Understanding Medicare Eligibility & Coverage

If you currently receive Social Security benefits, you will be automatically enrolled in Medicare Parts A and B the month you turn 65. However, if you do not receive Social Security benefits, you will need to enroll yourself.

Medicare enrollment begins three months before your 65th birthday and will end three months after. This is called your initial enrollment period.

It’s important to do a Medicare eligibility check and act right away because delaying your enrollment can result in a 10% Part B premium increase for every year you’re eligible but don’t enroll. If you don’t select prescription drug coverage and later enroll, you may have a penalty of 1% of the national base Medicare Part D monthly premium for each month you were not enrolled.

Medicare and Medicare Railroad are similar. The difference is that the Palmetto GBA Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) administers Part B benefits to retired railroad beneficiaries. 

Who is not eligible for Medicare? People who are not U.S. Citizens or legal residents are not eligible for Medicare.

Let us now take a closer look at medicare eligibility requirements:

Eligibility for Original Medicare (Part A and Part B)

Original Medicare eligibility criteria depends on age and citizenship or legal residency. You must be a U.S. citizen age 65 or older to receive Medicare benefits in the United States to be eligible for Original Medicare.

This health insurance plan has Parts A and Parts B. Part A coverage will pay for most of your stay at a hospital and Part B coverage will pay for medical services and supplies to treat your medical issues. 

Eligibility for Medicare Part C

You are eligible for Medicare Part C after you’ve enrolled in Medicare Part A and Medicare Part B and you live within a Medicare Advantage service area. 

Eligibility for Medicare Part D

You are eligible for Medicare Part D, the Medicare drug plan, if you are enrolled in Medicare Part A and/or Medicare Part B and reside within a Medicare prescription drug coverage service area. 

Medicare Eligibility for Those Under 65

It’s important to understand the differences between Social Security and Medicare. You can start to receive Social Security Retirement benefits at the age of 62. This amount is typically reduced until you reach the age of 65.

The average person does not qualify for Medicare until age 65, but there are exceptions. Plus, you may qualify for Medicare before 65 if you have Lou Gehrig’s Disease (ALS) or End-Stage Renal Disease.

You are automatically enrolled in Medicare once you have received Social Security benefits for two consecutive years. This means if you started receiving benefits at age 62, you will qualify for Medicare at age 64.

Eligibility for People With Disabilities and Illnesses

You may qualify for Medicare disabilities if you have end-stage renal disease (ESRD), if you need kidney transplant drug therapy for 36 months after your surgery, if have permanent kidney failure, or if you have Lou Gehrig’s disease, also known as Amyotrophic Lateral Sclerosis (ALS).

Additionally, approval for SSDI, which entitles you to social security disability benefits, also makes you eligible for Medicare after two years. 

Eligibility for Medigap

If you have Original Medicare, you are also eligible for Medigap. Medigap is extra health insurance that you can purchase from private insurance companies. It pays for health care costs that aren’t covered by Medicare Part A and Part B, such as copayments and deductibles. 

You may also qualify for Medicare supplement and Medicaid. As a “dual eligible” most of your healthcare costs will be covered. Who is eligible for Medicaid? You must be age 65 or older, have a permanent disability, be blind, be a pregnant woman, or be a child or parent or caretaker.

You must also be a U.S. citizen or meet particular immigration rules, be a resident of the state where you submit your application, and have a social security number.

An Overview of Medicare Coverage

Medicare coverage is organized around different categories: Original Medicare (Part A and Part B), Medicare Part C, and Medicare Part D. There is also Medigap coverage that covers what is not covered in Medicare Part A and Part B. 

What Original Medicare Covers

Original Medicare health coverage consists of Medicare Part A and Part B. Medicare Part A coverage is hospital insurance while Medicare Part B coverage is medical insurance. 

What Medicare Part C Covers

Private insurance companies under contract with Medicare administer Medicare Part C, also known as the Medicare Advantage plan. It covers everything offered by Original Medicare, and it may offer extra benefits, too. 

What Medicare Part D Covers

Medicare Part D covers prescription drugs, paying for both brand-name drugs and generic drugs. Private insurance companies can get Medicare approval to offer Medicare drug plans.

What Medigap Covers

Medigap pays for healthcare costs, such as copayments and deductibles, that are not covered by Medicare Part A and Part B. It also covers healthcare costs for US citizens traveling outside the country.

However, Medigap does not cover long-term care, nor does it cover preventative-type healthcare services, such as vision care, eyeglasses, dental care, and hearing aids. 

How Do I Enroll in Medicare?

If you have been receiving Social Security benefits, Medicare enrollment for Medicare Part A and Part B occurs automatically the month after you turn 65 years of age. 

It’s important to sign up when you reach the Medicare eligibility age because there is a late enrollment penalty for those who delay enrolling on time. According to medicare.gov, “Medicare calculates the penalty by multiplying 1% of the ‘national base beneficiary premium’ ($32.74 in 2020) times the number of full, uncovered months you didn’t have Part D or creditable coverage.

The monthly premium is rounded to the nearest $0.10 and added to your monthly Part D premium.” 

How Much Does Medicare Cost?

The Medicare program in 2020 will have a standard monthly premium cost of $144 for Part B. If you and your spouse have been paying Medicare taxes while working for a certain amount of time, you will not have to pay a Medicare Part A monthly premium, a policy called premium-free Part A.

Medicare beneficiaries must join Part D, and the Medicare income limit for healthcare is $25,000 for single people and $33,800 for married couples. 

Contact Us Today

A comprehensive Medicare plan can help cover your medical expenses after age 65. If you need clarification on Medicare eligibility and coverage, we can help!

We can, for instance, answer questions like, “What are the criteria to qualify for medicare“ or “Who is eligible for Medicare and Medicaid?”

Call us at 844-431-1832 or contact us here today.