Medicare Eligibility

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Medicare Eligibility

Are you eligible for Original Medicare (Part A and Part B)? Generally, you’re eligible for Medicare at age 65 if:

  • You’re a U.S. citizen,
    OR
  • You’re a legal permanent resident (green card holder) and you’ve lived in the United States for at least five years in a row prior to applying for Medicare.

You can also qualify for Original Medicare if you:

  •  You’re younger than age 65 and receiving Social Security or certain Railroad Retirement Board Disability benefits for at least two years.
  •  You’ve been diagnosed at any age with Lou Gehrig’s Disease, also called Amyotrophic Lateral Sclerosis (ALS), and received Social Security Disability.
  • You’ve been diagnosed at any age with End Stage Renal Disease, also known as ESRD, have been on dialysis for at least three months, or have had a transplant.

Part A is known as Original Medicare, and it covers hospital expenses, skilled nursing, limited home care and hospice.

Eligibility for Medicare Part A requires you or your spouse to have legally worked and paid income taxes for at least 40 quarters (10 years) in the United States.

Because you paid taxes (FICA) during your employment, you won’t be required to pay Part A premiums when you’re eligible.

If you haven’t worked the mandatory 10 years to qualify, purchasing Part A is still an option, but you’ll be required to pay for this coverage.

To find out the exact premium that you will have to pay, you will need to contact Social Security.

Part B is also part of Original Medicare. It helps pay for services that are medically necessary like doctor office visits, lab services, outpatient surgery, x-rays and preventative care.

Just like Part A, you’re eligible for Part B at age 65.  This coverage, however, is not free. You’ll pay a monthly premium based on your annual household income.

You may have to pay a penalty if you don’t enroll in Part B within your initial enrollment period.

Medicare Advantage, also referred to as Medicare Part C, offers more coverage than Original Medicare, bundling together Part A and Part B and usually Part D as well.

To be eligible for Medicare Advantage, you must be enrolled first in both Medicare Parts A and B.  You must also live in the plan’s service area.

Medicare Advantage plans are private health plans that are approved by, and have contracts with, Medicare. 

You can choose to enroll in a Medicare Advantage plan if you prefer to get your benefits through a private insurance company instead of Original Medicare.  However, if you enroll in a Medicare Advantage plan, you can’t drop Part B to avoid paying its monthly premium.  You must continue to be actively enrolled in Parts A and B.

With Medicare Part C plans, you generally are required to use providers that are approved by Medicare, and some of these plans include built-in Part D coverage.

Part D Medicare Prescription Drug plans are offered by private health insurance companies that are approved by Medicare. You can obtain drug coverage by a stand-alone Part D (PDP) plan or a Medicare Advantage Plan that includes prescription drug coverage (MAPD).

You must be actively enrolled in either Part A and/or Part B to be eligible to enroll in a Part D plan offering prescription benefits. You also must live in the service area of the plan that you choose.

Medicare Part D is optional but recommended if you have no other drug coverage. Be aware that you can face a penalty if you do not enroll when you are first eligible.

If you’re enrolled in a Medicare Advantage plan with prescription drug coverage, you must be enrolled in Parts A and B, and pay your associated premiums for Part B—including late penalties.

To be eligible for a Medigap/Medicare Supplement policy, you must first be enrolled in Original Medicare (Parts A and B).  The ideal time to enroll in a Medicare Supplement plan is when you become eligible at the age of 65.  During the 6-month enrollment period (that includes your birth month), you can enroll and avoid any late-enrollment penalties. It is also during this time that you can join without medical underwriting.

Note: You can NOT have a Medigap policy if you have one of the following:
• A Medicare Advantage plan (Part C)
• A Medicare Medical Savings Account (MSA) plan

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