Medicare Eligibility & Enrollment

Medicare eligibility and enrollment are based on the number of years you and/or your spouse worked and paid into Social Security, your citizenship status, and possibly, your permanent disabilities.

Only those already receiving benefits from the Social Security Administration will receive automatic eligibility enrollment in Medicare when they turn 65. Therefore, most beneficiaries need to enroll themselves. This guide will explain when your eligibility starts, as well as when you can enroll in Original Medicare Part A and Part B.

Eligibility at 65 and Older

If you aren’t permanently disabled prior to turning 65, you will become eligible for Medicare benefits on your 65th birthday. If you also qualify for Medicaid services, you can and should still enroll in Medicare once your eligibility opens. Medicaid will help reduce or eliminate your out-of-pocket expenses.

  • Quick tip:

    If you want your Medicare coverage to begin as soon as you turn 65, enroll during the three months prior to your birthday month. Your Medicare health plan will begin the first day of your birthday month.

There are two requirements that you must meet to qualify for Medicare services:

  1. You’re a United States citizen or a legal permanent resident who has lived in the country for a minimum of five years. Providing a valid social security number or proof of residency satisfies this requirement.
  2. You or your spouse have worked and paid taxes for enough years to earn your place in the Medicare program. That works out to roughly ten years. If your work history qualifies you to receive Social Security or railroad retirement benefits, you should also qualify for Original Medicare.

Eligibility Under Age 65

You can qualify for Medicare before turning 65 if you have received disability benefits from the SSA or Railroad Retirement Board (RRB). You must receive Social Security disability benefits for at least 24 months before enrolling in Medicare, but those months don’t need to be consecutive. There are other requirements for beneficiaries qualifying based on RRB disability pensions.

If you have paid Medicare taxes over the years, you may also qualify to receive early enrollment in Medicare if you’re diagnosed with one of the following medical conditions:

  • End-stage renal disease (ESRD)
  • Amyotrophic lateral sclerosis (Lou Gehrig’s Disease)

To enroll in Medicare due to ESRD, you must be in permanent kidney failure with a need for a kidney transplant or dialysis. Medicare eligibility is immediate for those diagnosed with Lou Gehrig’s Disease.

Medicare Enrollment

You can act on your Medicare eligibility even if you want to continue working and don’t plan on receiving retirement benefits right away. If you are actively employed with adequate health insurance when you turn 65, you can also choose to delay Medicare enrollment. However, keep in mind that doing so may cause a delay when waiting for your first month of Medicare benefits.

The rest of this guide will focus on when and how to enroll in Medicare Part A hospital insurance and Medicare Part B primary care insurance. If you have a unique situation, you may want to talk to a professional to help determine the best time for Medicare enrollment.

Initial Enrollment Period for Medicare

Every beneficiary has an initial enrollment period that lasts seven full months. The first month is your birthday month, the year that you turn 65. The period starts three months prior and ends three months after.

If you enroll during the first three months, your coverage will begin on the first day of your birthday month. If you enroll during your birthday month or the final three months, coverage will begin the first day of the month following enrollment.

If you miss this period, you may need to wait for an open enrollment period to sign up. That may delay the start date for your Medicare coverage. Timing is important to ensure you don’t have a short-term lapse in health care coverage.

How to Enroll in Medicare

How do you apply for Original Medicare when you’re ready? The fastest option is to apply online. If you have all the needed information, it shouldn’t take long to fill out and submit the online form.

You will need basic personal information like birth date, social security number, and place of birth. The form also asks questions about your children, current and previous marriages, employers and income for the past two years, and military service. Before starting the application, gather social security numbers for all current and past spouses and children.

You may also need to submit some documentation to support your Medicare application. For instance, you may need to prove your citizenship or provide tax information and earnings records.

Where you can enroll in Medicare:

  • Apply online at the Social Security website.
  • Social Security Administration is toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
  • Visit your local Social Security office. The agency has a Social Security office locator on its website.
  • Quick tip:

    Use the Medicare documentation checklist provided by the SSA. It will make sure you have the information you need prior to starting the enrollment process.

Open Enrollment Periods for Medicare

Medicare has an open enrollment period every year from October 15 to December 7. You could use this period to enroll in Medicare if you didn’t do so during your initial enrollment period. Once enrolled, this period is your yearly opportunity to make changes to your plan.

Special Enrollment Periods for Medicare

If you didn’t enroll in Medicare during your initial enrollment period and don’t want to wait until the next open enrollment, you may qualify for a special enrollment period. These periods allow you to enroll in Medicare or make changes to your plan immediately due to special circumstances.

The most common reason for a special enrollment period is justified enrollment delay due to gainful employment. For example, beneficiaries may delay enrollment if they have adequate health care coverage through an employer when they turn 65. Eventually, they will stop working and lose that coverage. That’s when a special enrollment period can allow them to sign up for Medicare Parts A and B right away.

Late Enrollment Penalties for Medicare

A late enrollment penalty increases your Part B premium if you don’t enroll in Original Medicare during your initial enrollment period or a special enrollment period. The penalty is 10% of the standard Part B premium for the first year you failed to enroll in Part B. After that, it goes up every year that you go without Part B coverage.

You will pay the late enrollment penalty yearly as long as you’re enrolled in Medicare Part B.

Medicare Part A penalties differ because most beneficiaries qualify for premium-free Part A. That means there is no monthly premium to increase, so there technically is no late enrollment penalty. However, beneficiaries who don’t qualify for premium-free Part A and are at least two years late enrolling may face higher premiums as a penalty.

Suppose you delay enrollment in Original Medicare because you or your spouse is still working when your Medicare eligibility opens. In that case, you shouldn’t face any late enrollment penalties once you lose your employer’s health care coverage. Instead, you will have a short special enrollment period to sign up for Medicare benefits without penalty.

Eligiblity by State

Ready To Learn More?

Choosing the right Medicare Plan is not a decision that should be taken lightly. With Policy Guide’s assistance, you will have access to the knowledge and expertise of professional agents who can help you compare different health plans, prices, and policies to ensure that you make an informed decision. Let us guide you through this process, so that your chosen plan best suits your needs.

Article Resources

 

Mark Prip

Since 2003, Mark Prip has been leading  Policy Guide, Inc., providing knowledgeable information about Medicare, life insurance, and dental coverage to clients in over forty states. With his unparalleled hands-on experience aiding countless Medicare beneficiaries in selecting an appropriate health plan - it's clear that he is a prime example amongst other competitors for expertise and assistance. Mark has held is Florida Health & Life Insurance License (E051889) since 2003. View his license profile on the Florida Department of insurance website.