Medicare offers its beneficiaries much-needed coverage for their healthcare needs, but it isn’t always the easiest program to understand. But, as with many of life’s milestones, it’s up to you to figure it out.
Of course, that’s why you’re here. So, keep reading, because we’re going to walk you through the various criteria for Medicare eligibility (age is not the only factor) as well as how enrollment works (it isn’t always automatic).
Age-Related Medicare: Are You Turning 65 this Year?
Most people meet Medicare’s eligibility requirements the year they turn 65. However, the Initial Enrollment Period (IEP) actually lasts for seven months. It begins three months before the month of your 65th birthday and extends through the three months that follow your birthday. So, if your birthday is on Valentine’s Day, your Medicare entitlement begins in November and extends through May. Coverage begins on the first day of the month of your 65th birthday. In this example, that would be February 1.
The Medicare and Social Security Connection
For many of us, Medicare and Social Security benefits are closely linked. That’s because, until recently, eligibility for both began at age 65. And, if you receive Social Security benefits by age 65, you do enjoy automatic enrollment in Medicare. However, in 2012, the Social Security Administration increased the retirement age to 66 for individuals born between 1948 and 1954. What’s more, people born after 1954 won’t receive their Social Security benefits until age 67. In other words, Medicare and Social Security eligibility are no longer linked.
Medicare Eligibility Is Not Automatic
One of the more common misconceptions about Medicare eligibility is that everyone receives their benefits upon turning 65. This is not true.
Age-related Medicare eligibility requires meeting the following criteria:
- You are either an American citizen or a permanent, legal resident who has resided in the U.S. for at least five years.
- Either you or your spouse worked for at least 10 years to earn the 40 credits necessary to receive railroad retirement or Social Security benefits. One credit equals three months (one-quarter of a year). You receive Part A services without paying a premium only if you earned 40 credits.
- Either you or your spouse is employed by or retired from the government and did not pay into Social Security but did pay Medicare taxes while employed.
If you did not earn 40 credits, you must pay a monthly premium for Medicare Part A hospital insurance. As of 2018, cost is $227 per month if you have between 30 and 39 credits. If you have fewer than 30 credits, your cost is $413 per month.
You can also apply for Part A coverage without paying a premium based on your spouse’s work record if you are at least 65 and your spouse is at least 62.
Medicare Entitlement when Under the Age of 65
You may qualify for Medicare benefits before turning 65 if you meet one of the following criteria:
- You have received Social Security Disability Insurance checks for at least 24 months
- You receive a disability pension from the Railroad Retirement Board and meet certain conditions
- You have amyotrophic lateral sclerosis (ALS, commonly known as Lou Gehrig’s disease)
- You need a kidney transplant or dialysis due to permanent kidney failure and your spouse paid the requisite amount in Social Security taxes for a specified period
Medicare Enrollment Is Not Automatic
Many people are also surprised to learn that they are not automatically enrolled in Medicare Parts A and B. This is particularly true now that the retirement age (as per Social Security) is either 66 or 67. Previously, if you received Social Security benefits at age 65, you received your Medicare card around three months before your 65th birthday.
You need to sign up for Medicare if you:
- Have end stage renal disease
- Are within three months of your 65th birthday but do not receive Railroad Retirement Board or Social Security benefits
- Are a resident of Puerto Rico and receive Railroad Retirement or Social Security benefits, in which case you receive Part A on your 65th birthday but must sign up for Part B
You can apply for Medicare online here. Assuming the information you enter matches Medicare’s records, you do not need to submit documentation, such as a birth certificate. However, if there are any discrepancies in your records or you were not born in the United States, you may need to apply in person or over the phone via the Social Security office.
Please note that, if you do need to apply for Medicare through Social Security, you typically need to schedule an appointment, which may take months. If you expect there are any discrepancies in your records, call your local Social Security office to make an appointment as soon as possible.
When to Enroll in Medicare
Automatic enrollees receive their Medicare card in the mail three months before they turn 65. For them, no further action is required. For everyone else, make note of Medicare’s different enrollment periods. These allow you to complete your initial enrollment or make changes to your existing coverage.
- The Initial Enrollment Period (IEP) begins three months before your birthday month and ends three months after your birth month.
- The General Enrollment Period (GEP) is for beneficiaries who miss their IEP. It runs from January 1 through March 31 with coverage beginning July 1 of the year you enroll.
- The Special Enrollment Period (SEP) covers those who wait to enroll in Medicare Part B because they currently have coverage through either their or their spouse’s employer. If you lose coverage, you have eight months to enroll in Part B without receiving a penalty.
- Part D Enrollment allows you to sign up for a Medicare Prescription Drug Plan from October 15 through December 1, with plans beginning on January 1.
- Part C Medicare Advantage (MA) Enrollment also runs from October 15 to December 7 and allows you to either switch to an MA plan or switch back to Original Medicare. You may also make that change from January 1 to February 14 during the Medicare Advantage Special Enrollment Period.
- Last Chance Enrollment allows you to apply during the next GEP if you missed both your IEP and SEP. However, you face penalties and your coverage does not begin until July.
Final Thoughts on Medicare Eligibility
Not everyone gets automatic enrollment in Medicare. As soon as you become eligible for Medicare coverage, you should enroll. Failure to do so puts you at risk and may result in financial penalties.
For more information, please call us toll free at (844) 839-0813 to speak with a licensed agent.