Medicare Eligibility & Enrollment
You are qualified for full Medicare benefits at 65 if you meet specified eligibility requirements. You may qualify before 65, but only if you have certain medical conditions or disabilities. Your initial enrollment is open from three months before the month of your 65th birthday to three months after it, but there are other windows for Medicare enrollment as well.
- You are eligible for Medigap, Medicare Advantage and Plan D prescription drug coverage at the same time you become eligible for Original Medicare.
- Income does not impact your Medicare eligibility, but it does impact how much you’ll pay for premiums.
- You can still get Medicare if you’ve never worked, but it will most likely be more expensive and depends on your spouse’s total work history.
- Medicare enrollment is automatic only if you are already receiving Social Security benefits. If you have not received Social Security benefits, you must enroll for Medicare manually.
- You can apply for Medicare even if you are not planning to retire right away; however, you can only enroll at certain times.
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.
Medicare Eligibility at 65 and Older
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.
- You or your spouse must have worked long enough to also be eligible for Social Security benefits or for railroad retirement benefits. This usually means you have worked for at least 10 years. You must be eligible for these Social Security benefits even if you are not yet receiving them.
- You or your spouse is either a government employee or retiree who did not pay into Social Security but did pay Medicare payroll taxes while working.
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.
Other Ways To Get Medicare Coverage at Age 65
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 can pay premiums for Medicare Part A hospital insurance. Premium costs vary based on how long you have worked and paid into Medicare.
- You can pay monthly premiums for Medicare Part B medical services insurance. You’ll pay the same premiums as anyone else enrolled in Part B.
- You can pay monthly premiums for Medicare Part D prescription drug coverage. Your premium will be the standard rate and would depend upon the plan you choose.
Medicare Eligibility If You Are Under 65
- You have been receiving Social Security disability benefits for at least 24 months. These do not need to be consecutive months.
- You have end-stage renal disease requiring dialysis or a kidney transplant. You qualify if you or your spouse has paid Social Security taxes for a specified period of time, based on your age.
- You have amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease. You qualify for Medicare immediately upon diagnosis.
- You receive a disability pension from the Railroad Retirement Board and meet certain other criteria.
Who Is Eligible for Medicare Advantage Plans?
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.
- You must be a U.S. citizen, a U.S. national or lawfully present in the U.S.
- You must be enrolled in Medicare Parts A and B.
- You must live in the chosen Medicare Advantage plan provider’s service area.
- You must not have end-stage renal disease (ESRD).
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.
Medicare Supplement Plan Eligibility
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.
- You must be 65 or older.
- You have been diagnosed with Lou Gehrig’s disease.
- You have been entitled to Social Security or U.S. Railroad Retirement Board disability payments for at least 24 months.
- You have been diagnosed with end-stage renal disease, requiring regular dialysis or a kidney transplant.
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.
Initial Enrollment Periods for Medicare
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.
How to Enroll in Medicare
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.
Open Enrollment Periods for Medicare
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.
Special Enrollment Periods for Medicare
Medicare special enrollment periods can happen any time during the year due to changes to your personal circumstances.
- Moving somewhere outside of the coverage area of your current Medicare Advantage plan
- Phasing out of your employer’s health insurance plan
- Your current Medicare Advantage provider ending its contract with Medicare
Late Enrollment Penalties
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.
Frequently Asked Questions About Medicare Eligibility & Enrollment
You are typically eligible for Medicare when you turn 65 if you are a U.S. citizen or permanent legal resident. You can become eligible at a younger age if you have certain rare conditions or disabilities like amyotrophic lateral sclerosis (ALS) or end-stage renal disease.
To qualify for premium-free Part A, you must have worked and paid Medicare payroll taxes for at least 10 years.
You have a window to enroll in Medicare that begins three months before the month of your 65th birthday and ends three months after. You may be automatically enrolled at 65 if you are already receiving Social Security benefits.
Income does not affect your eligibility for Medicare but may impact how much you pay for it. Your Part B premium, which is typically $170.10 in 2022, can increase depending on your level of income.
If you have health insurance through your or your spouse’s employer, you may not have to enroll in Medicare when you turn 65.
If the employer has 20 or more employees, you can delay enrolling in Medicare until your employer’s health coverage ends without any penalties. Then, you will encounter a special enrollment period to sign up for Medicare.
If the employer has fewer than 20 employees, the company can require you to enroll in Medicare instead of using the company’s health insurance.
11 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2019, November 15). Original Medicare (Part and B) Eligibility and Enrollment. Retrieved from https://www.cms.gov/Medicare/Eligibility-and-Enrollment/OrigMedicarePartABEligEnrol
- U.S. Centers for Medicare & Medicaid Services. (2019, September). Understanding Medicare Advantage Plans. Retrieved from https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf
- U.S. Centers for Medicare & Medicaid Services. (2020, February 11). Top 5 Things You Need to Know About Medicare Enrollment. Retrieved from https://www.cms.gov/Outreach-and-Education/Find-Your-Provider-Type/Employers-and-Unions/Top-5-things-you-need-to-know-about-Medicare-Enrollment
- U.S. Centers for Medicare & Medicaid Services. (2020, February 11). Medicare Open Enrollment. https://www.cms.gov/Outreach-and-Education/Reach-Out/Find-tools-to-help-you-help-others/Medicare-Open-Enrollment
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Eligibility & Premium Calculator. Retrieved from https://www.medicare.gov/eligibilitypremiumcalc
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Get Started with Medicare. Retrieved from https://www.medicare.gov/basics/get-started-with-medicare
- U.S. Centers for Medicare & Medicaid Services. (n.d.). What’s Medicare Supplement Insurance (Medigap)? Retrieved from https://www.medicare.gov/supplements-other-insurance/whats-medicare-supplement-insurance-medigap
- U.S. Centers for Medicare & Medicaid Services. (n.d.). When Can I Buy Medigap? Retrieved from https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap
- U.S. Department of Health and Human Services. (2014, September 11). Who Is Eligible for Medicare? Retrieved from https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html
- U.S. Social Security Administration. (2019, September). Understanding Medicare Advantage and Prescription Drug Plan Enrollment Periods. Retrieved from https://www.medicare.gov/Pubs/pdf/11219-understanding-medicare-part-c-d.pdf
- U.S. Social Security Administration. (n.d.). Apply for Social Security Benefits. Retrieved from https://www.ssa.gov/benefits/forms/