare taxes while you were working, and you are 65 years old or more, along with being a citizen or a permanent resident of the United States, you might be able to purchase Part A. However, if you are under 65 years old, you can get Part A without paying premiums if you:

  • are a kidney dialysis or kidney transplant patient.
  • have been receiving Social Security or Railroad disability benefits for 2 years. (If you have ALS, your Medicare benefits begin the first month you get disability benefits.)

While most individuals do not need to pay a premium for Part A, each person has to pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not receive any of these payments, Medicare will send you a bill for your Part B premium every 3 months.

Medicare Eligibility for Part C (Medicare Advantage)

You are qualified for Medicare Advantage (also known as Medicare Part C) if:

  • The plan you want to join is available in your area.
  • You are signed up for Medicare Part A and Part B.
  • You do not have end-stage renal disease (ESRD).

Private insurance companies handle Medicare Advantage plans, therefore, premiums and coverage vary from one plan to another.

Medicare Eligibility for Part D

To be qualified for Medicare Part D (drug coverage) you need to first be signed up for Medicare Part A and/or Part B. You will not be qualified for a Part D drug plan if you are enrolled in Medicare Part C. Private insurance companies manage Medicare Part D plans, so premium prices and covered drugs will vary from one plan to another. You should sign up for a Medicare Part D plan when you are first eligible for Medicare, or you would have to pay a late enrollment penalty.

Medicare eligibility age

Medicare Eligibility for People 65 or Older

When Can I Start Receiving Medicare Part A Benefits?

You can start getting Medicare Part A (hospital insurance) benefits with no premium when you are 65 years old or more, if you or your husband/wife worked and paid Medicare taxes for at least 10 years. You will know you are qualified for premium-free Medicare A if you:

  • are a citizen of the United States or a permanent legal resident who has lived in the U.S. for at least five years
  • are getting Social Security Benefits or have worked long enough to be qualified for those advantages but are not yet collecting them.
  • currently get or are qualified for Railroad Retirement Board (RRB) benefits but are not yet collecting them.
  • or your husband/wife is a government employee or retiree who has not paid into Social Security but has paid Medicare payroll taxes while working.

If you were getting Social Security or RRB benefits at least four months before you turned 65, you will automatically be enrolled in Medicare Part A. If not, you will be required to file an application with the Social Security Administration.

When Can I Start Receiving Medicare Part B Benefits?

You can decide to buy Medicare Part B benefits in case you are qualified for Medicare Part A. It is a voluntary program for which you would have to pay monthly premiums. For 2020, the standard premium was $144.60 (or higher relying upon your pay). In the event that you do not enroll in Part B when you are first qualified, you might need to pay a late enrollment penalty for as long as you have Part B coverage. On the off chance that you got Social Security or RRB benefits at least four months before turning 65, you will automatically get Part B coverage (except if you live in Puerto Rico). You will be given a choice if you need to keep or deny enrollment. If you choose to refuse enrollment, you can re-enroll during a valid enrollment period, however you would have to pay a late enrollment penalty for as long as you have the coverage.

Can I Get Medicare If I Never Worked?

You can receive Medicare coverage even if you have never worked, however, you will be required to pay a premium for Medicare Part A. If you are a citizen of the United States, 65 years old or more, and you or your spouse have not paid Medicare taxes for at least 10 years, you might be qualified to purchase Medicare Part A health insurance. In 2020, senior citizens who did not get premium-free Part A coverage paid $458 per month. This was if they had paid Medicare taxes for less than 30 quarters (7 ½ years). The ones who paid Medicare taxes for 30 to 39 quarters paid $252 per month. You will not be signed up automatically, so you will be required to file an application with the Social Security Administration. You can then sign up for Medicare Part A and Part B for a monthly premium during a legitimate Medicare enrollment period. Keep in mind that you will not be able to buy Part A alone.

Medicare Eligibility for People Under 65

You are qualified for Medicare when you are less than 65 years old if you:

  • end-stage renal disease (ESRD)
  • have been entitled to Social Security disability benefits for at least 2 years (that need not be consecutive)
  • have Lou Gehrig’s disease, also known as amyotrophic lateral sclerosis (ALS), which will immediately make you eligible
  • have permanent kidney failure for which you need regular dialysis or a kidney transplant — and you or your husband/wife have paid Social Security taxes for a certain period, based on your age.
  • receive a disability pension from the Railroad Retirement Board and meet specific requirements

How to Get Medicare Part A and Part B Coverage

  • If you have been getting SSDI for 2 years, you will be automatically enrolled in Medicare Parts A and B at the start of the 25th month.
  • If you have ALS, you will automatically be enrolled in Medicare Parts A and B when you get the first month of SSDI benefits.
  • If you have ESRD, you need to sign up for Medicare benefits. Medicare eligibility is based on various factors, such as whether or not you are getting dialysis, have had a kidney transplant, and/or have paid Medicare taxes sufficiently.

Who qualifies for early Medicare?

A person can be eligible for Medicare insurance when they are 65 years old if they have one of the following conditions:

  • a disability that a doctor can confirm in writing
  • ESRD
  • ALS

In these situations, an individual may be able to get Medicare Part A without paying a premium. Part A covers in-hospital treatment and long-term skilled nursing care. They may also be able to get Medicare Part B, which pays for medical treatment and consultations, such as doctor’s visits and physical therapy sessions. Nevertheless, they will have to pay a monthly premium unless they receive help from their state’s insurance assistance program.

Social Security, disability, and Medicare

An individual may have a disability that limits their ability to work. Such people are usually eligible for receiving Social Security (SSA) or Railroad Retirement Board (RRB) benefits. When a person has been getting these benefits for 2 years, they can start a Medicare plan, despite being less than 65 years old.

If somebody has a disability, they may find it hard to get health insurance. This is because private insurers might charge them higher premiums due to pre-existing medical conditions. Medicare provides a more cost-effective inclusion for people with disabilities. Examples of disabilities that can make a individual eligible for Social Security or RRB benefits include:

  • back injuries and other musculoskeletal issues
  • bleeding disorders
  • cancer
  • heart conditions, including congestive heart failure
  • mental health disorders, like depression
  • sensory issues, like loss of vision
  • speech disorders
  • severe respiratory illnesses, like COPD

If children who are less than 18 years old want to claim disability benefits or enroll in Medicare, they would have to pass a certain Medicare criteria. The SSA does not cover disability benefits for a young person until they are 18 years old. For this reason, a person with a disability is not eligible for Medicare until they are 20 years old. However, people who are 18 years old and have ALS qualify for Medicare benefits as soon as they reach this age.

Eligibility for people with ESRD

End-stage renal disease (ESRD) is the last stage of chronic kidney disease and implies that a person’s kidneys are not functioning. Consequently, during waste removal, the kidneys are unable to filter fluids and electrolytes. A person suffering from ESRD produces very little urine, if any. Therefore, the waste that the body usually removes will accumulate in the body. This can become deadly if not treated property. However, an individual can get dialysis treatments to act as an artificial kidney system and remove waste from the body. Some people suffering from ESRD may require a kidney transplant.

Those with ESRD can be eligible for Medicare if they meet the following requirements:

  • They have ESRD, and their kidneys are not functioning anymore.
  • They need dialysis or have had a kidney transplant.

They also need to meet the following requirements:

  • They have been working for at least 40 quarters, in which they paid Medicare taxes.
  • They are qualified for or currently receive Social Security or RRB benefits.
  • They are the husband/wife or dependent child of an individual who meets the Medicare qualification requirements.

Benefits that come along with Medicare do not often start immediately, even if the person has ESRD and receives dialysis. Most people who have ESRD, Medicare coverage begins in the fourth month of dialysis. However, if a person takes part in a home dialysis training program to conduct their own dialysis with assistance from a healthcare professional, they can start getting Medicare benefits together with ESRD treatment. Nevertheless, not all people with ESRD are eligible for at-home dialysis.

Eligibility for people with ALS

ALS is a progressive, neurodegenerative disorder that affects a person’s ability to speak, move, eat, and eventually breathe. Unfortunately, this condition has no cure and can ultimately lead to death. Individuals who suffer from ALS, or Lou Gehrig’s disease, are eligible for Medicare when they are under 65 years old. As per the ALS Association, an estimated 16,000 people in the United States have the disorder. A doctor usually diagnoses ALS when a person is between 40–70 years old. Contrary to ESRD, those with ALS can get Medicare Part A benefits during their first month of getting Social Security or RRB benefits.

The SSA automatically signs a person up with ALS in a Medicare plan when they begin paying Social Security benefits. As per a 2017 review in Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, a person’s monthly expenses with ALS under Medicare can sum up to $10,398 during the month of their diagnosis. ALS usually develops rapidly and results in high healthcare expenses. This is the reason why a person’s Medicare benefits will usually begin as soon as possible.

Are all seniors eligible for Medicare?

Almost all Americans aged 65 or more are qualified for Medicare, and most of them are eligible for Medicare Part A (hospital insurance) with no premiums. Although three-quarters of Medicare beneficiaries are happy with their coverage, not all in this age group want to receive Medicare.

What is the maximum income to qualify for Medicare?

Let us first take a look at the Medicare premiums you would have to pay.

Medicare Part A premiums

The vast majority will pay nothing for Medicare Part A. Your Part A coverage is free insofar as you are qualified for Social Security or Railroad Retirement Board benefits. You can likewise get premium-free Part A coverage regardless of whether you are not prepared to get Social Security retirement benefits yet. Therefore, if you are 65 years of age and are not prepared to retire, you can in any case take advantage of Medicare coverage. Part A has a yearly deductible. In 2021, the deductible is $1,484. You will have to spend this sum before your Part A coverage dominates.

Medicare Part B premiums

For Part B coverage, you will pay a premium every year. A lot of people will pay the standard premium sum. In 2021, the standard premium is $148.50. Nonetheless, in the event that you make more than the preset income limits, you will pay more for your premium. The additional premium sum is known as an income-related monthly adjustment amount (IRMAA). The Social Security Administration (SSA) decides your IRMAA depending on the gross income on your tax return. Medicare utilizes your tax return from 2 years ago. For instance, when you apply for Medicare coverage for 2021, the IRS will give Medicare with your pay from your 2019 tax return. You might pay more based on your income. In 2021, higher premium sums start when people make more than $88,000 each year, and it goes up from that point. You will get an IRMAA letter via the mail from SSA if it is determined, you need to pay a higher premium.

Medicare Part D premiums

Medicare Part D is prescription drug coverage. Part D plans have their own different premiums. The national base beneficiary premium sum for Medicare Part D in 2021 is $33.06, however costs can vary. Your Part D Premium will rely upon the plan you pick. Similar to your Part B coverage, you will pay an increased expense on the off chance that you make more than the preset pay level. In 2021, if your pay is more than $88,000 each year, you will pay an IRMAA of $12.30 every month on top of the expense of your Part D premium. IRMAA sums go up from that point at higher levels of pay. This implies that in the event that you make $95,000 each year, and you select a Part D plan with a monthly premium of $36, your complete monthly cost will really be $48.30.

You can get Medicare coverage regardless of your income. Keep in mind that:

  • When you hit specific income levels, you will be required to pay higher premium costs.
  • If your pay is more than $88,000, you will get an IRMAA and pay extra expenses for Part B and Part D coverage.
  • You can request for an IRMAA if your circumstances change.
  • If you are in a lower income bracket, you can get assistance in paying for Medicare.
  • You can enroll through your state’s Medicaid office for special programs and Medicare assistance.

Most people will pay the standard sum for their Medicare Part B premium. However, you will owe an IRMAA if you make more than $88,000 in a given year. For Part D, you will pay the premium for the plan you choose. Based on your income, you will also pay an extra amount to Medicare.

There are various brackets for married couples who file taxes separately. If you file in this manner, you will pay the following amounts for Part B:

  • $148.50 per month if you make $88,000 or less
  • $475.20 per month if you make more than $88,000 and less than $412,000
  • $504.90 per month if you make $412,000 or more

Your Part B premium expenses will be directly eliminated from your Social Security or Railroad Retirement Board benefits. If you do not receive either benefit, you will get a bill from Medicare every 3 months.

Similar to Part B, there are various brackets for married couples who file separately. In this case, you will pay the following premiums for Part D:

  • only the plan premium if you make $88,000 or less
  • your plan premium plus $70.70 if you make more than $88,000 and less than $412,000
  • your plan premium plus $77.10 if you make $412,000 or more

$500,000 is the maximum income for you to be qualified for Medicare, while $88,000 is the minimum.

How can I appeal for an IRMAA?

You can request for your IRMAA if you think that it is wrong or if you have had a significant change in life circumstances. You will be required to get in touch with Social Security to request a reconsideration. You can request an appeal if:

  • the information sent by the IRS was incorrect or old
  • you amended your tax return and think that the SSA received the wrong version

You can also request an appeal if you have had a significant change to your financial circumstances, including:

  • death of a spouse
  • divorce
  • marriage
  • loss of income from another source
  • loss or reduction of pension
  • retiring or losing your job
  • working fewer hours

For instance, if you started work in 2019 and made $120,000, but you retired in 2020 and are currently only making $65,000 from benefits, you could request your IRMAA. You can fill out the Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event form and give supporting documentation about changes in your income.

Medicare savings programs

People who have a limited income can get assistance when it comes to covering the expenses for original Medicare and Part D. Medicare savings programs are present to help pay premiums, deductibles, coinsurance, and other expenses. There are four kinds of Medicare savings programs. They are as follows:

Qualified Medicare Beneficiary (QMB) program

You can be eligible for the QMB program if your monthly income is less than $1,084 and your total assets are less than $7,860. For people who are married, the monthly threshold is less than $1,457 and the total threshold is less than $11,800. You will not be liable for the expenses of premiums, deductibles, copayments, or coinsurance amounts under a QMB plan.

Specified Low-Income Medicare Beneficiary (SLMB) program

In case you earn less than $1,296 a month and have less than $7,860 in assets, you can be eligible for SLMB. Couples who are married should earn less than $1,744 and have less than $11,800 in resources in order to be eligible. Your Part B premiums are covered by this program.

Qualifying Individual (QI) program

The QI program also pays for Part B expenses and is run by each state. You will be required to reapply annually. The applications are approved on a first-come, first-served basis. You will not be eligible for the QI program if you have Medicaid. On the other hand, if you earn less than $1,456 monthly or a joint monthly earning is less than $1,960, you are qualified to apply for the QI program. If you are filing individually, you will need to have less than $7,860 in assets. However, married couples need to have less than $11,800 in assets. Income thresholds are higher in Alaska and Hawaii for all programs. Moreover, if your pay is from employment and benefits, you could be eligible for these programs even if you make slightly more than the limit. You can get in touch with your state Medicaid office if you think you might be qualified.

Qualifying Individual (QDWI) program

The QDWI program assists in covering the Medicare Part A premium for specific people who are under 65 years old and are not eligible to qualify for premium-free Part A. You need to meet the following income requirements to be able to sign up in your state’s QDWI program:

  • an individual monthly income of $4,339 or less
  • an individual resources limit of $4,000
  • a married couple monthly income of $5,833 or less
  • a married couple resources limit of $6,000

You can also get help in paying for your Part D expenses. This program is called Extra Help through which you can get prescriptions at much lower expenses. In 2021, you will pay a maximum of $3.70 for generics or $9.20 for brand-name medications.

Conclusion

To be qualified for premium Part A, an individual should be 65 years old or more and should be enrolled in Part B. People already getting Social Security or RRB benefits no less than 4 months prior to being qualified for Medicare, and living in the United States (aside from inhabitants of Puerto Rico) are automatically enrolled in both premium-free Part A and Part B. Individuals living in Puerto Rico who are qualified for automatic enrollment are only enrolled in premium-free Part A. People who are not getting a Social Security or RRB benefit are not enrolled automatically. These people should apply by getting in touch with Social Security.

Individuals with ESRD, ALS, and certain disabilities might qualify early for Medicare. Those with ESRD qualify following 2 months of dialysis or after taking a home dialysis training class. Individuals who live with disabilities can apply following 2 years of getting Social Security benefits. However, people with ALS, become qualified for Medicare as soon as they can begin getting Medicare coverage. It is best for people to directly get in touch with Medicare to talk about the eligibility criteria for their conditions.

Sandra Johnson

Sandra Johnson

Sandra Johnson was a few years out of school and took a job as a life insurance agent in California, selling coverage door-to-door for Prudential. The experience taught her about the technical components of insurance and its benefits for individuals and society, as well as the misunderstandings people often have about insurance. She has over ten years’ experience in the insurance industry, having worked as both a Broker and Underwriter, assisting clients across a broad range of industries. At Insurance Noon, Sarah diligently gathers all the required information and curates up pieces to provide meaningful insurance solutions. Her personal value proposition is to demonstrate a genuine interest in always adding value for clients.Her determined approach to guiding clients has turned her into a platinum adviser to multiple insurers.