Who is eligible for Medicare insurance coverage? Well, it’s not just for those turning age 65. There are other scenarios when you can obtain Medicare coverage. Medicare eligibility can be based on Age (turning 65), Social Security Disability, ALS (Lou Gehrig’s Disease), and ESRD (End Stage Renal Disease). Let’s break it down…
Age (Turning 65)
The most common Medicare eligibility scenario is when you turn 65. In this case, you’re eligible for Medicare if…
You’re turning 65...AND
You’re a US citizen (or permanent legal resident who has lived in the US for at least 5 years)...AND
Part A will have no monthly premium if…You’ve contributed to the Medicare system for 40+ quarters (which is about 10 years of work history)
If you don’t have the necessary work history, you may be able to enroll under your spouse’s work record...assuming you’ve been married at least 1 year, your spouse has 40+ quarters of work, and is at least age 62.
This is also available under an ex-spouse if you were married at least 10 years.
Note: Part B has a monthly premium that’s based on your income. You can see the monthly premium table on our Medicare Costs page.
Do you need Medicare when covered in a group health plan?
When you’re Medicare-eligible at age 65 and covered in a group health plan based on your active employment or your spouse’s, you can delay Medicare Part A and/or Part B when the employer has 20+ employees. The group health plan is primary to any Medicare in this scenario. Some people enroll in Part A only in this situation,
But if the employer has less than 20 employees, Medicare is primary and you need to enroll in Medicare Part A & B when you’re first eligible to avoid a potential late enrollment penalty, as well as coordination of benefits issues.
Medicare enrollment based on Age:
Automatic Enrollment -- If you’re receiving Social Security retirement benefits, your Medicare card will automatically arrive about 3 months prior to your Medicare eligibility month. You must keep Medicare Part A (hospital) benefits in this scenario, but you have the option to deny Part B (medical/outpatient) benefits. Reference our video 4 Reasons Why You Should Delay Medicare for a couple scenarios when Medicare enrollment is not beneficial.
Proactive Enrollment -- If you’re NOT receiving Social Security retirement benefits and want Medicare coverage, you need to proactively enroll in Medicare online at www.ssa.gov. Watch our video How to Enroll in Medicare Online for step-by-step instructions to get this done.
Social Security Disability
If you’re disabled and receiving SSDI (Social Security Disability Insurance) benefits prior to age 65, you’ll automatically be eligible for Medicare after 24 months of disability. Your Medicare card will arrive about 3 months prior to your 25th month of disability benefits.
Because of the SSDI payments, you must keep the Part A (hospital) coverage. Part B (medical/outpatient) coverage is optional, but be very careful in this situation. Depending on your existing health insurance coverage, you may be required to have Part B.
An example of this is when you’re covered in a group health insurance plan with less than 100 employees. When you’re Medicare eligible due to disability prior to age 65, Medicare is primary to the group health plan when there are less than 100 employees at the employer. But if the employer has 100+ employees, you have the option to deny the Part B coverage, because the group health plan would be primary.
Medicare enrollment based on Disability:
Automatic Enrollment -- Since you’re already receiving Social Security disability benefits, you’ll receive your Medicare card automatically about 3 months prior to your 25th month of disability benefits.
ALS (Lou Gehrig’s Disease)
If you have ALS (Amyotrophic Lateral Sclerosis), you’re automatically eligible for Medicare the month your Social Security disability benefits begin. Just as we mentioned in the case of Disability, you’ll need to consider whether to keep Part B, based on your existing health insurance coverage.
Medicare enrollment based on ALS:
Automatic Enrollment -- Since the ALS would qualify you for Social Security disability benefits, you would receive your Medicare card automatically the month those benefits begin. This assumes you already applied for Social Security disability.
ESRD (End-Stage Renal Disease) - Kidney Failure
Medicare based on ESRD can get very complicated. We strongly suggest you consult with Social Security directly and read every section of Medicare’s ESRD reference page at https://www.medicare.gov/basics/end-stage-renal-disease.
Here’s a summary of the basics...
If your kidneys no longer work, and you need regular dialysis or have already had a kidney transplant...you’re eligible for Medicare coverage...as long as one of the below scenarios applies to you also:
You have the necessary amount of work history to qualify (be sure to confirm with Social Security if you qualify based on work credits, age, and time of ESRD application)...OR
You already receive Social Security benefits...OR
You’re the spouse or dependent child of a person who meets one of the above requirements
When will your Medicare coverage start?
If you’re on dialysis, Medicare will usually start the first day of the 4th month of dialysis treatment.
Medicare can potentially start immediately if you’re doing a home dialysis training program.
Medicare can also start immediately when you’re admitted to a Medicare-approved hospital for a kidney transplant.
When you’re covered in a group health plan, the first 3 months of dialysis will run exclusively through your employer health plan because Medicare typically won’t start until the 4th month of dialysis.
The next 30 months (also known as “Coordination Period”) of dialysis coordinates between the group health plan and Medicare. The group plan will be primary and Medicare will be secondary during this time period.
After the “Coordination Period” ends, Medicare will become primary and the group plan will switch to the secondary position, if needed.
Regardless, we highly recommend taking both Part A and Part B coverage when eligible based on ESRD. If you don’t keep the Part B coverage and later try to enroll, you might have a late enrollment penalty.
And there is a lot more to mention about Medicare and ESRD coverage, so we urge you to reference all the details at www.medicare.gov.
Medicare enrollment based on ESRD:
Proactive Enrollment -- While you might automatically qualify for Medicare because of ESRD, you still need to proactively submit an enrollment application for Medicare. This should be done through a local Social Security office or by phone (800-772-1213). ESRD enrollments cannot be done online.
As you can see, Medicare coverage can begin for many reasons outside of turning age 65.
Reference Links
4 Reasons Why You Should Delay Medicare
www.ssa.gov
How to Enroll in Medicare Online
www.medicare.gov
Getting Medicare If You Have A Disability
Medicare & ESRD
Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.
