Qualifying for Medicare is a matter of eligibility due to age or disability. The number of years you or your spouse worked and paid Medicare taxes according to the Federal Insurance Contributions Act (FICA) also determine whether or not you qualify to pay nothing in monthly premiums for your Part A hospital insurance. Qualifying for Medicare Advantage or Medicare Supplement policies is determined by age, location, and timing.
The majority of Medicare beneficiaries qualify due to age. American seniors age 65 or older who are U.S. citizens or have been permanent legal residents for at least five years qualify for benefits. You will need to enroll in Medicare Part A and Part B when you turn 65 to avoid having to pay a late enrollment penalty that follows you for the lifetime of the policy.
Your Initial Enrollment Period begins three months before the month of your 65th birthday and extends three months after. During this time you can decide to purchase Part A and Part B as well as select a Part D prescription drug plan, choose a Medicare Advantage plan, or sign up for a Medicare Supplement policy.
You can delay enrollment in Part B if you qualify for a Special Enrollment Period (SEP). The most common reason to delay is if you or your spouse are still working and have an employer group health plan. You can wait to sign up for Part B (and delay paying those monthly premiums) until you lose coverage or are no longer employed, whichever comes first.
You can otherwise delay if you have TRICARE and are an active duty service member or the spouse or dependent child of an active duty service member. You should be sure to enroll in Part B before the service member retires to keep your full benefits.
If you decide you do not want to be enrolled in Part B, you can contact Social Security to drop the coverage. Those who were automatically enrolled can follow the instructions that came with the card to drop Part B coverage. If your Medicare coverage has already started, you should contact Social Security to learn how to submit a signed request.
After you have received your disability benefits from Social Security or the Railroad Retirement Board for at least 24 months, you are eligible for Medicare benefits. You automatically get Medicare Part A and Part B, so you do not need to sign up. You will receive your red, white, and blue Medicare card in the mail three months before your 25th month of disability benefits. Coverage begins on the first day of the 25th month.
As long as you are medically disabled, you can keep your Medicare coverage, even if you decide to go back to work. You will not have to pay for your Part A premium for the first 8.5 years but will then have to pay your premium. If you cannot afford your Part A premium, you can see if you qualify for a Medicare Savings Program. The Qualified Medicare Beneficiary program helps to pay for Part A and Part B premiums as well as cost-sharing expenses such as deductibles and copayments. The Qualified Disabled and Working Individuals (QDWI) Program helps to pay your Part A premium once you lose your premium-free Part A because you go back to work. There are qualifying monthly income limits and resource limits to qualify for the program.
People who are diagnosed with Amyotrophic Lateral Sclerosis (also known as Lou Gehrig’s Disease) are eligible for Medicare benefits during the first month they start receiving disability benefits. You can apply for disability benefits from Social Security or the Railroad Retirement Board as soon as you become disabled.
You do not need to sign up for Medicare because you automatically receive Part A and Part B. You will receive your Medicare card in the month your disability benefits begin. Coverage begins this same month. You are also eligible for a Chronic Condition Special Needs Plan tailored to your neurologic condition. Read more under Eligibility for Medicare Advantage.
You can choose whether or not to enroll in Medicare. To get the full benefits available to cover dialysis and kidney transplant services, you need to be enrolled in both Part A and Part B. You can do so by contacting Social Security. With ESRD, you will be exempt from the Part B late enrollment penalty.
If you have ESRD, you can receive Medicare benefits at any age if:
If you are on dialysis, coverage kicks in after a four-month waiting period. Medicare coverage will start on the first day of the fourth month of your dialysis treatments. If you have an employer group health plan, they will be the primary insurance for the first three months of treatment.
You may be able to receive coverage in the first month of dialysis if you perform it at home instead of at an outpatient treatment center. You will have to participate in a home dialysis training program from a Medicare-certified training facility during the first three months of your regular course of dialysis as well as have the approval and confidence of your doctor that you will finish training and be able to do your own dialysis.
Coverage for people with ESRD is retroactive from the time you enroll for up to 12 months, depending on how long you waited to enroll after you qualified for Medicare. These 12 months go back as early as the first month you began to qualify for Medicare due to ESRD. You are also eligible for a Chronic Condition Special Needs Plan, which is discussed under Eligibility for Medicare Advantage.
One of the main benefits for Medicare beneficiaries is premium-free Part A. Most Medicare beneficiaries qualify for premium-free Part A because they or their spouse have fulfilled the work and tax requirements.
If you are 65, you can receive premium-free Part A if:
Medicare beneficiaries who have worked (or whose spouse has worked) between 30 and 39 calendar quarters while paying Medicare taxes do not qualify for premium-free Part A and will pay $259 each month in 2021. Those who worked or whose spouse worked fewer than 30 calendar quarters while paying Medicare taxes will pay $471 in monthly premiums in 2021.
If you are under 65 years of age, you can receive Part A with $0 premiums if:
To be eligible for a Medicare Advantage plan, you must be enrolled in Medicare Part A and Part B and live within the service area of the plan you want to join. You can sign up for a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-for-Service (PFFS), or Medicare Medical Savings Account (MSA) plan.
If you meet the eligibility requirements for a Special Needs Plan, you can join one as long as you are also enrolled in Part A and Part B and live within the plan’s service area. There are three types of Special Needs Plans: Chronic Care, Dual-Eligible, and Institutional.
Chronic Care Special Needs Plans (C-SNPs) are available for people who have qualifying chronic conditions as decided by the Centers for Medicare and Medicaid Services (CMS). You can also find a plan that has a pairing or grouping of comorbid conditions. These plans have networks of healthcare providers and specialists who specialize in treating the conditions of the plan members. The prescription drug coverage under these plans also includes the medications used to treat the specific chronic conditions covered under the plan.
Dual Eligible Special Needs Plans (D-SNPs) are available for people who are eligible for both Medicare and Medicaid. These federal and state-administered programs are based on income and resources, bringing healthcare to people who may not otherwise have been able to afford it. If you exceed the income limits, you may be able to qualify for a program if you have high healthcare spending that reduces your income advantage. Some states limit the eligibility for these Medicare Advantage plans to people in certain levels of the Medicaid programs.
Institutional Special Needs Plans (I-SNPs) are available for people who have lived in an institution (such as a long term care skilled nursing facility, intermediate care facility for people with intellectual disabilities, or inpatient psychiatric facility) for at least 90 days and who are receiving an institutional level of care. This level of care is assessed by an independent, impartial party. These plans often have county-based service areas.
You can have a Medicare Advantage plan or Medicare Supplement plan, but not both.
To sign up for a Medicare Supplement plan, you must be enrolled in Medicare Part A and Part B. To be eligible for a Medicare Supplement plan, you must be a U.S. citizen or have been a permanent legal resident for five years and also:
Those who qualify for Medicare because of a disability and who are under the age of 65 are less likely to find a Medigap policy that will agree to cover them. Plans are not obligated under federal law to offer you a policy if you are not 65 or older. You may not be able to get the plan you want or any plan if the insurance company does not voluntarily sell you a policy. Many states require insurance companies to offer at least one supplement plan to people under 65. The plan may cost more to purchase for someone under age 65 than it would for a senior citizen. These plans may use medical underwriting for people under 65, which can increase your premiums.
The prime time to sign up for a Medicare Supplement plan is during your Medicare Supplement Open Enrollment Period. During the six months after you are 65 or older and first enrolled in Part B, you cannot be turned away from a Medicare Supplement policy due to medical reasons: you are not subject to medical underwriting.
You can apply to a Medicare Supplement plan outside of your six month Medicare Supplement Open Enrollment Period but will be subject to medical underwriting. This means the insurance company will look at your health problems and pre-existing conditions when selling you the policy, which can increase your premiums or make you ineligible for a plan. Each plan may vary, so check the plan’s official plan documents to see how your health conditions will affect your policy.
If you have any additional questions related to Medicare, our team of Colorado Medicare experts is happy to help you. Contact us at 970-233-0063 today.
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