Who Qualifies for Medicare? Exploring Eligibility Requirements and Coverage Options

Introduction

Medicare is a federal health insurance program that provides coverage to people 65 and over, as well as certain younger individuals with disabilities, and people with end-stage renal disease (ESRD). According to the Centers for Medicare & Medicaid Services (CMS), the program paid out over $742 billion in benefits to more than 59 million people in 2019 alone.¹

In this article, we’ll discuss the eligibility requirements for Medicare, the four parts of Medicare, financial factors for eligibility, special cases for qualification, how to apply for coverage, and how Medicare compares to other health insurance options.

Eligibility Requirements

To qualify for Medicare, you must meet certain criteria based on your age, disability, or ESRD. We’ll go over each of these criteria in more detail below.

Age

If you’re 65 or older, you are generally eligible for Medicare. In addition, if you’re under 65 but have been receiving Social Security disability benefits for at least two years, you may be eligible.² You may also qualify if you’re under 65 and have amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ESRD).

Disability

If you’re under 65 and have a disability, you may be eligible for Medicare. To qualify, you must have received Social Security Disability Insurance (SSDI) benefits for at least two years. If you’re under 65 and have ALS or ESRD, you’re also eligible for Medicare regardless of whether you’ve received SSDI benefits.³

End-Stage Renal Disease (ESRD)

If you have ESRD, you’re eligible for Medicare regardless of your age. However, you must be undergoing dialysis or have had a kidney transplant to qualify.⁴

Medicare Parts A, B, C, and D

Medicare is divided into four parts: Part A, Part B, Part C, and Part D. Each part covers different types of care, and there are differences between them in terms of cost and coverage. We’ll go over the details of each part below.

Part A: Hospital Insurance

Part A, also known as hospital insurance, helps cover the costs of inpatient care in hospitals, skilled nursing facilities, hospice care, and some home health care services.⁵ Most people don’t have to pay a premium for Part A since they’ve already paid for it through their payroll taxes while they were working.⁶

Part B: Medical Insurance

Part B, also known as medical insurance, helps cover the costs of doctor visits, outpatient care, and preventive services. It also covers some medical equipment and supplies, such as wheelchairs and walkers.⁷ People who choose to enroll in Part B must pay a monthly premium in addition to any deductibles or copayments.⁸

Part C: Medicare Advantage Plans

Part C, also known as Medicare Advantage plans, are offered by private companies approved by Medicare. These plans combine the benefits of Part A and Part B and often include additional benefits, such as vision, hearing, and dental coverage.⁹ People enrolled in Part C must pay a monthly premium in addition to any deductibles and copayments.¹⁰

Part D: Prescription Drug Coverage

Part D, also known as prescription drug coverage, helps cover the costs of prescription drugs. People enrolled in Part D must pay a monthly premium in addition to any deductibles and copayments.¹¹

Financial Factors for Eligibility

In addition to meeting the age, disability, or ESRD criteria, you must also meet certain financial criteria to qualify for Medicare. We’ll go over the income, resources, and other factors that can affect eligibility below.

Income

Your income can affect your eligibility for Medicare. If your income is above a certain threshold, you may be required to pay an income-related monthly adjustment amount (IRMAA) in addition to your regular premiums.¹²

Resources

Your resources, such as savings and investments, can also affect your eligibility for Medicare. If your resources exceed a certain limit, you may be required to pay an additional premium.¹³

Other Factors

There are other factors that can affect your eligibility for Medicare, such as where you live and whether you’re eligible for Medicaid. You should contact your local Social Security office for more information.¹⁴

Special Cases for Qualification

In some cases, you may be eligible for Medicare even if you don’t meet the age, disability, or ESRD criteria. We’ll go over two of these cases below.

Military Service

If you’re a veteran who has served at least 90 days of active duty, you may be eligible for Medicare. You must also have been discharged or released from service under conditions other than dishonorable.¹⁵

Certain Immigration Status

If you’re a lawful permanent resident of the United States who has lived in the country for at least five continuous years, you may be eligible for Medicare. You must also meet other criteria, such as having a valid social security number.¹⁶

Applying for Coverage

Once you’ve determined that you’re eligible for Medicare, you can apply for coverage. You can apply online or by mail, and there are several enrollment periods throughout the year.¹⁷ Here’s an overview of the application process.

Online Application

You can apply for Medicare online through the Social Security Administration website. You’ll need to provide information such as your name, address, date of birth, and Social Security number.¹⁸

Paper Application

You can also apply for Medicare by mail using a paper application. You can request a paper application by calling the Social Security Administration or visiting your local Social Security office.¹⁹

Enrollment Periods

The enrollment periods for Medicare vary depending on the type of coverage you’re applying for. For instance, the initial enrollment period for Part A and Part B is seven months long and begins three months before the month you turn 65.²⁰ It’s important to note that you may have to pay a late enrollment penalty if you don’t sign up during the initial enrollment period.²¹

Comparing Medicare to Other Health Insurance Options

When it comes to choosing a health insurance plan, it’s important to compare your options. Here’s a look at how Medicare compares to other health insurance options in terms of cost, coverage, and limitations.

Cost

Medicare typically has lower premiums than other health insurance plans. However, you may have to pay deductibles, copayments, and coinsurance for certain services.²²

Coverage

Medicare generally offers more comprehensive coverage than other health insurance plans. It covers a wide range of services, including hospital stays, doctor visits, preventive care, and prescription drugs.²³

Limitations

Medicare does not cover all medical expenses, such as long-term care, dental care, vision care, and hearing aids. You may need to purchase a supplemental insurance policy to help cover these expenses.²⁴

Conclusion

Medicare is a federal health insurance program that provides coverage to people 65 and over, as well as certain younger individuals with disabilities, and people with end-stage renal disease (ESRD). To qualify for Medicare, you must meet certain criteria based on your age, disability, or ESRD, as well as certain financial criteria. Medicare is divided into four parts: Part A, Part B, Part C, and Part D. Each part covers different types of care, and there are differences between them in terms of cost and coverage. When comparing Medicare to other health insurance options, it typically has lower premiums and more comprehensive coverage, but does not cover all medical expenses.

This article has provided an overview of the eligibility requirements for Medicare, the four parts of Medicare, financial factors for eligibility, special cases for qualification, how to apply for coverage, and how Medicare compares to other health insurance options. If you think you may be eligible for Medicare, you should contact your local Social Security office for more information.