Medicare Eligibility

Medicare Eligibility

We’re going to break down the Medicare eligibility requirements, Medicare eligibility rules, and the Medicare eligibility criteria even if you’re not 65-years-old.

It’s likely that you’ll become Medicare eligible the first day of the month you turn 65. In certain circumstances, you may find yourself eligible for Medicare prior to your 65th birthday.


Medicare Eligibility Check & Criteria

If you’re 65 years or older in the United States, you may be eligible for Medicare coverage.

Medicare is primarily for people who meet the following eligibility requirements:

  • You’re a U.S. citizen or a permanent resident living in the United States for 5 consecutive years
  • You (or your spouse) worked 10 years and became eligible for Social Security or Railroad Retirement Benefits

Payroll taxes will only guarantee that you won’t have to pay a premium on Part A. There are no work requirements for Part B or Part D coverage.


Medicare and Social Security

The Centers for Medicare and Medicaid Services (CMS) manages Medicare. The Social Security Administration works alongside with the CMS by enrolling certain people in Medicare.

If you’re disabled and have been approved or you receive Social Security Disability Insurance benefits you’ll also receive Medicare.

However, if you’re approved for Supplemental Security Income you’ll receive Medicaid benefits. SSI Medicare eligibility does not start until you reach the age of 65.

Medicare eligibility under 65 is possible.

Eligibility for Medicare may be available to you if:

  • You’re receiving Social Security Disability Insurance (SSDI)
  • You must be currently receiving SSDI benefits for at least 24 months
  • This 24-month period starts the first month you get an SSDI check
  • Your 24-month period is also known as the two-year waiting period

At the start of the 25th month that you receive SSDI checks, you’ll automatically be enrolled in Medicare.

Please note there are exceptions to this rule:

  • Certain circumstances do not require patients to wait for the 24-month waiting period
  • If SSDI checks because of ALS (Amyotrophic Lateral Sclerosis) Medicare will automatically start the same month that your SSDI benefits start
  • Medicare is not responsible for determining whether you’ll receive or qualify for SSDI checks; Social Security oversees that decision as they are the ones who administer the checks.

If you have any questions regarding this matter it is best you contact your local Social Security Administration office, as they can better assist you.


Medicare and ESRD

If you’re under the age of 65 and diagnosed with End-Stage Renal Disease (ESRD) you may also be eligible for Medicare benefits.

If you’ve been diagnosed with ESRD, you might qualify for Medicare if:

  • You had a kidney transplant
  • Receive dialysis treatments
  • Applied for Medicare benefits retroactively for up to 12 months AND:
    • You’re SSDI eligible
    • Eligible for Railroad Retirement benefits
    • You or your spouse have paid taxes to Medicaid for a certain amount of time

If you’re under the age of 65 and have ESRD, the beginning date of your SSDI is when you should apply for Medicare.


Eligibility Requirements for Medicare

Let’s break down the basics of your potential eligibility for Medicare; this can be confusing to many people.

Generally, your Medicare eligibility age is the month you turn 65. At this time, Part A and Part B will become available to you the first day of the month of your 65th birthday.

You’re also eligible for Medicare as long as your spouse has worked and paid Medicare taxes for a minimum of 10 years and one of the following statements is true for you:

  • Currently, you’re receiving or are eligible to receive Social Security
  • Currently, you’re receiving ore are eligible to receive RRB (Railroad Retirement Board) benefits
  • Your spouse or yourself has worked for a Medicare-covered government job

If you or your spouse didn’t pay Medicare taxes for at least 10 years and you’re over the age of 65 you may still be eligible for purchase of Medicare.


Medicare Automatic Enrollment

If you receive Social Security and Medicare, you could be eligible for automatic enrollment for Part A as well as Part B.

Automatic enrollment won’t apply to those who haven’t worked enough time to receive automatic enrollment for Medicare benefits.

If you’re one of these individuals, you’ll be required to file an application through the Social Security Administration.

Once enrolled through the SSA, you may enroll in Part A and Part B at a monthly premium rate, during an allowed Medicare enrollment period.


Medicare Disability Eligibility

Many people in the United States receive Medicare disability coverage.

You may qualify for Medicare Disability Eligibility under Part A and Part B coverage if you’re:

  • Diagnosed with ESRD, or ALS – you’ll automatically be enrolled in both Part A and Part B as soon as your first month of SSDI benefits is received
  • Receiving SSDI for 24 months or more, automatic enrollment for Part A and B will start at the 25th of the month following that 24th month of receiving SSDI

For those with ESRD, your application for Medicare benefits is required. Medicare disability eligibility will be determined based on several factors.

Factors may include:

  • Whether you’re getting regular dialysis treatments
  • If you’ve had a kidney transplant
  • If you’ve paid into taxes for Medicare sufficiently


Medicare Age Requirements & Eligibility

As stated above, generally your Medicare-eligible at age 65, have been on disability for two years, or have ESRD or ALS. However, coverage can also depend on a beneficiaries specific situation.


Medicare Age 62

You’ll be eligible for premium-free Part A if your spouse paid Medicare taxes for the required amount of time. Additionally, he or she must be 62 years old when you’re 65. This is because of the Medicare age limit.

Qualification may also be available based on the work record of a divorced or deceased spouse.

A 2015 ruling by the Supreme Court States that individuals in same-sex marriages can qualify for Medicare with a spouse’s work record, no matter the location for Medicare eligibility age 62.


Medicare Age 55

In October 2017, talks of Medicare age 55 were in the works. This idea proposed that Medicare-at-55 would allow you to switch from your current insurance to enroll in Medicare.

Medicare would have to raise the Medicare payroll tax contribution. The idea of Medicare-at-55 is still up in the air as far as our nation’s insurance coverage goes, we’ll have to wait and see what the future holds.


Medicare Age 67

Projections have shown that healthcare costs are on a continuous growth upward, life expectancy is increasing, and more & more baby boomers are reaching the current Medicare age of 65. In order to reduce the budget deficit, the Congressional Budget Office proposes to increase the age of Medicare eligibility to 67.


What is dual eligibility for Medicare and Medicaid?

When you receive both Medicare and Medicaid, you become “dual eligible”.

You’ll have enhanced benefits, and here’s how it works:

  • Medicare is the persons’ primary insurer
  • Beneficiaries may see any provider that accepts Medicare assignment

Medicare supplements, as well as Medicare Advantage plans, will be your secondary insurer.


Medicare Eligibility for Nursing Home Care

Although Medicare does cover skilled nursing care, coverage is generally for a short-term stay. Many limitations come with Medicare Eligibility for Nursing Home Care.

However, you may qualify for coverage if you meet the following Medicare eligibility rules:

  • You must have Part A – hospital insurance
  • You must have stayed inpatient for a minimum of 3 days in a row PRIOR to nursing home admission
  • A nursing home must be Medicare-certified
  • Your nursing home start date is within 30 days after spending 3 days in the hospital
  • Your doctor must order nursing home care and services
  • Services must be provided by skilled professionals


Medicare Savings Program Eligibility

The Medicare Savings Program helps with some out-of-pocket expenses, such as Part A and Part B. One of these programs can help you pay for your premiums, deductibles, copayments as well as coinsurances associated with Medicare.

Medicare Savings Programs has 4 Types:

  • QMB – Qualified Medicare Beneficiary Program
  • SLMB – Specified Low-Income Medicare Beneficiary Program
  • QI – Qualifying Individual Program
  • QDWI – Qualified Disabled and Working Individuals Program.

Aside from the QDWI Program, all these programs will help pay for your Part B premiums.

Medicare Savings Program eligibility automatically qualifies you for Extra Help. The Extra Help program helps you cover the costs of prescriptions. However, if you qualify for Extra Help, that does not mean you also qualify for the Medicare Savings Program.


Medicare Eligibility Check

To avoid any issues later down the road as well as ensure proper billing of Medicare services, the first step is a Medicare eligibility check.

Medicare eligibility should get reviewed at the very least:

  • At the start of admission to your agency
  • Before submitting the home health request for anticipated payment (RAP)
  • Before submitting the hospice notice of election (NOE)
  • And before submitting each claim


How to Check Medicare eligibility?

If you want to know how to check Medicare eligibility, talking to a licensed insurance agent will benefit you immensely.

First, make sure you have the following information in order to determine your Medicare eligibility verification:

  • First and last name
  • Medicare number
  • Date of birth of the person applying
  • Gender

Options for checking Medicare Eligibility:

  1. Talk to a licensed insurance agent in your state
  2. Automated phone services
  3. Several online services can assist you and prevent errors to calculate your eligibility properly


If I’m Eligible, How Much Will My Medicare Premium Be?

Not all Medicare premiums are the same; your situation is different than the next persons and therefore the premium won’t be the same.

If you have any questions or concerns regarding your eligibility, please contact a Medicare expert. You can reach a licensed Medicare expert by calling the phone number above or by filling out the online rate form.