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Medicare Eligibility: Your Comprehensive Guide 2020

Understand eligibility for Original Medicare, Medicare Advantage, Part D, and Medigap.
Medicare Eligibility Comprehensive Guide 2020

Whether you are a complete beginner to the world of Medicare or already have some familiarity with how Medicare health insurance works, you may be wondering what criteria apply to Medicare eligibility.

We’ve found that some of the most common questions regarding eligibility are: At what age am I eligible? Do I qualify for Original Medicare coverage? Is my spouse eligible too?

In this guide, we’ll cover those questions and a few others. At the end of this guide, you should have a thorough understanding of the rules that govern eligibility. From there, you will be prepared to begin your enrollment process, compare and shop health plans, or discuss your options with an insurance agent.


Am I Eligible for Medicare?

If you fit the following criteria then you are eligible for Medicare:

  • 65 years of age and older (or younger in the case of disability).

  • Citizen or permanent resident of the U.S. for at least 5 years.


For those already receiving benefits from Social Security or the Railroad Retirement Board, you will receive a letter from Medicare notifying you of your eligibility. The letter will be accompanied by informational material on Medicare.

What to know about this letter from Medicare:

  • Your letter will arrive roughly 3 months prior to your 65th birthday.

  • The informational material will explain your Medicare choices and how to act on them.

  • You have the option to accept Medicare enrollment or postpone it. For example, if you’re still employed and covered by employer insurance, you may decide to postpone enrollment until your retirement.


If you aren’t already receiving benefits from Social Security or the Railroad Retirement Board, then you won’t receive a letter from Medicare. In this case, you will need to sign up for Medicare on your own.

Be sure to sign up in the 3 months prior to your 65th birthday to avoid any gaps in coverage or late enrollment penalties.


Eligibility for Original Medicare

There are four different parts to Medicare coverage, as well as supplemental coverage options. Each part covers different healthcare needs. Once you are eligible for Medicare, you can choose the coverage that you need.


The 4 parts of Medicare.

Parts A and B are known as Original Medicare, which the federal government provides. If you or your spouse paid Medicare taxes (FICA) for at least 10 years, you are eligible for premium-free Part A coverage. Also, at this time you are eligible to enroll in Part B, though Part B comes with a monthly premium.


Am I Eligible for Medicare Part A?

As mentioned above, you are eligible for Part A if you are 65 years old and a citizen or permanent resident of the U.S. Most individuals receive Part A coverage without a monthly premium. Here are the eligibility criteria for premium-free Part A coverage:

  • You are at least 65 years old.

  • You (or a spouse) have worked and paid Medicare taxes for at least 10 years.


You are also eligible for premium-free Part A at the age of 65 if:

  • You are currently receiving (or are eligible to receive) benefits from Social Security or the Railroad Retirement Board.

  • You (or your spouse) had Medicare-covered government employment.


If the criteria for premium-free Part A don’t apply to you, there is still the option to enroll in the Part A. However, your coverage will come with a monthly premium. If you are interested in purchasing this option, you will need to pay attention to its designated enrollment periods.


Note: If you choose to purchase Part A coverage, you must also purchase Part B coverage. This will mean two monthly premium payments, Part A and Part B.

In the case of disability, you may be eligible for premium-free Part A earlier than 65. Any of the following circumstances would make you a candidate for early eligibility:

  • You have been entitled to disability benefits from Social Security or the Railroad Retirement Board for 24 months.

  • You have End-Stage Renal Disease.

  • You have Lou Gehrig’s Disease (in this case, your Medicare benefits begin the first month you receive disability benefits).

Am I Eligible for Medicare Part B?

If you are eligible for Medicare Part A (as listed above), then you are also eligible for Medicare Part B. Part B coverage, however, comes with a monthly premium.

If you are not eligible for premium-free Part A coverage, you may decide that you want to only purchase Part B coverage. Some people take this route, rather than paying two monthly premiums. While you can’t purchase only Part A coverage, you do have the option to purchase only Part B.


How to Check Your Medicare Eligibility

If you would like to check your Medicare Eligibility, Medicare offers free use of their Eligibility & Premium Calculator. By answering a few questions, you can check your current eligibility status and view an estimation of what your Part B monthly premium will cost.

It is a straightforward tool to use. The questions should only take a few seconds to answer. Even if you know that you are not yet eligible, you can still check the eligibility calculator to get the exact dates of your upcoming Initial Enrollment Period.


Eligibility for Additional Medicare Coverage

If you want additional coverage to Parts A and B, you have a few more options to consider. While the federal government does not provide additional coverage, private insurance providers offer a variety of supplemental plan options.

If you would like to add additional benefits, you must choose between two options:

Option 1: Keep Original Medicare and Add Supplement Insurance

If you want to keep your Original Medicare coverage, you can add additional policies to achieve your desired level of coverage. For example, you can add Part D to your Original Medicare for prescription drug coverage. You also have the option of adding a Medicare Supplement plan that may meet a more specific healthcare need.

Option 2: Enroll in a Medicare Advantage Plan (Part C)

You also have the option of purchasing a Medicare Advantage Plan. In this case, you are purchasing a plan from a Medicare-approved private company. The plan will provide all of your Part A and Part B coverage. Most plans also offer prescription drug coverage, as well as benefits like vision, hearing, dental, and wellness programs.


Am I Eligible for Medicare Part C?

If you are eligible for Original Medicare (Parts A and B), then you are also eligible to join a Medicare Part C plan, otherwise known as a Medicare Advantage plan. These plans bundle the benefits of Parts A, B, and often times D (prescription drug coverage). Many plans also provide extra coverage for hearing, dental, and vision care. If you choose to join a Medicare Advantage plan you cannot also enroll in Medicare Part D or any Medigap policies due to overlapping benefits.

You have the option to enroll in a Medicare Advantage plan during your Initial Enrollment Period, which is when you first become eligible for Original Medicare. However, you can also enroll at a later date, or switch to a Medicare Advantage plan, during the annual Open Enrollment Period (October 15 – December 7).


Am I Eligible for Medicare Part D?

If you are eligible for Original Medicare (Parts A and B), then you are also eligible for Medicare Part D, otherwise known as Medicare prescription drug coverage. If you choose to enroll in Part D coverage, you cannot also enroll in a Medicare Advantage Plan (Part C).

You have the option to enroll in Medicare Part D during your Initial Enrollment Period, which is when you first become eligible for Original Medicare. However, you can also enroll later during the annual Open Enrollment Period (October 15 – December 7). If you don’t enroll when first eligible, however, you may have to pay a late enrollment penalty.


Retirement and Your Medicare Choices

Retiring Before 65:

You are only eligible for Medicare once you reach the age of 65, except in the case of a qualifying disability. So, if you retire before reaching 65 and insurance coverage from your employer ends, you will need to find an alternative insurance plan until you reach Medicare eligibility.

Retiring at 65:

Once you have reached the age of 65, you are eligible for Medicare. At this time you may also choose to enroll in supplemental coverage or choose a Medicare Advantage plan. Some employers offer health insurance to their retirees. If this applies to you, be sure to review your employer’s plan, as it may require that you enroll in Original Medicare, as well.

Continuing to Work Past 65:

If you continue working past the age of 65, you have the option to either sign up for Medicare or postpone enrollment. Many choose to enroll in at least Part A, as it is premium-free. However, when you work past 65 you are eligible for a Special Enrollment Period when you do choose to retire. This period allows you 63 days to enroll in Medicare without facing any late enrollment penalties.


Is My Spouse Eligible for Medicare?

Some might assume that once they are eligible and enrolled in Medicare, there spouse is automatically covered, as well. However, Medicare does not offer a family coverage plan. The same eligibility criteria that apply to you, also apply to your spouse.


So, this means that your spouse will have to meet the age of eligibility for Medicare (65) and other qualifications regardless of your own eligibility. If you are retiring from your job and enrolling in Medicare, your spouse will need to find an alternative health insurance option until they reach eligibility.


Premium-Free Part A Based on Spouse’s Work History:

If you do not meet the criteria for premium-free Part A coverage but your spouse does, you may be eligible for premium-free Part A based on their work history. Check the following circumstances to see if this applies to you:

Currently Married – You have been married for at least one year and your spouse is eligible for Social Security benefits.

Divorced – You had been married for at least 10 years and your former spouse is eligible for Social Security benefits.

Widowed – You were married for at least 9 months before your spouse passed away and you are currently single.




Up Next: Medicare Enrollment Guide



Helpful Resources:

HHS.gov: Who is Eligible for Medicare?

Medicare.gov: Get Started With Medicare

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