Medicare Eligibility and Enrollment
- Did you know that Medicare enrollment might not be automatic in every case? Find out how to get a Medicare card and what types of plans may be available to you and when.
Medicare is a federally sponsored health care benefits program that helps cover medical expenses for older adults and qualified individuals with certain health conditions or disabilities.
But contrary to what you might think, Medicare enrollment isn't always automatic as soon as you turn 65.
Find out more about Medicare health coverage, including the types of benefits you might qualify for and how to enroll in them, below.
Who Is Eligible for Medicare Coverage?
Medicare eligibility falls into three categories. You're usually eligible if you meet the requirements of one of these categories:
- You are age 65 or older
- You are younger but have a permanent disability
- You have end-stage renal disease (ESRD) that requires a kidney transplant or dialysis
How Do You Sign Up for Medicare?
For those who are turning 65 soon and who meet the eligibility requirements, there are a few ways to enroll in Medicare.
If you're 65 or turning 65 within the next three months and you're already receiving Social Security benefits, you will likely be enrolled in Medicare Part A and Part B automatically.
You'll get a packet in the mail with information about your coverage options, so you do need to pay attention to whether or not you received that so you can finalize enrollment appropriately and choose your plan options. You should receive your red, white and blue Medicare card in the mail sometime around 3 months before your 65th birthday.
If you aren't getting Social Security or Railroad benefits by 4 months prior to turning 65, then you may need to act to enroll in Medicare. You can sign up for Medicare during your personal Initial Enrollment Period (IEP), which lasts for 7 months. The period includes the month you turn 65 as well as the previous 3 months and the following 3 months.
You may also be able to enroll in Part A and/or Part B during the General Enrollment Period between January 1 and March 31 of each year if you don't enroll during your Initial Enrollment Period.
Depending on your situation, you may be able to enroll in Part A and/or Part B during a Special Enrollment Period (SEP), which can happen at any point during the year depending on your circumstances.
You can complete an online application for Medicare via the Social Security Administration's official website. You don't have to be ready to retire or accept Social Security retirement benefits to complete the application just for Medicare.
What Types of Medicare Coverage Are There?
Medicare includes a few specific programs:
- Part A, which is inpatient hospital insurance coverage
- Part B, which is Medicare coverage for certain outpatient services, medical care and durable medical equipment
Medicare Part A and Part B are commonly referred to together as Original Medicare. They are provided by the federal government.
There are two additional parts of Medicare, both of which are offered by private insurance companies and regulated by the government.
- Part C, also called Medicare Advantage, which refers to coverage offered by approved private companies that replaces Part A and Part B and, in many cases, offers additional benefits not covered by Original Medicare
- Part D, which refers to Medicare prescription drug coverage
Part A: Eligibility, Coverage and Costs
Part A Medicare is designed to pay major medical benefits, such as inpatient hospital expenses. It may also cover surgery, lab tests, hospice care, treatment in a skilled nursing facility and some home health care.
If you are age 65 or older and you or your spouse worked and made tax payments toward Medicare for 10 or more years during your life, then you can get Part A coverage without paying premiums. You might also qualify for Medicare Part A without premium costs if you are 65 and older and you are eligible to receive Social Security or Railroad benefits or if you or your spouse worked for certain government employers.
If you're over the age of 65 and don't meet these requirements, you can still get Part A, but you may have to pay a premium for the coverage. Medicare.gov offers an eligibility tool to help you understand what your costs might be.
Those under age 65 who qualify for Medicare due to disability or renal failure typically aren't required to pay premiums for their Part A coverage.
Part B: Eligibility, Coverage and Costs
Part B coverage helps pay for outpatient procedures, such as doctor's visits and physical therapy, as well as durable medical equipment and some medical supplies, including diabetic testing equipment.
Part B is optional coverage that comes with a monthly premium. The cost of the premium depends on your income, but as of 2020, the standard Part B premium is $144.60 per month.
Part B coverage also comes with a deductible — $198 per year as of 2020 — and typically a 20% coinsurance charge for services you receive after you meet your deductible.
Many people choose to purchase supplemental insurance plans that pay secondary to Medicare to cover that 20%. These plans are called Medicare Supplement Insurance plans, also known as Medigap. They can help pay for out-of-pocket Medicare costs like deductibles, copays, coinsurance and more.
Medicare beneficiaries who also qualify for Medicaid may also be able to use it to cover the Part B deductible and copay amounts left by Part B.
If you're eligible for Medicare part A at age 65, you are typically eligible for Part B.
Part C: Medicare Advantage Plans
Individuals can choose to enroll in traditional Medicare Part A and/or B or select a Medicare Advantage Plan. These plans typically work as HMO and PPO insurance plans that you might be experienced with through employer-sponsored health insurance programs.
While these plans must follow Medicare rules and offer benefits at least on par with traditional Medicare, they can also offer additional coverage options.
Some Medicare Advantage plans may offer dental, vision and hearing coverage or wellness programs to help pay for gym memberships, for example. They might also have different rules for how you access coverage, such as whether you need a referral from your primary care physician before you can see a specialist.
Most Medicare Advantage plans offer prescription drug coverage.
Because they offer different benefits, Medicare Advantage plan costs may vary with regard to premiums, deductibles and coinsurance. Some plans may offer $0 monthly premiums. If you're considering one of these plans, make sure you understand the benefits structure so you know if you're getting a good value for whatever premiums you might pay.
Part D: Prescription Drug Coverage
You can add prescription drug coverage to your Medicare Part A and Part B coverage (or to your Medicare Advantage plan, if it doesn’t include prescription drug coverage) by enrolling in a Medicare Part D plan.
Part D coverage is often included in Medicare Advantage Plans. You can also purchase a separate standalone Part D plan, which is often referred to as a PDP.
When choosing a plan for prescription drug coverage, it's important to look at the list of covered drugs(called a formulary), how generic and brand-name drugs are covered, and what tiers the insurance pays for so you can understand how much your medicine might cost.