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Medicare Eligibility: Who May Enroll in Medicare

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Medicare eligibility – Part A and Part B

To be eligible for Medicare Part A and Part B, you must be a U.S. citizen or a permanent legal resident for at least five continuous years. You must also meet at least one of the following criteria for Medicare eligibility:

Be age 65 or older and eligible for Social Security: You may be automatically enrolled into Medicare Part A (hospital insurance) when you reach age 65 and become eligible for Social Security. Further, if you are already getting benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Part A and Part B starting the first day of the month you turn 65. (If your birthday is on the first day of the month, your Part A and Part B coverage starts the first day of the prior month.) But, if you’re not receiving retirement benefits from Social Security or the Railroad Retirement Board (for instance, because you’re still working), you must sign up for Medicare Part B when you meet the age requirement, as your enrollment isn’t automatic.

Be permanently disabled and receive disability benefits for at least two years: You automatically get Part A and Part B after you get disability benefits from Social Security for 24 months or certain disability benefits from the Railroad Retirement Board (RRB) for 24 months.

Have end-stage renal disease (ESRD) (permanent kidney failure that requires dialysis treatment or a kidney transplant): You need to sign up for Medicare, as your enrollment isn’t automatic.

Have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, or ALS): You automatically get Part A and Part B the month your disability benefits begin.

Most individuals don’t have to pay a premium for Medicare Part A if they or their spouse paid Medicare taxes while working for at least 10 years (or 40 quarters). If you’re not eligible for premium-free Part A, you will have to pay a monthly premium of up to $413 in 2017.

In addition, you must also pay the Part B premium each month. This amount may vary depending on your situation. If you enrolled in Part B before 2017 and you are receiving Social Security benefits, your monthly premium will typically be lower than the standard premium described below. If one or more of the following applies to you, you’ll pay $134 in 2017:

  • You enrolled in Part B for the first time in 2017.
  • You aren’t currently receiving retirement benefits from Social Security or the Railroad Retirement Board.
  • You’re a dual eligible (meaning you have both Medicare and Medicaid), and Medicaid pays for your premiums.
  • You’re billed directly for your Part B premiums.

Also, keep in mind that individuals with a higher income may have to pay more for their Part B premium. Be aware that if you don’t sign up for Medicare Part B when you first become eligible, you may have to pay penalty of 10% at the time you do enroll for each full 12-month period you could have had it but didn’t sign up (some exceptions apply).

Medicare Part C eligibility

Medicare Part C (also called Medicare Advantage ) is an alternative to Medicare Part A and Part B and is available through private insurers. To be eligible for Medicare Part C, you must already be enrolled in Medicare Part A and Part B, and you must reside within the service area of the Medicare Advantage plan you want. You can get more information about and enroll in a Medicare Advantage (Part C) plan by contacting one of the following:

  • 1-800-MEDICARE (1-800-633-4227; TTY users 1-877-486-2048), 24 hours a day/7 days a week; or www.medicare.gov
  • The health insurance plan directly
  • Your or your spouse’s employer
  • A licensed insurance agent or broker, such as eHealth.

With Medicare Part C coverage, you won’t need a Medicare Supplement insurance plan (Medigap), because Medicare Advantage plans typically cover more than Original Medicare (Part A and Part B).

The Medicare Advantage plan (Part C) Initial Coverage Election Period is generally the same as the Initial Enrollment Period for Medicare Part A and Part B (the seven-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65). Or, you can sign up during the Annual Election Period (AEP) from October 15 to December 7 for coverage effective January 1 of the following year. You can also enroll during a Special Election Period (SEP), if you qualify.

Medicare Part C is optional, and there is no penalty for not signing up. But you must have Medicare Part A and Part B to get Part C, and live in the service area of a Medicare Advantage plan. You also generally can’t have end-stage renal disease (with some exceptions).

If you have Medicare Part C, you must continue paying your Part B premium even if you enroll in a Medicare Advantage plan. Monthly rates and plan coverage for Medicare Advantage plans vary by the insurance company you choose and your specific plan details.

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Medicare Part D eligibility

Medicare Part D covers prescription drugs and, like Medicare Part C, is available through private insurers that are approved by Medicare. To be eligible to enroll in a Medicare prescription drug plan (PDP), you must have Medicare Part A and/or Part B and you must live in the service area for the prescription drug plan in which you want to enroll. To be eligible to enroll in a Medicare Advantage plan with prescription drug coverage (MAPD), you must have Medicare Part A and Part B, and you must live in the service area for the MAPD plan you’re considering.

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