Understanding Medicare / Eligibility & Enrollment

Medicare Eligibility & Enrollment

Medicare eligibility and enrollment can be tricky, but we’re here to help you make sense of it all.

Jump to Section

Key takeaways
Medicare Eligibility
Medicare Eligibility Calculator
Medicare Enrollment
Combining Medicare Plans
FAQs

Key Takeaways

Some people simply think of Medicare as their health insurance plan for retirement, but not everyone will retire when they turn 65. And, while most U.S. adults become eligible for healthcare coverage from Medicare when they turn 65 years old, some may qualify sooner.

To plan for your healthcare needs in the years ahead, you should know what to expect by the time of your initial Medicare enrollment window.

Medicare Eligibility

Age 65 or older

Typically, you’re eligible for Medicare if:

You are a U.S. citizen or a permanent resident.
You or your spouse have paid Medicare taxes for at least 10 years through employment.

Under 65

You may become eligible for Medicare before you turn 65 if:

You receive Social Security disability or Railroad Retirement Board benefits for 24 consecutive months.
You have been diagnosed with end-stage renal disease (ESRD). In most cases, you would qualify on the first day of your fourth month of dialysis treatments.
You have been diagnosed with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease. You can begin Medicare once you start receiving Social Security disability payments, as opposed to waiting the standard 24 months.

You’re generally eligible for Medicare benefits when you turn 65, but don’t assume your Medicare card will arrive in the mailbox along with your birthday cards. The Social Security Administration (SSA) oversees Original Medicare enrollment and automatically enrolls individuals who receive Social Security benefits or Railroad Retirement Board benefits at least four months before turning 65.

Your Medicare ID Card

Medicare sends new members a Welcome Kit that contains useful information and the red, white, and blue Medicare ID card in the mail. You should receive your Medicare ID card and further instructions in the mail about three months before turning 65.

What If I’m Not Automatically Enrolled?

It is up to you to apply for Medicare through the Social Security Administration online, on the phone, or in person. You’ll need to provide information including your Social Security number, where you were born, and some details about any health insurance you currently have.

Once you’re enrolled, Medicare will automatically renew each year.

Am Signed Up for Medicare?

If you applied for Medicare online, you can check the status of your application through your Medicare or Social Security account. You can also check the status of your application by visiting or calling a Social Security office.

When Can I Enroll in Medicare?

There are multiple opportunities to enroll in Medicare or change your plan. Think ahead to make sure you get the benefits and coverage you need.

If you don’t sign up during your IEP, you have up to three Medicare enrollment periods during the calendar year.

Initial Enrollment Period

You may also change your Medicare plan during these periods if you meet the criteria. It’s essential to understand how these enrollment periods work because they are not all the same.

Initial Enrollment Period (IEP)

If you are new to Medicare, you have an Initial Enrollment Period. For most people, this seven-month period includes the three full months before and after the month you turn 65.

For example, if you turn 65 in June:

Three months before you turn 65: March, April, May
Your birth month: June
Three months after you turn 65: July, August, September

However, if you were born on the first of the month, then you can enroll up to four months before your birth month and up to two full months afterward.

If you are eligible for premium-free Part A but miss your initial window, you may sign up at any time, and the benefits will be retroactive for up to six months.

Use GoHealth’s Enrollment Calculator below to find your dates.

Medicare Eligibility Calculator

Discover when your Initial Enrollment Period is.

Open Enrollment Period (OEP)

January 1 to March 31

Change from one Medicare Advantage plan to another.
Switch from Medicare Advantage back to Original Medicare.
After switching from Medicare Advantage back to Original Medicare, you can add a Medicare Part D plan.

Annual Enrollment Period (AEP)

October 15 to December 7

Switch from Original Medicare to a Medicare Advantage plan.
Go from a Medicare Advantage plan back to Original Medicare
Join, drop, or switch a Medicare Part D prescription drug plan
Switch from one Medicare Advantage plan to another.

Special Enrollment Period (SEP)

Varies on a case-by-case basis.

You can qualify for a Special Enrollment Period based on certain life events like moving out of your current Medicare Advantage plan’s service area or losing eligibility for Medicaid.

Which Medicare Plans Can I Combine During Enrollment?

When you enroll in Medicare, all the possibilities for coverage can be confusing. Let’s take a look at some of the options that could get you the care and benefits you need.

Original Medicare (Part A and Part B)

Original Medicare is federally administered health insurance for U.S. adults who are over 65 or have certain disabilities.
Part A provides hospital coverage, and Part B provides medical coverage. You can add Medicare Supplement and Medicare Part D plans to Original Medicare.
Part A is premium-free for anyone age 65 or older who paid Medicare taxes for at least 10 years (or had a spouse who did). Part B requires a monthly premium.

Medicare Advantage (Part C)

Private insurance companies administer Medicare Advantage, also called Medicare Part C, which substitutes for Original Medicare coverage.
Medicare Advantage Prescription Drug Plans include Part D prescription drug coverage.
Plans may also offer a range of additional benefits.
Most people on Medicare Advantage plans still pay their Part B premium.
If you are enrolled in a Medicare Advantage plan, you cannot join a Medigap plan.

Prescription Drug Plan (Medicare Part D)

These policies from private insurance carriers can be added to Original Medicare to cover prescription drug costs.
If you go more than 63 days without drug coverage that Medicare considers creditable (meaning that the coverage is equivalent to what you’d get from a Part D plan) you will pay a late enrollment penalty when you do sign up. This penalty is a permanent increase to your premium.

Medigap Medicare Supplement

Also known as Medigap, these plans are offered by private insurance carriers.
A Medigap plan can be added to Original Medicare to fill in the gaps in your coverage, paying for out-of-pocket costs such as coinsurance and copayments.

FAQs

What information do I need to enroll in Medicare?

To enroll, you’ll need to provide some basic information:

Name
Current address
Phone number
Social Security number
Identification documents (birth certificate, driver’s license, or passport)

Should I consider enrolling in Medicare at age 65 even if I'm covered by an employee healthcare plan?

If your employer has 20 or more employees, it’s up to you. If your Part A is premium-free, signing up at 65 provides an extra level of coverage. Your employer coverage can be primary insurance with Part A as secondary. Part B is not premium-free, and it will be secondary to your employer coverage. This option could be expensive, so you will likely prefer to wait and join Part B when your employer-paid coverage ends.

If your employer has fewer than 20 employees, they can require you to sign up for Medicare at age 65. In that case, Medicare would be your primary insurance, so you should enroll in both Part A and Part B.

If you are covered by your spouse’s employer-sponsored health insurance, you may be eligible for a Special Enrollment Period if you lose that coverage.

What are the qualifying disabilities that could make me eligible for Medicare before the age of 65?

Regardless of your age, you will be automatically enrolled in Medicare after 24 months of receiving Social Security disability benefits. If you have Lou Gehrig’s Disease (also known as Amyotrophic Lateral Sclerosis or ALS), or End-Stage Renal Disease, you can qualify without the 24-month waiting period.

I have end-stage renal disease (ESRD) — is it true I can’t enroll in Medicare Advantage?

Not anymore. As of 2021, patients living with ESRD are allowed to enroll in Medicare Advantage. Previously, ESRD patients were restricted to Original Medicare. This is a sizable shift for ESRD patients because they can now take advantage of the out-of-pocket maximums that come with Medicare Advantage plans.

What happens if I delay enrollment?

If you choose not to enroll in Medicare Part B when you become eligible and then decide to enroll later, you risk delayed coverage and a higher premium. Your Part B premium can increase as much as 10% for each 12-month period you’re eligible (when you turn 65) and don’t enroll.

Possible exceptions include:

You receive health insurance from your employer or your spouse’s employer
You receive veterans’ benefits
You have private health insurance

Sources:

Ready to sign up for Part A & Part B. Medicare.gov.

Original Medicare (Part A and B) Eligibility and Enrollment. CMS.gov.

Social Security Administration. SSA.gov

Want to know more about your Medicare options?

We’re here to help you navigate your choices and find the right plan for your needs.

Talk to a Licensed Insurance Agent about Your Needs