Healthcare Educators


Do I Qualify for Medicare?

by | Feb 20, 2023

If you find yourself asking this question you are not alone in trying to understand Medicare’s eligibility rules. Eligibility for Medicare is usually determined by age or by disability. In either case, there are some basic requirements that must be met.

You are eligible:

  • If you are a U.S. citizen or a permanent legal resident who has lived in the United States for at least five years.
  • Are entitled to receive Social Security benefits.

In this case “Medicare” refers to what is known as Original Medicare which includes Part A (inpatient hospital care) and Part B (doctor visits and outpatient care).

Qualifying at Age 65

Most people know they qualify for Medicare when they turn 65, but they don’t always know when they should sign up.

If you are collecting Social Security retirement benefits or Railroad Retirement Board benefits, you will automatically be enrolled in Medicare Parts A and B. Your Medicare card will be mailed to you about three months before your 65th birthday. Your benefits will start the first day of the month you turn 65.

If you are not collecting Social Security retirement benefits you need to take steps to enroll during what is known as your Initial Enrollment Period. This is the 7-month period that includes the three months before your 65th birthday, your birthday month, and three months following. If you enroll during the three months prior to your birthday benefits will be effective the first day of your birthday month, otherwise you could face a delay of up to three months.

It’s important to understand the timelines for enrolling so you avoid any late penalties  and potential gaps in coverage. Late penalties continue to accrue the longer you wait, and you will pay them for your entire lifetime.

Should I Enroll if I am Working Past 65?

The answer to this question will vary depending on your individual situation.

Medicare Part A

It is recommended that you enroll in Part A when you turn 65, even if you continue to work. Part A is usually free to those who have worked at least 40 quarters, or 10 years.

If you have not met that requirement, you will have to pay a monthly premium for Part A. The premium is based on how many quarters you paid taxes. In 2023 if you’ve worked anywhere between 30 and 39 quarters, you will pay a premium of $278 per month. Anything less than 30 quarters your premium will be the full $506. The premiums change each year.

If you haven’t worked enough to earn the necessary 40 credits, it may be possible to qualify for premium free Part A based on your spouse’s work history and Medicare eligibility.

You may qualify if:

  • You are at least 65 years old.
  • Married – If you are currently married for at least one year and your spouse is eligible for Social Security benefits under disability or retirement.
  • Divorced – Individuals who are now single but were married to their former spouse for 10 or more years.
  • Widowed – You were married at least nine months before your spouse died and you are currently single.

For Medicare Part B and Part D drug plans, Medicare Advantage and Medicare Supplement plans, your work history has no impact on the premium amounts you pay. Paying a premium for Part A will not impact what you pay for other coverage.

Medicare Part B

Whether you should sign up for Part B if you are still working at age 65 is determined by the size of your employer.

Large Group Employer- If your company has 20 or more employees, you can delay enrolling without worrying about late penalties or gaps in coverage. Your employer coverage will be your primary insurance. When you leave your job you will have an eight month Special Enrollment Period to sign up for Part B. You must enroll during this time or face late penalties and a possible gap in coverage.

Small Group Employer – If your company has fewer than 20 employees, you will need to enroll in Part B. By law, your employer group insurance is only required to pay after Medicare pays first as your primary insurance. If you fail to enroll you could be responsible for the 80% that Medicare usually covers. To avoid late penalties and a delay in coverage you should enroll in both Part A and Part B during your Initial Enrollment Period at age 65.

If you are covered under your spouse’s employer health insurance the rules are the same.

Qualifying Due to Disability

If you qualify for Medicare based on a disability, you don’t have to be 65 years old. In most cases enrollment in Part A and B is automatic for people with disabilities receiving Social Security disability benefits.

You qualify for Medicare if:

  • You have been entitled to disability benefits from Social Security or the Railroad Retirement Board for at least 24 months (that need not be consecutive). You will automatically be enrolled on the 25th month.
  • You have Lou Gehrig’s disease (ALS). You will automatically be enrolled the month you start receiving disability benefits.
  • You have permanent kidney failure requiring regular dialysis or a kidney transplant. You will automatically be enrolled the month you start receiving disability benefits. You must also meet one of the following: you meet the work criteria under Social Security, the Railroad Retirement Board or government employee guidelines; you’re eligible for or are already receiving benefits from Social Security or the Railroad Retirement Board; or you’re the spouse or dependent child of a person who meets one of the first two requirements.

Other Medicare Decisions

Once you are enrolled in Parts A and B you have some additional decisions to make. Original Medicare does not cover everything and comes with out-of-pocket expenses. Part A has an annual deductible of $1,600 in 2023 and has annual limits on benefits, which means there is no cap on how much you may have to spend in one year. Part B has a standard premium of $164.90 per month in 2023 (those with higher incomes may pay more) and has an annual deductible of $226. Once that is met Medicare typically pays 80% and you are responsible for the other 20%. Also there is no prescription drug coverage included with Part A and B.

There are a couple options on how to cover these expenses and pick up a Part D prescription plan:

  • Medigap or Medicare Supplement Plans are designed to reimburse you for some of the expenses not covered by Parts A and B. You can also pick up prescription coverage with a stand-alone Medicare Part D plan.
  • Medicare Advantage or Part C plans are offered by private insurers and may cover additional services such as vision, dental, hearing, and gym memberships and most provide prescription drug coverage.

Depending on your income, you might qualify for a Medicare Savings Programs that helps pay premiums, deductibles, coinsurance and copayments.

How To Enroll

You can apply for Medicare online, over the phone at 1-800-772-1213 or in person at your  Local Social Security Office. It is recommended that you sign up when you are first eligible to avoid late penalties and gaps in coverage.

Medicare can be complex and confusing. It’s important to make the right decision at the right time based on your individual situation. Medicare Educators is here to help. Call us today.