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Are you eligible for Medicare?

Do you qualify for Medicare? Based on your situation and circumstances you may need to dig a little deeper to find out. This article answers some of the common questions people ask about Medicare eligibility.

Are you eligible for Medicare?

In most cases, determining your Medicare eligibility is fairly straight-forward. If you are a citizen of US and are about to turn 65, you are eligible. However, there are many other situations which make one eligible for Medicare, and factors which limit one’s eligibility. Some of these are Age, Citizenship status, Marriage, Location, Chronic Condition and Disability. Let us discuss them one by one.

Age

As you are probably aware, people turning 65 become eligible for Medicare.

However, there are situations like Chronic condition and Disability, which may qualify one for Medicare even before turning 65. These are discussed later.

Also, many people continue to have equivalent health insurance coverage after turning 65 either from their own or a spouse’s employer. Even though eligible, they may defer their enrollment into Medicare till the time such coverage ends when they will be eligible for a Special Enrollment Period (SEP).

Citizenship Status

To be eligible for Medicare, you must either be a US citizen or a legal permanent resident (Green Card holder) living in the US continuously for last five years. The five-year residency requirement may not apply if you have been married to a US citizen for at least one year.

Note that if you are eligible for Medicare but not Social Security, some terms may apply differently e.g. you may need to purchase Part A. This becomes a little complicated if your spouse is eligible for Social Security but you are not. We talk about this later.

Marriage

Medicare is individual-based. There is no such thing as a Medicare Family Plan. However, marriage may sometimes impact eligibility and benefits.

If you do not qualify for premium-free Part A on your own, you may still qualify for it if your Spouse qualifies for Social Security benefits and you have been married for at least one year. This applies to legal permanent residents as well. Different rules apply if you are divorced or widowed.

A tax status of ‘Married filing jointly’ may also impact your Part B and Part D premiums since they are based on income, as well as eligibility for Medicare Savings Programs / Medicaid.

Location

Note that Medicare typically provides services within the US only but you may enroll from anywhere in the world if otherwise eligible.

If you live outside the US but plan to return, you may still want to enroll into Medicare at the right time to avoid paying late enrollment penalties.

If you are living abroad you may be able to enroll only in Original Medicare (Part A and Part B). Medicare Advantage (Part C) and Prescription Drug (Part D) Plans need you to reside in their service area.

Chronic Condition

Though the list of Medicare-recognized chronic conditions is quite long and includes conditions like Diabetes, only End Stage Renal Disease (ESRD) impacts eligibility.

If you have ESRD, you may enroll into Medicare at any time irrespective of age provided you, your spouse or a parent for whom you are a dependent child qualifies under Medicare’s work history criteria.

You may need to get Original Medicare (Part B covers outpatient dialysis) along with a Prescription Drugs Plan (Part D). Depending on your State, you may also be able to get a Medigap (a.k.a. Medicare Supplement) Plan though it may cost much more if you are not in a guaranteed issue rights period. Special Needs Plans (SNPs), which are Medicare Advantage Plans, may also be available sometimes. Starting 2021, all MA Plans may need to cover ESRD.

Disability

If under 65, you automatically get Medicare Part A and Part B after getting Social Security (SSDI) or Railroad disability benefits for 24 months.

Those with Lou Gehrig’s disease (ALS) do not have to wait 24 months. They get Medicare Part A and Part B as soon as their disability benefits begin.

Once you have Medicare Part A and Part B, you may enroll into other Medicare Plans as per their signup periods.

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General / Informational Disclaimers

This website (LightedRoadInsurance.com) contains information about and access to insurance plans for eligible and soon to be eligible Medicare beneficiaries and their advisors. It is operated by Lighted Road Insurance Services, an agency affiliated with HealthCompare Insurance Services Inc., a licensed health insurance agency to sell Medicare products.

LightedRoadInsurance.com and Lighted Road Insurance Services are not endorsed by the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (DHHS), or any other government agency.

HealthCompare Insurance Services Inc. is a licensed and certified representative of Medicare Advantage HMO, POS, PPO and PFFS organizations and Medicare Prescription Drug plans with a Medicare contract. Enrollment in any plan depends on contract renewal.

For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

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Last Updated: 11-17-2019