Medicare Qualifications

By Medicare Benefits - August 31, 2020

For people living without insurance, paying out-of-pocket for medical emergencies and routine medical care can be extremely stressful, and even catastrophic. Statistics show that over 27 million adults are currently living without the protection of health insurance.

Fortunately for Americans who are 65 years of age or older, and some individuals under 65 who qualify due to disability, Medicare provides access to quality healthcare insurance at an affordable cost. There are over 52 million seniors 65 and approximately 8 million beneficiaries under 65 who depend on Medicare to help cover the cost of medical expenses.

Who is eligible for Medicare?

You may qualify for Medicare Part A and Medicare Part B if you meet the following criteria:

  • You are 65 years of age or older
  • You are a United States citizen or a permanent legal resident who has lived in the U.S. for five years or longer
  • You are under 65 who have been receiving Social Security disability benefits for 24 months
  • You get disability benefits from the Railroad Retirement Board
  • You are diagnosed with amyotrophic lateral sclerosis (Lou Gehrig’s disease or ALS)
  • You have end-stage renal disease or permanent kidney failure which requires dialysis or a kidney transplant.

Part A

Medicare Part A helps cover the cost of inpatient hospital stays, skilled nursing facility care, home health care, and hospice. Most people get Part A premium-free because you or your spouse have worked and paid Social Security taxes for at least 40 quarters, or the equivalent of 10 years.). If you or your spouse works for the U.S. government or is a government retiree who paid Medicare payroll taxes rather than Social Security taxes, you are still eligible.

If you or your spouse’s work records do not meet the required 40 quarters for Medicare eligibility, you may be eligible to purchase your Medicare Part A coverage. For instance,
if you have under 30 credits, you would pay a monthly premium of $458.00 as of 2020. If you have between 30 and 39 credits, you would pay $252.00 per month in 2020. If you continue working while you pay for Part A and you eventually reach 40 quarters, your coverage continues as premium-free Part A.

Part B

Medicare Part B helps cover the cost of medically necessary outpatient services and supplies, including doctor visits, outpatient procedures, preventive care, and durable medical equipment. When you qualify for Medicare, you may be automatically enrolled in Part A, but Part B (medical insurance) is optional. You can opt out of Part B coverage, but most people enroll in Part B as soon as they are eligible to avoid paying late enrollment penalties later.

You will likely be responsible for paying a monthly premium for Part B benefits. In 2020, the standard monthly premium amount is $144.60 based on your income.  You will also need to pay an annual deductible before Medicare will start to pay.

Part C

When you qualify for Medicare, you can choose to get your benefits from Original Medicare or through Part C, known as Medicare Advantage. Original Medicare is the federal program that administers your Part A and Part B benefits. You can choose to stay with Original Medicare or you can enroll in a Medicare Advantage plan. Medicare Advantage plans are offered by private insurance companies that contract with Medicare to provide your Part A and Part B coverage, but most MA plans include additional benefits.

Once you have both Part A and Part B, you may be eligible to enroll in a Medicare Advantage plan. You may enroll in Medicare Advantage during your Initial Enrollment Period, which is the 7-month period that begins 3 months before you turn 65, continues during your birth month, and ends three months after your birthday. If you have Original Medicare, you can switch to a Medicare Advantage plan during the Annual Enrollment Period, which begins October 15 and lasts until December 7 each year.


Part D

Part A and Part B benefits do not include prescription drug coverage, so many Medicare recipients choose to enroll in Medicare Part D. If you have Original Medicare, you can enroll in a standalone Prescription Drug Plan (PDP). As an alternative, you can choose to get your Part A and Part B benefits through a Medicare Advantage plan with prescription drug coverage (MA-PD).

PDPs and MA-PDs are sold by private insurance companies. Each plan can have its own formulary, or list of covered drugs. Coverage and costs can vary between plans. If you do not enroll in a Part D plan when you are first eligible, you may incur late enrollment fees when you enroll later on.


Medigap

Medigap, or Medicare Supplement, plans are sold by private insurance companies to help cover some of the costs that Original Medicare does not. You will be eligible to purchase a Medigap plan once you turn 65 and are enrolled in Part B. You will have a 7-month Medigap enrollment period during which you have a guaranteed issue right to purchase any Medigap plan sold in your state. During this time, you will not be subject to medical underwriting. If you want to buy a Medigap plan after your initial enrollment period ends, you can be turned down or charged more due to pre-existing conditions.

Please note that Medigap plans are not usually offered to Medicare recipients under the age of 65, but if you are interested in purchasing a plan, check with your state to find out if any plans are offered. If you are enrolled in a Medicare Advantage plan, you cannot purchase Medigap coverage.

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