Medicare Eligibility

You’ve probably heard of Medicare, the federal health insurance program for people age 65 or older and younger people with qualifying disabilities and End Stage Renal Disease. And if you’re nearing 65, or have family members who are, you’re probably wondering about Medicare eligibility.

Senior couple embrace and look at a lake and mountains

The different parts of Medicare

There are four parts of Medicare—Part A, Part B, Part C and Part D. Here’s what they cover and how much they typically cost:

Part A (Hospital Insurance) covers expenses typically related to hospital care, such as inpatient hospital stays, care in a skilled nursing facility, hospice care, and limited home health care. Most people receive Medicare Part A without having to pay a monthly premium. That’s because they’ve had Medicare taxes deducted from their paycheck for at least 10 years.

Part B (Medical Insurance) covers expenses that are typically related to general medical care, such as doctors’ services, preventive services and medical supplies (i.e. clinical research, ambulance services, mental health, and durable medical equipment). Part B comes with a monthly premium. The standard premium in 2019 is $135.50 a month.

Part C (Medicare Advantage) plans are an alternative to Original Medicare (Part A and Part B) offered through private insurance companies that have been approved by Medicare. These plans combine Part A and Part B benefits in a single plan, and many offer prescription drug coverage and additional benefits. Because Part C is offered through private insurance companies, the costs can vary.

Part D (prescription drug coverage) adds prescription drug coverage to Medicare. You can either get Part D coverage through a Medicare Advantage plan (MA-PD), or through a standalone Prescription Drug Plan (PDP) that can be used with Original Medicare or Medicare Advantage plans that don’t offer drug coverage.

Like Medicare Advantage plans, PDPs are sold by private insurers and costs and availability may vary.

Qualifying at 65

Even when you turn 65, you still have to meet a few more requirements to be eligible for Medicare. You are eligible for Part A and Part B at 65 if:

  • You are a U.S. citizen or permanent legal resident who has lived in the U.S. for five continuous years
  • You or your spouse have worked long enough to be eligible for Social Security or Railroad Retirement benefits
  • You or your spouse are government employees or retirees who have not paid into Social Security but have paid Medicare payroll taxes

Qualifying under 65

Just because you aren’t 65 doesn’t mean you don’t qualify for Medicare. You can still receive Medicare benefits under 65 if you:

  • Have been receiving Social Security disability benefits or certain Railroad Retirement Board disability benefits for at least 24 months
  • You have ALS (amyotrophic lateral sclerosis or Lou Gehrig's disease)
  • You have End-Stage Renal Disease (ESRD) and you or your spouse have paid Social Security taxes for a certain length of time

Automatic enrollment

Some people are automatically enrolled in Medicare Part A and Part B and don’t need to manually sign up. You are automatically enrolled if:

  • You are already receiving benefits from Social Security or the Railroad Retirement Board (RRB)
  • You are under 65 and have been receiving Social Security and RRB benefits for 24 months
  • You have ALS

Enrollment when you aren’t automatically enrolled

If you aren’t automatically enrolled in Medicare Part A and Part B, you’ll need to actively enroll during the Initial Enrollment Period (that begins three months before the month you turn 65 and extends three months after) or during a special enrollment period. You’ll need to actively enroll if:

  • You do not already receive Social Security or RRB benefits (this could be because you are still working)
  • You have End-Stage Renal Disease (ESRD) and qualify for Medicare
  • You live in Puerto Rico and want to sign up for Medicare Part B

Medicare Part C and Part D eligibility

When you’re eligible to enroll in Original Medicare, you also become eligible to enroll in a Medicare Advantage plan. You need to enroll in Original Medicare before you enroll in Medicare Advantage.

The types of Medicare Advantage plans available in your area may vary by insurance carrier. Medicare Advantage plans are typically based on one of five models, which may impact the type of provider network the plan has and whether or not you need referrals to see a specialist.

If you decide not to enroll in Medicare Advantage, you may add a Medicare Part D Prescription Drug Plan to your Original Medicare coverage. Again, the types of PDPs available in your area will depend on what plans private insurers offer.

To be eligible for Medicare Part C, you must already be enrolled in Part A and Part B. To be eligible for Medicare Part D, you have to be enrolled in Medicare Part A and/or Part B.

How to get Medicare

Part A and Part B — If you don’t qualify for automatic enrollment, don’t stress. Signing up for Medicare is relatively simple once you know if you qualify. To enroll in Medicare Part A and Part B, you can:

Part C and/or Part D — To sign up for Part C (Medicare Advantage) and Part D (prescription drug plan) you’ll need to find a local private insurance provider.

The easiest way to do this is to speak with a licensed insurance agent at   TTY Users: 711.

Copyright © 2018 TZ Insurance Solutions LLC. All rights reserved.

MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts; enrollment in any plan depends upon contract renewal.

Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

Medicare has neither reviewed nor endorsed this information.