Medicare Eligibility & Enrollment

Medicare is best known as a federal health insurance program for people 65 and older. But not everyone will automatically qualify for Medicare benefits when they turn 65.

There are several requirements you must meet in order to qualify for the program. These requirements include a minimum number of years you have to have paid into the Medicare program via payroll taxes, as well as your U.S. citizenship and immigration status.

You can apply for Medicare the year you turn 65, but you generally must meet three eligibility requirements to qualify for full Medicare benefits at this age.

The chief requirement is that you must be a U.S. citizen or permanent legal resident who has lived in the U.S. for at least five years.

If you pay Medicare payroll taxes for 10 full years, you won’t have to pay premiums for Medicare Part A, which covers hospital care.

You don’t need the work credits to qualify for Medicare Part B, which covers doctor visits or outpatient services, and Medicare Part D, which covers prescription drugs. Everyone pays premiums for both regardless of work history.

If you are still working at 65, you don’t have to sign up for Medicare — but there are benefits to signing up while still employed. Similarly, if you have never worked, you can still get Medicare. It may be more expensive depending on your spouse’s work history.

If you don’t qualify for premium-free Medicare Part A coverage, you may be eligible to buy coverage. However, you must still be a U.S. citizen or a permanent resident for at least five years to qualify.

You will not be able to purchase a Medicare Advantage plan or Medigap supplemental insurance unless you are enrolled in Original Medicare — Medicare Parts A and B.

People younger than 65 may qualify for Medicare if they have certain costly medical conditions or disabilities.

You’ll automatically qualify for Medicare Advantage (Part C) once you qualify for Part A and Part B coverage. Advantage plans are sold by private companies and are designed to cover some of the out-of-pocket costs Original Medicare does not cover.

While regular Medicare Advantage does not cover ESRD, you may qualify for a Medicare Special Needs Plan (SNP). SNPs are special types of Advantage plans specifically designed for a particular condition or financial situation.

You can keep your Medicare Advantage plan if you purchased it before developing ESRD. You can also buy an Advantage plan after being medically determined to no longer have ESRD — usually from a successful kidney transplant.

Like Medicare Advantage, Medicare supplemental insurance — often called Medigap because it fills in the out-of-pocket coverage gaps in Medicare Parts A and B — is also purchased from private insurers.

Medigap helps cover copayments, coinsurance and deductibles from Medicare Part A and Part B.

Enrollment is automatic if you’re already receiving Social Security benefits. If not, you can sign up online, by phone or in person at your Social Security office. Enrollment takes less than 10 minutes online, according to the Social Security Administration (SSA).

You can apply for Medicare even if you are not planning to retire right away; however, you can only enroll at certain times of the year.

It’s important to understand how Medicare enrollment works so that you can avoid common mistakes and penalties.

Your initial enrollment period is open three months before your 65th birth month, includes your birth month and runs until the next three months after it.

You enroll in Medicare through the SSA. After that, your benefits will be administered by the U.S. Centers for Medicare & Medicaid Services.

When you first enroll, you will sign up for Medicare Part A hospital insurance. If you’ve worked and paid Medicare payroll taxes for at least 10 years, there will be no premium. At that point, you’ll be given the choice to sign up for Medicare Part B medical insurance.

During this time, you’ll also be able to sign up for a Medicare Advantage plan. If you stay with Original Medicare, you can select a Medicare Part D plan for stand-alone prescription drug coverage. Otherwise, Medicare Part D is often included in a Medicare Advantage plan.

Outside of the initial enrollment period, there are certain times each year when you can switch or enroll in different Medicare plans. One such time is called the Medicare open enrollment period.

Open enrollment is made available to beneficiaries because Medicare health and drug plans can make changes once per year. Plan changes may include how much the plans cost, what the plan covers or which doctors, pharmacies and other health care providers are in the plan’s network.

The Medicare open enrollment period gives you a chance to switch plans if you don’t like the changes made by your provider to your plan.

Medicare special enrollment periods can happen any time during the year due to changes to your personal circumstances.

You can decline Part B coverage during initial enrollment if you don’t want to pay the premium — but applying for it later will cost you a monthly penalty. The cost of your Part B monthly premium will increase by 10% for each 12-month period you were eligible but did not enroll.

You may also have to pay a late enrollment penalty on Medicare Part D if you go more than 63 days without creditable prescription drug coverage after your initial enrollment period ends.

There is no late enrollment penalty fee for Medicare Advantage plans.