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Medicare Eligibility: Who Qualifies for Medicare?

Medicare Made Easy

Medicare Eligibility: Who Qualifies for Medicare?

What Is Medicare?

Medicare is a government-run health program for older or disabled individuals. There are several parts to Medicare, and each part covers different things. The four main parts are:

Part A: Hospital coverage

Part B: Doctor’s visits, lab work, x-rays, etc.

Part C: Medicare Advantage (combines both A & B in one plan)

Part D: Prescription drug coverage

Then there are many more types that are specific to certain situations. Most of these are Medicare Advantage plans, which we’ll discuss below.

Understanding the various parts of Medicare is critical to making the right choices and taking the right steps at the right time.

Medicare Eligibility:

Most people become eligible for Medicare when they turn 65, based on their work record or the work record of their spouse.

There are other ways to qualify, such as through Social Security disability income.

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. What Medicare covers is based upon, Federal and state laws, National coverage decisions made by Medicare about whether something is covered, and local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Medicare Part B is available at a monthly rate set annually by Congress ($134 in 2017 for incomes $85000.00 or less for an individual). Part B covers certain doctor’s services, outpatient care, medical supplies, and preventive services. Some seniors are eligible to receive the medical insurance portion (Part B) free as well, depending on their income and asset levels. For more information, inquire about the Qualified Medicare Beneficiary (QMB), Special Low Income Medicare Beneficiary (SLMB), and Qualifying Individual programs through your county social services office.

Remember, in most cases, if you don’t sign up for Part B when you are first eligible, you will have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period so you could have had Part B but didn’t sign up for it. Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B, and coverage will start on July 1 of that year. Usually, you don’t pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period (SEP).

Medicare Part C (Medicare Advantage Plans) is a type of Medicare health plan offered by a private insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans (PFFS), Special Needs Plans (SNP’s), and Medicare Medical Savings Account Plans (MSA’s). If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and are not paid for under Original Medicare. Most Medicare Advantage Plans have prescription drug coverage included.

Medicare Part D (prescription drug coverage) adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare.

Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. Keep in mind, that you may owe a late enrollment penalty if you go without a Medicare Prescription Drug Plan (Part D), or without a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage, or without creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over.

How To Enroll in Medicare?

If you are already receiving Social Security benefits when you turn 65, you will be automatically enrolled in Medicare Part A and Part B.

If you’re not receiving Social Security benefits when you turn 65, you need to sign up for Medicare Part A and Part B either online or at the Social Security office.

If you are eligible for Medicare, you should be receiving many offers from Part C and Part D providers.

Next, learn: How Medicare Works