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Who Can Get Medicare? An Overview of Requirements

Who Can Get Medicare?

An Overview of Requirements

Many questions surface for people regarding this program: What do you have to do to be eligible for Medicare? When does coverage begin? How can the Medicare program help you manage your healthcare costs?

In this article we will explain in a straightforward way all the requirements to qualify for Medicare, what to do in order to enroll, and how you can go about using the Medicare program to help cover and offset your healthcare costs.

WHAT IS MEDICARE?

Initially, the Medicare program was set up during President Roosevelt’s administration to act as a social safety net for the aging American population and other specific groups that may have a hard time accessing adequate healthcare insurance coverage because of specific medical conditions and disabilities.

Traditionally, all of these groups would have a hard time finding adequate health insurance coverage at a reasonable price in the private insurance sector.

Because of their age, their disabilities, or their illnesses, they are significantly more difficult to insure, and so the Medicare program was established to ease the financial burdens associated with their healthcare costs.

There are specific requirements that you must meet in order to be eligible for Medicare. We will talk about each of these eligibility conditions in detail.

ELIGIBILITY REQUIREMENT #1: AGE 65

Specifically, Medicare was designed to be a government-sponsored form of healthcare insurance for people 65 and older.

When you turn 65, you automatically become eligible for Medicare if you meet either of the following requirements:

You are 65+ and you either receive or qualify to receive Social Security retirement benefits

or

You are 65+, currently live in the United States, and are either a U.S. citizen or you are a permanent U.S. resident who has lived in the United States for five continuous years before applying.

While you are eligible to be covered under the Medicare program if you meet these conditions, keep in mind that your premiums will be based on whether you or your spouse also contributed any Medicare taxes during your career. We will address this in more detail later in the article.

ELIGIBILITY REQUIREMENT #2: SOCIAL SECURITY
DISABILITY INSURANCE (SSDI)

In addition to those over age 65, Medicare is also available for those who qualify to receive Social Security Disability Insurance (SSDI).

It is important to understand that the Social Security administration, and not Medicare, always makes the determination if you are eligible for Social Security Disability Insurance.

Generally, if you have been receiving SSDI checks for more than 24 months, you qualify to receive Medicare due to a disability. This 24-month waiting period begins the first month you receive a SSDI check, and you will be automatically enrolled in Medicare at the beginning of the 25th month of receiving disability checks.

The one exception to this two-year waiting period is for disabilities caused by Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease. For people suffering from ALS, Medicare eligibility automatically begins the first month that your SSDI benefits begin. These citizens do not have any waiting period imposed on their Medicare eligibility or benefits.

ELIGIBILITY REQUIREMENT #3: END-STAGE RENAL DISEASE?

People who are under age 65, can also become eligible for Medicare benefits if they have End-Stage Renal Disease (ESRD), which is permanent kidney failure that requires either dialysis or a kidney transplant.

If a patient has been diagnosed with ESRD and they are receiving dialysis treatments or have received a kidney transplant, they can apply for Medicare benefits.

In these cases, exactly when the Medicare benefits start depends on each patient’s individual circumstances, including whether they receive dialysis at home or at a medical facility, whether or not they get a kidney transplant, and when they apply for Medicare benefits.

WHAT COVERAGE DO YOU QUALIFY FOR?

Now that you know the eligibility requirements for Medicare, we will explain what Medicare covers and how the premiums are determined.

Medicare is divided into parts A-D. Each part covers a different area of healthcare costs. For our discussion on eligibility we will start by focusing on parts A and B, which make up what is known as Original Medicare.

  • Part A (Inpatient/hospital coverage)
  • Part B (Outpatient/medical coverage)

Part A is the portion of Original Medicare that covers hospitalization and inpatient care. It pays for hospital bills and costs related to hospital care including medical care in a skilled nursing facility or nursing home. It will also cover hospice care and home health services.

Any type of inpatient care would fall under the coverage provided by Part A, including inpatient medical supplies and prescription drugs. If you are homebound it will cover physical or occupational therapy, and it also provides for doctors, medication and grief counseling for terminally ill patients.

Medicare Part B covers two things: preventive services and medically necessary outpatient services.Medically necessary services include all the medical care required to diagnose and treat your medical conditions, including doctor visits, lab work, tests, and medical equipment or devices.

Preventive services refer to medical care received in order to prevent illness, like the flu, or healthcare services undergone for early detection, like screenings and routine physicals. Usually, Part B also covers ambulance services, durable medical equipment (DME), outpatient mental health services, second opinions on medical advice, and even a very limited amount of prescription drugs.

If either you or your spouse worked and paid Medicare payroll taxes for at least ten years, then when you are eligible to receive Medicare Part A without paying any premiums. (If you did not pay Medicare taxes, you may still be able to purchase Part A, given that you meet the other eligibility requirements.)

While most people do not have to pay a premium for Medicare Part A, everyone must pay a premium for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not receive any of these payments, Medicare will send you a bill for the Part B premium every three months.

To find out more about your particular eligibility and your projected premiums, you can use the Medicare.gov eligibility tool.

ANOTHER OPTION

Choosing Original Medicare isn’t the only option for people eligible for Medicare. There are also Part C plans, which are also known as Medicare Advantage Plans. Part C planscover the same things as Original Medicare (Part A and B—both inpatient and outpatient healthcare costs), but Part C plans often have less expensive premiums.

Part C premiums are generally lower because these plans have certain restrictions about where you can receive your medical care and there can be a few limitations on the type of illnesses covered as well.

Part C plans are run by private insurance companies that contract with the federal government to provide the service. Many times, Part C plans will also include basic dental and vision coverage. Additionally, most Part C or Medicare Advantage Plans also include Medicare Part D coverage (which is prescription drug coverage) as part of their Medicare package.

If you are eligible for Medicare, Part C plans can give you more coverage with smaller premiums if you are willing to receive your care within a specific service area. Additionally,it’s important to understand that Original Medicare (Parts A and B) pays only 80% of your healthcare costs, while Medicare Advantage Plans give you full coverage of healthcare costs minus your copayments. This can be very helpful in reducing out-of-pocket costs for Medicare recipients.

ENROLLING IN MEDICARE

Now that we have talked about eligibility requirements and what the program covers, it is important to give you an outline to understand how to enroll in the program. When you enroll you can decide if you want Original Medicare (Parts A and B), or if you would rather choose a Medicare Advantage Plan (Part C) with Prescription Drug coverage (Part D).

It is important to know that if you do not enroll in Medicare when you become eligible and begin making your premium payments (for Part B) you will incur penalties if you try to enroll later.

To enroll in Medicare, the steps are different depending on whether you are collecting your Social Security retirement benefits when you enter you Initial Enrollment Period, or IEP.

If you are already receiving your retirement benefits then you will be automatically enrolled in Medicare Parts A and B. You will receive a package in the mail three months before your coverage starts with your Medicare card and an explanation of the program. Once you are enrolled in parts A and B you can switch your plan to a Part C Medicare Advantage Plan.

If you meet the eligibility requirements for Medicare, but you are not yet receiving your Social Security retirement benefits, you will not be automatically enrolled in the program, and need to enroll during one of three specific time periods. When you enroll you may choose either Original Medicare or a Medicare Advantage Plan.

1. Initial Enrollment Period (IEP)

Your Initial Enrollment Period is a seven-month period surrounding your 65th birthday. It includes the three months before your 65th birthday, the month of your birthday, and the three months after your birthday. You can enroll in Medicare anytime during this seven-month period. Keep in mind that the date when your Medicare coverage begins depends on when you sign up. For example:

  • If you enroll during the first three months of your IEP (the three months before your 65th birthday), coverage begins the month in which you first become eligible for Medicare.
  • If you enroll during the fourth month of your IEP, coverage begins the month following the month of enrollment.
  • If you enroll during the fifth month of your IEP, coverage begins the second month following the month of enrollment.
  • If you enroll during the fifth month of your IEP, coverage begins the second month following the month of enrollment.

For example, let’s say you turn 65 in August. Use the following chart to determine when you can enroll in Medicare and when your coverage would start.

YOU CAN ENROLL ANYTIME IN: YOUR COVERAGE BEGINS:
May August 1st
July August 1st
July August 1st
August September 1st
September November 1st
October January 1st
November February 1st

Take note that if your birthday falls on the first day of the month, your IEP is the seven months surrounding the month prior to the month of your birth. For example, if you turn 65 on June 1, your IEP is the seven months surrounding May, and runs from February 1st to August 31st.

2. Special Enrollment Period (SEP)

Special Enrollment Periods (SEPs) are enrollment opportunities outside of the usual enrollment period. They are only triggered by a specific set of circumstances. One of these is the Part B SEP.

Special Enrollment Periods (SEPs) are enrollment opportunities outside of the usual enrollment period. They are only triggered by a specific set of circumstances. One of these is the Part B SEP.

The Part B SEP allows you to enroll in Medicare without penalty for up to eight months after you lose your group health coverage or you or your spouse stop working, whichever comes first.

Medicare coverage begins the first month after you enroll. For example, if you retire and sign up for Medicare in September, your coverage will begin on October 1st.To protect yourself and avoid a gap in coverage, you should enroll in Medicare the month before your job-based insurance ends.

3. General Enrollment Period (GEP)

If you did not enroll in Medicare when you originally became eligible for it (either during your IEP or an SEP), you can sign up during the General Enrollment Period which occurs from January 1st to March 31st every year. If you sign up during the GEP, your coverage will start on July 1st of that year. Be aware that you may incur a Part B late enrollment penalty and you may face gaps in coverage waiting for your benefits to begin.

CONTACT A MEDICARE INSURANCE AGENT TODAY

Medicare is a healthcare insurance program provided by the United States federal government for those 65 and older as well as those with specific disabilities or End-Stage Renal Disease.

In this article, we have explained the eligibility requirements and enrollment options for Medicare to help you as you prepare to enter the program.

If you still have concerns and questions or if you are nearing the age of Medicare eligibility and need help and advice navigating the different enrollment periods or coverage options available, we are here to help you and provide expertise in the Medicare insurance industry.

As Medicareinsurance agents with knowledge and experience, we can give you a full understanding of your enrollment options as well as find you the most competitive and comprehensive coverage options for you at a reasonable and affordable premium.

You do not have to navigate this process alone. We have years of experience and knowledge and can guide you successfully through enrollment eligibility, sign-up periods, and the variouscoverage options to help you manage and meet your healthcare insurance needs.

We’re here to help! Call us today.

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