Do You Qualify for Medicare?

August 7, 2019

Simply put, Medicare is a Federal Health Insurance program for people 62 and older who meet certain qualifications. It includes four parts:

Part A deals with the costs associated with a hospital stay, a stay in a skilled nursing facility, home health care, hospice services and inpatient medicine administration.

Part B deals with costs associated with paying bills for doctors, outpatient services, medical equipment, medicine from doctors, as well as their services within the hospital.

Part C allows for you to receive your Medicare benefits in different ways. This includes private health plans, such as Medicare Advantage plans (mainly HMOs and PPOs) that cover Part A, Part B and often Part D services in one package.

Part D helps pay the cost of prescription drugs and other necessary drugs. You must be enrolled in a part D plan or in a Medicare Advantage plan that offers Part D drugs.

Medicare enrollment

Source: Getty

How Do You Get Medicare?

You cannot simply purchase Medicare coverage. You must qualify for it at some level. You can qualify for Medicare based on a set of two different criteria. If you are 65 and over there is one set of qualifications you must meet. If you are under 65, there is another set of qualifications.

You qualify for Medicare over the age of 65 if:

  • You are a US citizen. If you are not a citizen, you must be a permanent legal resident with five years of living within the United States.

  • You qualify for Medicare Part A and B during an enrollment period of three months before your 65th birthday and three months after if you are not working/retired. You and/or a spouse must not have health insurance.

  • You are working and receive Social Security benefits, then you are automatically enrolled and can choose to decline Part B coverage if you prefer the coverage of your employer or spouse’s employer. You are still qualified to enroll in Part B when health coverage ends or you or a spouse stops working.

  • You or a spouse are eligible for social security benefits or railroad benefits.

  • You or your spouse are a government employee/retiree that has paid Medicare payroll taxes regardless of paying into Social Security.

  • Your spouse is at least 62 and you at are least 65.

You may also have accumulated credits during your work history. These credits apply to Medicare Part A (directly related to paying a premium on hospital expenses). If you have 40 credits or more (about 10 years of work), you will not have to pay premiums for Medicare Part A.

If you are 65 and older, and work for an employer with 20 employees or fewer, you may or may not have to enroll in Part B. If you have to enroll in Part B, Medicare will become your primary coverage. Your employer stills pays for anything that Medicare does not. You should not opt out, because If you forgo enrolling, your employer will not pay anything that would have been covered by your primary insurance (Medicare).

You qualify for Medicare under 65 if:

  • You are entitled to Social Security disability benefits for at least 24 months. This time period doesn’t have to be consecutive.

  • You get a disability pension from the Railroad Retirement Board or,

  • You have Lou Gehrig’s disease.

  • You have permanent kidney failure and must undergo regular dialysis or a kidney transplant. You or your spouse need to have paid Social Security taxes for a certain period of time, depending on your age.

Medicare

Source: Getty

Special Circumstances for Medicare

  • If you have a Health Savings Account at work, you cannot contribute to it after enrolling in Part A or Part B. You can, however, continue to use what you have already contributed.

  • If you are receiving Social Security benefits, you can not pay into a HAS because you will automatically receive Medicare Part A and B (which you can decline) upon becoming eligible.

  • If neither you or your spouse is a US citizen, you must have lived here for five years and can enroll three months after receiving your green card (you have seven months to enroll).

  • If you are not a US citizen, you can qualify if you have been married for longer than one year to a US citizen. They must be over 62 and must have 40 work credits (around 10 years of employment).

  • Medicare does not cover healthcare overseas. If you are not working, you can either enroll or delay Medicare coverage with penalties. If you have not worked enough to acquire Part A and have to pay a premium, you cannot enroll while out of the country and must wait until you return. You will also have to buy into Part A.

  • Regarding prison: You are eligible to enroll in Part B, and are expected to pay the required premiums while you’re incarcerated.

  • Regarding same-sex marriage: Circumstances do not vary in any way for same-sex marriage.

  • Regarding domestic partnerships: You must live in a state that recognizes common law marriages. Your partnership must meet the definition of a common law marriage. You must be the opposite sex of your partner.

  • If you need disability, you can qualify as a family member under your partner’s employer. The employer must employ more than 100 people and you can be opposite or same sex.

Issues With Qualification

Medicare

If you do not qualify and still cannot use a spouse to qualify, there are alternative ways to obtain full Medicare benefits. You will have to pay the premiums for Part A which ensures your hospital insurance. You can also pay for Part B at the same amount those eligible pay.

Paying for Part D is an option as well, and you will be paying the same as those who are eligible to enroll in this part of the program. Keep in mind, if you want Part A, you must buy Part B. You can also get Part D if you have A or B.

How To Check On Eligibility

For more clarification on eligibility and on special circumstances, it is important to contact Medicare at www.Medicare.gov or call the toll free number 1-800- Medicare. You can also call 1-800-772-1213 on weekdays until 7 PM or visit the local Social Security Office after making an appointment.

For information on how you can benefit from a Medicare supplement plan, check out our Medicare Supplement plan guide.