Trying to learn the ins and outs of Medicare doesn’t have to be overwhelming. This guide will lay out who is eligible for Medicare, available options, and how to get the coverage you need.
Qualifications for Medicare
To qualify for Medicare, you must fit specific criteria. You are eligible if:
- You are aged 65 years or older and have begun collecting retirement benefits.
You may also enroll if you are younger than 65 and:
- You have been receiving social security disability benefits for 24 months.
- Have end-stage renal disease (ESRD).
- Have Lou Gehrig’s disease (ALS).
Age-Based Eligibility for Medicare
You can enroll in Medicare anytime three months before your 65th birthday, the month you turn 65, and three months after your 65th birthday.
If your birthday is in May, you may enroll in the months of February, March, April, May, June, July, and August. This time period is known as your Initial Enrollment Period.
If you worked but did not contribute social security payments you may still purchase Part A health insurance, but you will be required to pay a premium. Remember: It’s the Social Security Administration, not Medicare, that determines your eligibility.
Whoever qualifies for free Medicare Part A, premium-free, requires a minimum of 10 years or 30 quarters worked by you or your spouse while paying into social security.
Disability-Based Eligibility for Medicare
Disability: If you’ve received social security disability benefits for 24 months, you’re automatically eligible for Medicare.
ALS: If you’re diagnosed with ALS, you are eligible in the first month of your diagnosis with no waiting period.
ESRD: Those diagnosed with ESRD are eligible for premium-free Part A if they receive dialysis treatments or qualify for a kidney transplant and meet one of the following criteria:
- Have worked 10 years or 30 quarters while paying into social security.
- Are receiving or eligible to receive social security benefits.
- Are the spouse or dependent child of a person who either worked 10 years or 30 quarters while paying into social security or is receiving social security benefits.
For those in this category, Part A coverage begins:
- The third months after regular dialysis treatments begin; or
- The first month of regular dialysis treatments with self-dialysis training; or
- The month of their kidney transplant; or
- Two months before the month of scheduled transplant, if you are hospitalized during the months prior in preparation for the transplant.
Your Medicare Coverage
To ensure adequate healthcare coverage, it’s important to learn what parts of Medicare you need. Medicare is broken down into four parts: Part A, B, C, and D.
Part A: Covers costs related to hospital stays and typically has no premium.
Part B: Covers costs related to doctor visits and carries a monthly premium.
Part C: Combination of Part A, B, and D, and carries a separate monthly premium in addition to Part B monthly premium.
Part D: Covers costs related to prescription drugs and carries a monthly premium.
Here’s a closer look at what each part covers.
|Part A||Inpatient hospital coverage||Might have premium|
|Part B||Outpatient care
Home health services
|Will have premium +
Medicare pays 80%
You pay 20% of everything else
No cap or maximum
|Part C||Inpatient hospital coverage
Prescription drug coverage
|Will have premium
|Part D||Drug coverage||% deductible varies|
* Not all Medicare Part C Plans cover these items.
Medicare Parts – Optional Or Required?
Not all parts of Medicare are automatically applied to a Medicare enrollee. Knowing which parts are automatic and which need to be chosen will help you make the right decisions when the time comes.
- Part A is automatic and everyone eligible is enrolled.
- Part B is optional but necessary to deflect the high cost of doctor visits and lab tests.
- Part C, also known as Medicare Advantage, offers the most coverage, providing coverage for A, B, and D, while potentially covering other options such as dental and vision.
- Part D is optional but highly recommended to cover prescription drug coverage.
Reference the chart above for an estimate of fees and charges associated with each part of Medicare.
Timely Medicare Enrollment
It’s important to enroll in Medicare as soon as you become eligible. When enrolling in Part A, you will need to decide whether you will opt into Part B and D, or choose Part C. Timely enrollment is crucial to ensure coverage begins when your employee coverage ends. Speaking with a Medicare expert will ensure that you understand all of your coverage options.