Medicare Eligibility: Who Qualifies for Medicare?

Read our Advertiser Disclosure.
Contributor, Benzinga
July 31, 2023
verified by Jesse Slome

Medicare is a federal health insurance program in the United States that provides essential coverage for millions of Americans. Understanding Medicare eligibility is crucial for individuals who are seeking healthcare coverage.  

In this blog post, we will delve into the topic of Medicare eligibility, answering the question, "Who qualifies for Medicare?" Read on to discover the different criteria and enrollment options available.

Medicare Eligibility Requirements

To determine if you qualify for Medicare, you need to meet specific eligibility requirements. The program primarily serves individuals who fall into the following categories:

  • Age-Based Eligibility:
    • You are 65 years or older.
    • You are a U.S. citizen or a permanent legal resident who has resided in the country for at least five continuous years.
  • Disability-Based Eligibility:
    • You are under 65 years old.
    • You have received Social Security Disability Insurance (SSDI) for at least 24 months.
    • You have certain qualifying medical conditions, such as end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).

Medicare Enrollment Periods

Once you determine your eligibility for Medicare, you need to be aware of the different enrollment options available. These options include:

Initial Enrollment Period (IEP):

  • Your IEP is the 7-month period that starts three months before your 65th birthday month and ends three months after the month of your 65th birthday.
  • It is recommended to enroll during the initial enrollment period to avoid late enrollment penalties unless you have a qualifying exception (such as employer-provided coverage in place).

Special Enrollment Period (SEP):

  • SEPs are available for individuals who delay enrolling in Medicare due to having creditable health coverage through an employer/union or for other special life events that may trigger a requirement for change.
  • You can enroll without penalty during SEP when the creditable coverage ends.

General Enrollment Period (GEP):

  • If you missed your IEP, GEP is the next earliest opportunity for you to enroll in Medicare 
  • GEP is from January 1 to March 31 each year.  Late enrollment penalties (for not enrolling during your IEP) may apply if you enroll during GEP, and you were not eligible for a special enrollment period.

Medicare Coverage Options

Medicare consists of different parts, each providing specific coverage. Here's an overview of the primary parts:

Medicare Part A (Hospital Insurance):

  • Covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services.
  • Most people receive Part A without paying a premium if they or their spouse paid Medicare taxes while working.  Deductibles, copays and coinsurances are applicable.

Medicare Part B (Medical Insurance):

  • Covers doctor's visits, outpatient care, preventive services, and medical supplies.
  • Part B requires payment of a monthly premium, which can vary based on your income.  You typically also pay 20% of the cost of health services.
  • Collectively the default government Part A and Part B are referred to as ‘Original Medicare’

Medicare Part C (Medicare Advantage):

  • Offered by private insurance companies approved by Medicare as an ‘alternate’ to Original Medicare.
  • Provides the same coverage as Part A and Part B, and often includes prescription drug coverage (Part D) and additional benefits not covered by Original Medicare such as dental, vision and hearing.

Medicare Part D (Prescription Drug Coverage):

  • Helps cover the cost of prescription medications.
  • Offered through private insurance companies approved by Medicare.

Compare Medicare Advantage Plans

If you’re eligible for Medicare and like the idea of bundled health insurance, then a Medicare Advantage plan is the way to go. The next step is choosing the best Medicare Advantage plan. Benzinga has assembled a list of trusted companies just right for you.

Conclusion

Understanding Medicare eligibility is vital to ensure you receive the healthcare coverage you need as you age or face specific medical conditions. By meeting the age or disability requirements and enrolling in the appropriate enrollment period, you can gain access to Medicare's comprehensive coverage options, including hospital care, medical services, and prescription drugs. Be sure to explore the different parts of Medicare and choose the coverage that best suits your needs. Don't wait—start planning for your Medicare enrollment today!

Frequently Asked Questions

Q

Can I get Medicare at 55?

A

The age to start receiving Medicare is 65, not 55. There are, however, exceptions, like if you’re disabled, or you have end stage renal disease or amyotrophic lateral sclerosis. If you qualify for SSDI, you’re eligible for Medicare after 24 months. You don’t have to check to see if you qualify — Social Security will enroll you automatically. You’ll receive Parts A and B, and your premiums for Part B will get deducted from your disability check — no matter what your age. SSDI is not based on age, so if you qualify you’ll receive Medicare whether you’re 65, 55, or younger.

 

Q

What qualifies you to receive Medicare?

A

If you’ve worked at a job for 10 years or more, or you and your spouse have a combined 10 years working and are U.S. citizens or permanent residents, you qualify for Medicare. There are other qualifications as well.

 

Q

What is the limit of income for Medicare for joint filers?

A

You must make below $182,000 to qualify for Medicare as joint filers.