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Medicare Eligibility Guidelines

Medicare Eligibility Guidelines Explained

What is Medicare? Medicare is the government-assisted healthcare program that workers in the United States are able use after they have paid enough money into the Social Security system through labor taxes. People who did not pay enough into the system can still receive Medicare benefits, but they will have to pay a monthly premium for Part A coverage, whereas it would be free to those who paid taxes. Here is a brief overview of the program’s eligibility requirements.

Medicare consists of two parts: Medicare Part A and Medicare Part B.

  • Medicare Part A covers the costs that are associated with going to a hospital and is known as hospital insurance. It will help cover any hospital visits, skilled nursing, nursing home care and hospice. In certain cases, home healthcare will also be covered. Under the Affordable Care Act, having Part A coverage alone is sufficient to meet the minimum standard coverage required by the law.
  • Medicare Part B is known as medical insurance. It will cover any doctor’s visits, tools, supplies and other materials that are judged to be “medically necessary” in order for a person to recover from a medical condition. It also covers preventive care, which includes tests that are designed to help detect the development of certain diseases, any steps that can be taken to prevent these diseases from developing and any research that needs to be done. Medicare Part B is the part of the Medicare that helps cover the costs of any treatments needed to mitigate the symptoms of mental illness, including psychoactive drugs, inpatient treatment, outpatient treatment and partial hospitalization programs.

What if a person is over 65?

The easiest way to become eligible for Medicare is to be 65 years of age or older. Any U.S. citizen or permanent legal resident (having lived in the U.S. for five years or more) who has turned 65 and also met the work requirements is eligible. The work requirements that need to be met in order for a person or his or her spouse to receive premium-free Part A benefits through Medicare are to earn 40 work credits. This is ordinarily accrued over the course of 10 years of paying payroll taxes through your employer.

Again, if neither the person nor their spouse earned 40 credits, they can still receive Part A coverage, but will have to pay a monthly premium. Government employees and their spouses who are over the age of 65 are also eligible for Medicare benefits if they have been paying Medicare payroll taxes, even if they have not paid into Social Security.

Spouses are able to gain Medicare benefits if their significant other is at least 62 and he or she is at least 65. If a spouse is deceased, his or her survivor might be eligible for the earned benefits on that spouse’s work record.

What if a person is under 65?

There are a few different requirements that a person must meet in order to be considered eligible for Medicare benefits if they are under the age of 65.

The first is if he or she has been eligible for and is receiving benefits from the Social Security Administration for at least 24 months. These months do not have to be consecutive. A person is able to receive Medicare benefits the month that he or she receives his or her 25th Social Security check. A person will then receive his or her Medicare card three months after receiving that 25th Social Security benefit check.

Those who have received pensions from the disability fund of the Railroad Retirement Board are also eligible. A person who is under the age of 65 is eligible for Medicare benefits due to receiving benefits from the Social Security Administration or the Railroad Retirement Board  In addition, they may qualify for Medicare benefits if they have one of the following conditions:

  • Lou Gehrig’s disease: If a person has Lou Gehrig’s disease, also known as amyotrophic lateral sclerosis (ALS), then he or she is automatically qualified for Medicare benefits. He or she will receive these benefits the first month that he or she receives a Social Security check (which he or she is also automatically enrolled in).
  • Permanent kidney failure (End-Stage-Renal Disease): A person qualifies for Medicare if he or she has permanent kidney failure and is either receiving frequent dialysis treatment or has had a kidney transplant. A person with this problem must have applied for Medicare benefits retroactively for up to 12 months. If a person who has gone through this process is considered eligible for Social Security benefits or Railroad Retirement benefits due to work history, then he or she will also be considered eligible for Medicare.

Medicare eligibility requirements

The federal department that manages Medicare is called the Centers for Medicare & Medicaid Services (CMS). CMS has tasked the Social Security Administration with the responsibility of managing enrollment into the Medicare program. A person who is eligible for Medicare can apply for Medicare: online; fill out a paper application and mail it in; or, travel to his or her local Social Security Administration office to fill out the application.

If a person is over the age of 65 and has earned 40 credits, it is likely that the Social Security Administration will automatically enroll the person in Medicare Part A. Again, this is free because they earned 40 credits. If this happens, the person will automatically receive their Medicare card in the mail before their 65th birthday. They will then have the responsibility of enrolling in Part B and Part D (prescription drug coverage), if they so wish.

If eligible due to age, the person is first allowed to submit an application for benefits when they are 64 years and 9 months old; in other words, three months before their 65th birthday. It is important to apply three months before becoming fully eligible because otherwise, the process that is needed to get the card will be delayed. The deadline to enroll is three months after the person turns 65.

Even if a person will still be receiving insurance benefits from his or her job, and they have already earned 40 credits, it is recommended that he or she fill out the application and at least enroll in Medicare Part A. The application should have a place to indicate that they are still receiving healthcare through their employer. There are strict deadlines of when to apply for Medicare and penalties for not enrolling in time. But receiving healthcare through your employer after you first become eligible for Medicare benefits will create a Special Enrollment Period (SEP). This means that the Medicare system will allow you to enroll in benefits, without penalty, for a certain period of time after you either stop working or stop receiving healthcare coverage through your employer.

Applying online is a much faster process. It allows an applicant to: have his or her application reviewed quickly; to submit any other necessary documents; and have his or her questions answered throughout the entire process. Ordinarily, a physical letter will be mailed to the applicant with that person’s decision regarding benefits.

What if a person is not eligible for Medicare, but is retired?

A person may not be eligible for Medicare due to age or disability, but has already retired and is no longer receiving health insurance through their employer. In that case, he or she must comply with the Affordable Care Act and get health insurance from the Federal Marketplace, the state exchange or a private marketplace.

Additionally, under the Affordable Care Act, every American is required to have health insurance. Enrolling in a plan through the health insurance Marketplace until eligible for Medicare benefits will ensure that the person will not be penalized with a tax for not being insured under the law.
More information about becoming eligible for Medicare and determining if a person has met that eligibility can be found at the Medicare website, which is here.