What Makes You Eligible for Medicare

By RetireMEDiQ

To be eligible for Medicare, there are certain requirements you must meet. You qualify for full Medicare benefits if:

  • You are 65 or older
  • You are a permanent legal resident who has lived in the United States at least five years or are a U.S. Citizen; and
  • You (or your spouse) are eligible for Social Security or Railroad Retirement Board benefits; or
  • You (or your spouse) are a government employee or retiree who has not paid into Social Security but has paid Medicare payroll taxes while working.

Are There Exceptions to These Requirements?

In some cases, you may be eligible to apply for full Medicare coverage under the age of 65. To qualify for early Medicare coverage, you must meet at least one of the following requirements:

  • You’ve been entitled to Social Security disability benefits for at least 24 consecutive (or non-consecutive) months; or
  • You receive a disability pension from the Railroad Retirement Board and meet certain conditions; or
  • You have Lou Gehrig’s disease, which qualifies you immediately
  • You have permanent kidney failure that requires regular dialysis or a kidney transplant — and you or your spouse has paid Social Security taxes for a certain length of time, depending on your age.

Be Aware of Special Circumstances 

You already have Medicaid. If you have Medicaid, you can also enroll in Medicare if you meet the eligibility requirements for both programs (sometimes referred to as dual eligibility). If you have both Medicare and Medicaid, Medicare will act as your primary insurance and Medicaid will be secondary. Through Medicaid, you may be eligible to receive financial assistance for your prescription drug costs and possibly even your Part B premiums.

You live outside of the U.S. or in Puerto Rico. If you live outside the U.S., even if you are a U.S. citizen, Medicare will likely not provide coverage to you. If you live in Puerto Rico and are receiving Social Security or Railroad Retirement Board benefits, you can receive Medicare benefits. You will automatically be enrolled in Part A, but you will probably have to manually enroll in Part B, if you wish to receive it.

You have or plan to get COBRA. If you are trying to decide between getting COBRA or Medicare, we understand how confusing this decision process can be. We strongly encourage you to contact one of our Benefit Advisors to discuss your situation and get their expert advice on what to do. If you already have COBRA and aren’t sure what to do when you turn 65, it may make the most sense for you to plan to enroll in Medicare during your Initial Enrollment Period. We encourage you to contact one of our Benefit Advisors to discuss the details of your situation and receive personalized advice on what is the ideal choice for you.

How other benefits (Social Security, Railroad Retirement Board, Veterans Affairs, TRICARE, etc.) could impact your Medicare benefits. If you receive retirement benefits from another source, Medicare may or may not work with those benefits. We encourage you to contact one of our Benefit Advisors to find out more about how Medicare may work with your benefits and what the right steps are for you.

How to know if you will pay for Part A or receive it premium free. Part A includes a monthly premium. However, most people do not have to pay for this. You can get “premium-free” Part A if you or your spouse paid Medicare taxes while working for at least 10 years (40 quarters). If you do not qualify for premium-free Part A, the monthly premium in 2018 is $422.

When you do/don’t need to enroll in Medicare Part A and/or Part B. Many retirees find that they automatically receive Medicare Part A and Part B benefits when they first become eligible for Medicare at age 65. However, there are some instances where you may have to manually sign up for Medicare benefits or even manually delay them to avoid penalties. You may receive Medicare Part A and/or Part B benefits automatically if:

  • You are already receiving Social Security or Railroad Retirement Board benefits.
  • You are under 65 and have a disability.
  • You have ALS (also called Lou Gehrig’s disease).

Expert tip: If you are automatically enrolled, you will receive your red, white and blue Medicare card in the mail three months before you turn 65 or during your 25th month of disability.

You may need to manually enroll in Part A or Part B if:

  • You aren’t receiving Social Security or Railroad Retirement Board Benefits (due to employment or other circumstances)
  • You qualify for Medicare due to End Stage Renal Disease (ESRD)

We strongly encourage you to contact one of our advisors to discuss your situation and ensure you know what to expect for your Medicare Part A and Part B eligibility. If you miss your chance to enroll in these benefits, or if you plan to continue working and fail to delay them, you could incur penalties that add unnecessary expense and stay with you for life.

How Medicare works with your employer insurance. When you have Medicare coverage as well as employer coverage, your plans are subject to “coordination of benefits” rules. Various factors contribute to who pays first for your medical expense, like the size of your employer. For more information, visit Medicare.gov for specific scenarios or call us to talk about your specific situation with one of our expert advisors.

How Can I Be Sure That I am Eligible?

If you want to do a quick check on your eligibility and see what your premium might cost, Medicare.gov offers a calculator.

We know this is confusing! If you have questions, we are here to provide answers. Call us at 1-866-600-5638.

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