Medicare Eligibility

Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) are available to the individuals below:

  • Age 65 or older
  • Disabled for more than 2 years
  • End-Stage Renal Disease (ESRD)

Individuals with these eligibilities should contact the Social Security Administration to find apply. Once you receive your Medicare card you can then apply for additional coverages to work with or in place of your Medicare.

Note: Individuals who are turning 65 and are already receiving Social Security income are generally automatically enrolled to Medicare on their 65th birthday and should receive their card no later than 3 months prior to the 65th birthday month.

Medicare Initial Enrollment Period

Once you are on Medicare, you can enroll onto a Medicare Advantage, Prescription Drug or Medicare Supplement. Your enrollment onto one of these plans must take place within the timelines described below.

New to Medicare Initial Enrollment Periods

Being new to Medicare is generally obtained by one of these 3 circumstances; Turning 65, Disabled for more than 2 years or have End Stage Renal disease. Once you receive your Medicare benefits, you can then choose to enroll in the plan of your choice; Medicare Advantage Plan, Prescription Drug plan or Medicare Supplement plan.

If you are new to Medicare and you are choosing a:

Medicare Advantage Plan (MA Plan):

  • Turning 65- you can enroll onto an MA plan during a 7-month window. 3 months before your 65th birthday, the month of your 65th birthday and 3 months after your 65th birthday.
  • Disabled-you can enroll onto an MA plan during a 7-month window. 3 months before your Medicare Part B begins, the month your Medicare Part B begins and up to 3 months after your Medicare Part B begins.
  • End Stage Renal Disease- In most cases, if you have End-Stage Renal Disease (ESRD), you can’t join a Medicare Advantage Plan.

Prescription Drug plan (Part D Plan):

  • Turning 65, Disabled or End Stage Renal Disease- You can enroll during a 7-month window. 3 months before your Medicare Part B begins, the month your Medicare Part B begins and up to 3 months after your Medicare Part B begins.

Medicare Supplements:

Medicare Supplement plans do not have an annual enrollment period; you can choose a Supplement plan anytime throughout the year. But, the best time to purchase a Medicare Supplement plan is during the 6-month Open Enrollment Period because you will not be subject to the underwriting requirements associated with Medicare Supplement policies.

If you apply for a Medicare Supplement policy outside of your initial open enrollment period or special election period, you may be subject to underwriting set forth by that policy. Generally, these eligibility questions are as follow:

1. Within the past two years, a licensed member of the medical profession provided medical advice or treatment for:

  • end stage renal (kidney) disease
  • kidney disease that may require dialysis
  • currently receiving dialysis
  • admitted to a hospital as an inpatient within the past 90 days

2. Within the past two years, has a licensed member of the medical profession recommended any of the following treatments for a medical condition, and that treatment has NOT been completed?

A YES answer to any of the above questions would automatically disqualify you from being able to apply, unless you have a Qualified Life Event or Special Enrollment Period that would otherwise grant guaranteed acceptance.

Guaranteed Acceptance on a Medicare Supplement Policy

You have a guaranteed issue right (which means an insurance company can’t refuse to sell you a Medigap policy) in these situations:

  • You’re in a Medicare Advantage Plan, and your plan is leaving Medicare or stops giving care in your area, or you move out of the plan’s service area.
  • You have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.
  • You have Original Medicare and a Medicare SELECT policy. You move out of the Medicare SELECT policy’s service area.
  • You joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to Original Medicare. (Trial Right)
  • You dropped a Medigap policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time, you’ve been in the plan less than a year, and you want to switch back. (Trial Right)
  • Your Medigap insurance company goes bankrupt and you lose your coverage, or your Medigap policy coverage otherwise ends through no fault of your own.
  • You leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn’t followed the rules, or it misled you.

Medicare Special Enrollment Periods

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP.

You change where you live
  • I moved to a new address that isn’t in my plan’s service area.
  • I moved to a new address that’s still in my plan’s service area, but I have new plan options in my new location.
  • I moved back to the U.S. after living outside the country.
  • I just moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital).
  • I’m released from jail.
You lose your current coverage
  • I’m no longer eligible for Medicaid.
  • I left coverage from my employer or union (including COBRA coverage).
  • I involuntarily lose other drug coverage that’s as good as Medicare drug coverage (creditable coverage), or my other coverage changes and is no longer creditable.
  • I had drug coverage through a Medicare Cost Plan and I left the plan.
  • I had drug coverage through a Medicare Cost Plan and I left the plan.
  • I dropped my coverage in a Program of All-inclusive Care for the Elderly (PACE) plan.
You have a chance to get other coverage
  • I have a chance to enroll in other coverage offered by my employer or union.
  • I have or am enrolling in other drug coverage as good as Medicare prescription drug coverage (like TRICARE or VA coverage).
  • I enrolled in a Program of All-inclusive Care for the Elderly (PACE) plan.
Your plan changes its contract with Medicare
  • Medicare takes an official action (called a “sanction”) because of a problem with the plan that affects me.
  • Medicare ends (terminates) my plan’s contract.
  • My Medicare Advantage Plan, Medicare Prescription Drug Plan, or Medicare Cost Plan’s contract with Medicare isn’t renewed.
Other special situations
  • I’m eligible for both Medicare and Medicaid.
  • I qualify for Extra Help paying for Medicare prescription drug coverage.
  • I’m enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility.
  • I dropped a Medigap policy the first time I joined a Medicare Advantage Plan.
  • I have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with my condition.
  • I’m enrolled in a Special Needs Plan (SNP) and no longer have a condition that qualifies as a special need that the plan serves.
  • I joined a plan, or chose not to join a plan, due to an error by a federal employee.
  • I wasn’t properly told that my other private drug coverage wasn’t as good as Medicare drug coverage (creditable coverage).
  • I wasn’t properly told that I was losing private drug coverage that was as good as Medicare drug coverage (creditable coverage).

Medicare and Medicaid Eligibility

Individuals who have both Medicare and Medicaid may qualify for additional benefits outside of traditional Medicare. Depending on your level of Medicaid eligibility, you may have some or most of your Medicare premiums, deductibles and coinsurance covered.

Levels of Medicaid eligibility based on percentage of Federal Poverty Level
(except Alaska and Hawaii)

Qualified Medicare Beneficiary (QMB):

  • Monthly Income Limits: (100% FPL + $20)

Specified Low-Income Medicare Beneficiary (SLMB):

  • Monthly Income Limits: (120% FPL + $20)

Qualifying Individual (QI):

  • Monthly Income Limits: (135% FPL + $20)

Qualified Disabled Working Individual (QDWI):

  • Monthly Income Limits: (200% FPL + $20)

Individuals who meet certain income requirements may qualify for Extra Help to pay the costs of Medicare prescription drug coverage.

As of 2016, Low Income Subsidy Program (LIS) could reduce your costs for medications to no more than $2.95 for each generic/$7.40 for each brand-name covered drug. Some people pay only a portion of their Medicare drug plan premiums and deductibles based on their income level.

To qualify, your yearly income could be up to $17,
820 for an individual and $24,030 for a married couple, with resources not exceeding $13,640 for and individual and $27,250 for a married couple.

If you are already entitled to Medicaid, your benefits should automatically include LIS program benefits.