Medicare was created in 1965 to help America’s seniors get affordable health insurance. It’s since expanded to include younger people with qualifying disabilities.
Here’s what you need to know about Medicare eligibility, starting with a quick recap on Original Medicare.
Original Medicare
Original Medicare is made up of two parts: Part A (hospital coverage) and Part B (medical coverage).
- Medicare Part A covers inpatient care, like hospital stays, skilled nursing facility care and psychiatric inpatient services. It also covers hospice.
- Medicare Part B covers medically necessary outpatient care. This includes routine doctor visits, preventive care (e.g., flu shots and cancer screenings), medical devices, and more.
You’ll notice that neither Part A nor Part B covers prescription drugs. Part B will cover a limited set of drugs, such as chemotherapy treatments, but the kind of drugs you get at the pharmacy counter and take yourself — blood pressure pills or insulin, for example — are not covered by Original Medicare.
For these, you would need to add a private plan to your coverage. Your options are a standalone Part D plan, which only covers prescription drugs, or a Medicare Advantage plan with prescription drug coverage.
Medicare eligibility is based on two factors: age and disability.
Eligibility Based on Age
Medicare was originally created for people over the age of 65, making age the most common factor for eligibility.
You’re eligible for Medicare based on age if:
- You’re turning 65 soon and
- You live in the U.S. lawfully (or one of its territories)
You likely also qualify for premium-free Part A if you have enough Social Security work credits (40) by the time you’re eligible for Medicare. Remember that Original Medicare is made up of two parts, A and B.
Nearly everyone pays a premium for Part B, but very few people pay a premium for Part A. That’s because payroll taxes help fund Part A. So if you or your spouse has accumulated 40 work credits by the time you’re eligible for Medicare, you won’t pay a premium for Part A.
- Note: You can check the status of your work credits with Social Security directly. It’s actually a good idea to do this before you’re eligible for Medicare, for accuracy. Visit mySocialSecurity to learn more about creating an account and what you can do with it.
You can still enroll in Medicare when you turn 65 if you don’t have enough work credits. But you’ll probably have to pay a premium for Part A, which changes each year.
Eligibility Based on Disability
Not everyone who has Medicare is 65 or older.
Generally speaking, you can be eligible for Medicare based on disability if you qualify for disability benefits from Social Security or the Railroad Retirement Board.
Important:
- Disability enrollment may be automatic.
Once you’ve been getting disability benefits from Social Security or the Railroad Retirement Board for 24 months, you’ll be automatically enrolled into both Part A and Part B on the 25th month of your disability payments.
- Rules differ for ALS and ESRD.
For people with amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), Medicare enrollment is automatic and starts the same month you start receiving disability benefits.
People with end-stage renal disease (ESRD) qualify for Medicare when they’re diagnosed, even if they aren’t 65. But enrollment is not automatic if you have ESRD. You’ll need to enroll yourself if you want the benefits. To learn more about ESRD qualifications, check out this info from Medicare.gov.
What if I’m still working at age 65?
Medicare eligibility isn’t based on your work status. It’s available to people 65+ and younger people with certain disabilities whether they’re working or not.
If you’re still working when you become eligible for Medicare, you have a couple of options:
- Enroll in Medicare anyway. If you don’t have job-based insurance or another form of coverage, then you may want to enroll in Medicare once you’re eligible since this tends to be a more affordable option for older adults. It might be your only option, too. In fact, it’s actually illegal for someone to sell you a Marketplace plan (a private plan under the Affordable Care Act) if you qualify for Medicare. Waiting to enroll could also mean premium penalties later.
- Wait to enroll in Medicare. If you have job-based insurance (yours or your spouse’s plan that covers you), then you may be able to wait to sign up for Medicare Part B without paying a late enrollment penalty. You may want to enroll in Part A regardless, though, since most people get this portion for free and it doesn’t hurt to have the coverage in place.
If you’re still working when you turn 65, talk to your HR department or contact Social Security directly for more specific guidance about your situation, or check out this page from Medicare.gov.
What if I’m retired but don’t qualify for Medicare?
Remember: Medicare eligibility isn’t based on retirement. It’s based on age and/or disability.
If you retire early, you’ll still need to wait until age 65 to sign up for Medicare if you don’t qualify based on disability.
If you’re retired and need health insurance but don’t qualify for Medicare, you can explore other options. Those might include:
- Retiree benefits from your former job
- Veterans or other military benefits, like TRICARE
- Medicaid
- Short term health insurance
- Private major medical benefits (Affordable Care Act/Marketplace plans)
Major medical benefits are only available during the open enrollment period in the fall, which runs from Nov. 1 through Jan. 15 each year. You can enroll in Medicaid (if you qualify) or short term benefits anytime.
Medicare was created to help older Americans get affordable health insurance. Once you’re eligible, you can choose how to get these benefits, whether it’s through Original Medicare with a Part D plan and/or Medigap, or a comprehensive Medicare Advantage plan. Explore and compare all of your options to find coverage that works for you.