Who Qualifies for Medicare?

You are automatically eligible for Medicare when you reach 65 years old. Additionally, if you are under 65, you might qualify under specific circumstances, particularly if you have a disability.

Medicare is a federal program that offers important health coverage, ensuring that those who qualify can get the medical care they need, regardless of their age or health status. This program helps cover the cost of hospital visits, doctor appointments and other medical needs.

Medicare eligibility primarily depends on age and specific health conditions. If you are 65 years old or older, you qualify for Medicare. Younger individuals with disabilities, End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) are also eligible. Additionally, you must be a U.S. citizen or a legal resident who has lived in the U.S. for at least five consecutive years.

Medicare is divided into different parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage, an alternative to Original Medicare) and Part D (prescription drug coverage). Each part of Medicare has different eligibility requirements, which helps ensure that participants receive coverage tailored to their medical and financial needs.

Medicare provides the same comprehensive health benefits to those under 65 with disabilities as it does to those over 65.

For more detailed information about your specific situation, especially if you have complex medical or disability conditions, contacting the Social Security Administration directly at 800-772-1213 is recommended.

To qualify for Medicare Part A without paying a premium, you need to have contributed to Medicare taxes through your work. Otherwise, you have to pay a premium to buy Medicare Part A. In any case, it’s important to apply for Medicare Part A as you approach your 65th birthday to ensure coverage when you need it.

You will be eligible for Part A and will not be required to pay any premiums if you:

• Qualify Through Work: If either you or your spouse has contributed to Medicare taxes for a minimum of 10 years, which equals 40 Social Security credits, you are eligible for premium-free Medicare Part A when you turn 65. This applies whether the credits were earned through your own employment or a spouse’s employment.
• Qualify Through Social Security or Railroad Retirement Benefits: You are also eligible for premium-free Part A if you qualify for retirement benefits from Social Security or the Railroad Retirement Board.
• Are a Government Employee: If you are a government employee who paid the Medicare portion of the Federal Insurance Contributions Act (FICA) taxes while working, you are eligible for premium-free Part A, even if you do not qualify for other Social Security benefits.

You need to pay premiums for Part A under the following conditions:

• Less Than 40 Quarters of Medicare Taxes: If you or your spouse didn't work for at least 10 years, you may have to pay every month for Part A. In 2024, the cost is $278 if you've paid into Medicare for 30 to 39 quarters. If you have paid for fewer than 30 quarters, it costs more, about $505.

However, if you continue working and earning credits until reaching the required 40 credits, you can stop paying premiums for Part A once you qualify.

• Low Earnings: If you earned less than $6,920 per year while working, you might need a longer work period to earn enough credits for free Part A.

• Voluntary Enrollment: Individuals 65 or older who do not meet the credit requirements can still enroll in Medicare Part A by paying the premium. This is also linked to enrolling in Medicare Part B, which covers outpatient services.

Medicare Part B, also known as Medical Insurance, provides coverage for preventive services and medically necessary outpatient care. Generally, if you qualify for premium-free Medicare Part A, you are also eligible for Part B. This includes those who are 65 or older, as well as individuals under 65 with certain conditions or disabilities.

If you don’t have premium-free Part A, you can still get Part B by meeting the following conditions:

• You must be at least 65 years old.
• You must be a U.S. resident.
• You must be a U.S. citizen or a permanent resident who has resided in the U.S. continuously for five years before applying.

Enrollment in Medicare Part B is not automatic for everyone. If you are not receiving Social Security or Railroad Retirement Board benefits before you turn 65, you need to sign up for Part B during your Initial Enrollment Period.

Medicare Part B has a monthly premium. In 2024, the standard monthly premium is $174.70, but it can be higher based on your income.

Be sure to enroll in Medicare Part B when you first become eligible to avoid a late enrollment penalty. If you don't sign up during this time, you can also sign up during the General Enrollment Period, which runs from January 1 to March 31 every year. If you sign up during this period, your coverage begins on July 1.

Medicare Part C, or Medicare Advantage, is an alternative to traditional Medicare that often includes extra benefits. To qualify for Medicare Part C, you need to have enrolled in both Medicare Part A and Part B.

Medicare Advantage plans are available based on your specific location — you need to live in the area where the plan is offered. To find out which plans are available in your area, you can visit the official Medicare website or check with individual insurance companies.

When considering a Medicare Advantage plan, check the details of what each plan covers and what it costs. This includes looking at the network of doctors and hospitals to ensure they meet your needs and understanding the costs involved, especially for out-of-network services if you're considering a PPO plan.

If you are enrolled in Medicare Part A or Part B, you qualify for Medicare Part D, which helps cover the cost of prescription drugs. You can choose from two types of plans:

• Stand-alone Part D plans for those with Original Medicare: For those with Original Medicare, enrolling in a stand-alone Medicare Part D plan, also known as Prescription Drug Plans, from a private insurance company can add prescription drug coverage. Choose a plan based on where you live, as availability varies by location. You can find plans in your area by searching on Medicare.gov or checking directly with insurance companies.
• Medicare Advantage (aka Medicare Part C) plans that include drug coverage: If you prefer a Medicare Advantage plan, most of these plans include prescription drug coverage, combining health and drug benefits in one plan. However, if you are enrolled in certain types of Medicare Advantage Plans, like a Private Fee-for-Service (PFFS), Medical Savings Account (MSA), Medicare Cost plan or certain employer-sponsored plans, you might be able to join a stand-alone Part D plan without losing your Medicare Advantage benefits.

When selecting a Medicare Part D plan, whether stand-alone or as part of a Medicare Advantage plan, make sure the plan covers the medications you need. Each plan has a formulary, which impacts your costs and care. It also helps you avoid any gaps in coverage.

To be eligible for a Medigap or Medicare Supplement plan, which helps cover some of the health care costs that Original Medicare doesn't, you need to meet specific criteria. First, you must be enrolled in both Medicare Part A and Part B.

Medigap is designed to supplement your Original Medicare benefits by covering expenses like copayments, deductibles and co-insurance.

Importantly, if you have a Medicare Advantage Plan, you cannot use a Medigap plan. You must switch back to Original Medicare if you want to purchase Medigap. Additionally, Medigap policies are individual plans, meaning you and your spouse would need to buy separate policies if you both want Medigap coverage.