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Medicare eligibility is generally based on:
Before you can enroll in any additional Medicare coverage such as Medicare Advantage, Part D, or supplements, you must be enrolled in Original Medicare (Part A and Part B).
Generally, individuals must be at least 65 years old to be eligible for Original Medicare (Part A and Part B). However, those who are under 65 and receive Social Security Disability Income (SSDI) for at least 24 months or have a diagnosis of amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ESRD) may also enroll in the federal healthcare program.
Then, if you meet the age or disability requirements, you will automatically qualify for health coverage through Medicare as long as you are a U.S. citizen or have legal residency in the U.S. for at least five years.
The foundation for eligibility in all other Medicare plans is enrollment in both Part A and Part B.
Many people enroll in Original Medicare (Parts A and B) at age 65. At that time, you will have what is called your Initial Enrollment Period (IEP).
Roughly 3 months before your 65th birthday, you will receive a notice in the mail—either that you have been automatically enrolled in Part A and/or Part B, or instructions on how to enroll.
It is good to mention that this coverage is not free of charge. However, Medicare Part A hospital coverage does not require a monthly premium, but only if you or your spouse qualify. To be eligible, you or your spouse must have paid Medicare taxes for at least 40 quarters or ten years. If not, you will need to pay for Medicare Part A based on how many working quarters you paid the tax. You can check your eligibility status and the cost of your premium-free Medicare Part A through your SSA.gov account by seeing how many eligible working quarters you paid Medicare taxes.
On the other hand, Medicare Part B premium is obligation for every enrollee. Monthly premium cost may be subject to change every calendar year. Currently the premium amount is 164.90$ for most beneficiaries. Some individuals may pay higher premium due to IRMAA or Income Related Monthly Adjustment Amount. How much your premium will be depends on calculation of your tax return from two years prior.
You may, however, be eligible before you turn 65 based on a few factors, one of which is your current health. If you have End-Stage Renal Disease (ESRD), Lou Gehrig’s Disease, or ALS, you have the opportunity to enroll in Medicare.
You can also be eligible before age 65 if you have a disability. After 24 months of receiving Social Security benefits, you will be automatically enrolled.
However, if you are on disability due to ALS, you will automatically receive Medicare coverage the same month your disability benefits start. The Social Security Administration decides whether you qualify for disability benefits, not Medicare. However, if you have an end-stage renal disease (ESRD), you must enroll yourself in Medicare. You can do this online or by contacting your local SSA office.
In order to be eligible for Medicare Advantage, you simply have to be enrolled in both Part A and Part B, including those under 65 due to disability. You can enroll in a Medicare Advantage plan if you live in the plan’s service area, and you will need to pay both the plan’s monthly premium and your Medicare Part B premium.. Patients with End-Stage Renal Disease (ESRD) may also qualify for Medicare Advantage, with coverage typically starting on the fourth month of dialysis. Medicare coverage for ESRD patients can end 12 months after the month their dialysis treatment ends or 36 months after receiving a kidney transplant. Special Needs Plans are available for those with chronic conditions, but their availability may vary based on where you live.. Once you have done so, providers of Advantage plan cannot turn you away for health issues.
To summarize, in order to qualify for a Medicare Advantage plan, you need to know your Medicare Part A and Part B effective date, have your Medicare card number, and live in the plan’s service area. If you are unsure of your Medicare eligibility, you can contact Social Security for further information.
If you are eligible for Medicare Advantage, there are multiple opportunities to select a Medicare Advantage plan. The Initial Enrollment Period is for those who turn 65, while the Initial Coverage Enrollment Period is for those who delay Medicare Part B. The Annual Enrollment Period is from October 15 to December 7, and the Medicare Advantage Open Enrollment Period is from January to March. Additionally, Special Enrollment Periods allow you to change plans during certain life-changing or policy-changing situations.
The same goes for Part D as Part C—as long as you’re enrolled in Original Medicare, you are eligible for Part D. However, if you have an Advantage plan, you may already have prescription drug coverage, and therefore don’t need Part D.
Note that, if you are already enrolled in a Medicare Advantage plan with prescription drug coverage, you cannot sign up for a separate Medicare Part D plan.
However, you can be to be enrolled in one part of Original Medicare to get Par D coverage. There are several plan combinations involving Medicare Part D, including Medicare Part A + Medicare Part D, Medicare Part B + Medicare Part D, Medicare Part A + Medicare Part B + Medicare Part D, Medicare Part A + Medicare Part B + Medicaid + Medicare Part D, Medicare Part A + Medicare Part B + Medicare Supplement + Medicare Part D, and Medicare Part C + Medicare Part D. However, as already explained, it is not possible to enroll in both a Medicare Advantage Prescription Drug plan and a standalone Medicare Part D plan because you cannot have two types of prescription drug coverage through Medicare.
Keep in mind that you will no longer be eligible for Part D if you have a supplement plan—you may only have one or the other.
Also keep in mind that if f you don’t enroll in Medicare Part D during your Initial Enrollment Period ( when you are first eligible) and you don’t have creditable drug coverage, you will be subject to the Medicare Part D late enrollment penalty when you do enroll in the future. Therefore, it is essential to have creditable drug coverage in place if you decide to delay Medicare Part D enrollment.
Medicare Supplement is available to anyone eligible for Original Medicare, but eligibility does not guarantee coverage as Medigap benefits come from private insurance carriers. There are several stipulations that can arise, such as being under 65 or having certain medical conditions. It is important to understand the guidelines and parameters that apply to individual situations.
To be eligible for a Medicare Supplement plan, individuals must be 65 or older and eligible for Original Medicare. They must also be a US citizen or legal resident for at least five years and reside in a state offering the plan they want. Medical underwriting is required for those outside of Open Enrollment or a Special Enrollment Period in most states.
However, many seniors will automatically enroll in Medicare Part A at age 65, and some will also automatically enroll in Medicare Part B.
During the six-month Medicare Supplement Open Enrollment period, which begins when you acquire both parts of Original Medicare, you can choose a Medigap policy without having to answer underwriting questions or being impacted by pre-existing conditions. It is recommended that beneficiaries take advantage of this once-in-a-lifetime opportunity, as waiting can result in being denied coverage by private insurance carriers. The best time to enroll in a Medicare Supplement plan with guaranteed acceptance is the month your Medicare Part B becomes active and the following five months. The closer you are to age 65, the better your chance of obtaining high-quality coverage.
Medigap plans are also available for those under 65, but individuals who qualify for Medicare due to disability have limited options, as not all states offer Medigap plans to this group. Only a few states require private insurance companies to offer at least one policy to those under 65. These individuals often have higher premiums as they pose a higher risk for claims. The only option for many people under 65 is the least comprehensive plan, Medicare Supplement Plan A. However, individuals under 65 who become eligible for Medicare Supplement should plan to purchase a Medigap plan during their second Medigap Open Enrollment Period to protect their savings from high healthcare expenses.
We are in the business of advice—after all, it’s in our name. Our top priority is getting you the Medicare coverage you really need.
We will get you the coverage and deals you can’t find on your own, no strings attached. If you are ready to get started, call Texas Medicare Advisors today at 512-900-3008.
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