Medicare Enrollment Eligibility, Requirements, and Coverage Options
Knowing how and when to apply for Medicare is very important. There are often financial penalties if enrollment is not done properly and on time. The good news is that Medicare clearly explains what the regulations are.
In this guide, we’ll summarize:
- Enrollment—eligibility and when to sign up
- Coverage options (Parts A, Part B, and Part D)
- Medicare Advantage plans (HMO, HMO-POS, and PPO)
- Medicare Supplement plans
- Combining Medicare with other insurers
When to Enroll: Eligibility & Requirements
In most cases, enrollment in Medicare is not automatic when an individual turns 65. However, there is a common exception to this rule: People who receive Social Security benefits are automatically enrolled in Medicare upon turning 65. If you don’t receive Social Security benefits, you should contact the Social Security Administration three months before your 65th birthday to enroll in Medicare.
It is advisable to always speak to a licensed Medicare professional and receive a free quote to minimize any out-of-pocket costs.
You need to sign up for Medicare during your Initial Enrollment Period, which is the seven-month window around the month when an individual turns 65 years old. Those seven months consist of the three months before the month that the birthday occurs, the birthday month itself, and the three months following the birthday month.
For example, someone turning 65 in September would have the three months before September (June, July, and August), the birth month of September, and the three months following the birth month (October, November, and December).
You will face penalties if you don’t sign up for Medicare within your Initial Enrollment Period, so it’s best not to delay this task.
Work History Requirements
Medicare eligibility at age 65 also requires that an individual has worked and paid Medicare taxes for at least 10 years before applying. If they don’t qualify on their own, they may be eligible at age 65 or older if they have a spouse who has worked and paid Medicare taxes for at least 10 years.
Exceptions to Age 65 Enrollment
As mentioned before, eligibility for Medicare coverage starts at age 65. However, there are a few exceptions:
- Individuals suffering from End Stage Renal Disease (ESRD) who undertake regular dialysis treatments or need a kidney transplant are eligible for benefits after receiving their first dialysis treatment. However, they are no longer eligible for Medicare benefits if they receive a transplant and no longer require dialysis. Upon turning age 65, they would be eligible again.
- Individuals with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s Disease, can receive benefits immediately following a diagnosis.
- If someone has qualified for and is receiving Social Security Disability Benefits, may also qualify for Medicare benefits at age 62. They must have been receiving Social Security Disability Benefits for at least 24 months to qualify for Medicare.
- If an individual is receiving Railroad Retirement Benefits (RRB), they’ll automatically be enrolled in Medicare Part A and Part B upon turning 65.
Medicare Coverage Options
When an individual is enrolling, it will be for Medicare Part A, Part B and possibly Part D. Here’s a breakdown of what these parts cover:
- Part A: Hospital coverage
- Part B: Medical insurance (doctor’s visits, outpatient care, etc.)
- Part D: Prescription drug coverage
The coverage start date for each option will depend on when you enroll (before or after you reach 65 years old).
Original Medicare (Part A and Part B)
Original Medicare refers to an application being made for, or having, Part A and Part B together.
Initial enrollment in Medicare is for Part A only. There is no cost for Part A. Application needs to be made for Part B and Part D, for which there is a cost.
It is in the best interests of the enrollee that application for Part B and Part D be made at the same time as enrolling in Part A. If the application is not made at the same time, there may be financial penalties which will increase the monthly premiums (payments) for Part B and Part D. Once the Initial Enrollment Period passes, the longer a person waits to enroll in Medicare, the more expensive it will be.
Minimizing Out-of-Pocket Expenses:
After enrolling in Part A and Part B, it is very important that the enrollee again review what is and isn’t covered under their Medicare plans. There can be significant gaps in the plans that may leave an individual facing considerable out-of-pocket expenses when medical treatment is received, either at the hospital (Part A) or a doctor’s office (Part B).
If you have Original Medicare, you have the option to sign up for a supplemental Medigap policy with a private insurer. Medigap policies cover more expenses that might not be covered by Medicare. We’ll cover this in a later section.
Medicare Advantage Plans (Part C)
An eligible individual may choose to enroll in a Medicare Advantage plan, also known as Part C coverage. This is sometimes referred to as an “all-in-one plan.” It includes Original Medicare coverage (Part A and Part B) and most often includes prescription drug coverage (Part D). It may also offer extra benefits such as vision, hearing, and dental.https://dailycaller.com/2019/12/13/does-medicare-cover-dental/
Medicare Advantage plans consist of three different options, of which one must be selected that is best suited for the individual’s financial situation. They are:
- Health Maintenance Organization (HMO) plans: HMOs are centered around preventive medicine but offer coverage for medical expenses. Treatment must be provided by a hospital or doctor that is in-network.
- HMO-Point of Service (HMO-POS) plans: These are similar to HMO plans but offer more flexibility as to which doctors can be seen.
- Preferred Provider Organization plans (PPO): These plans offer the most flexibility in which doctors and specialists can be seen. They typically will cost more than HMO plans.
Medicare Advantage plans usually require that a covered individual only goes to hospitals and doctors that are within their provider network, also referred to as “in-network.” There can be a reduction in covered costs if the insured goes “out of network.” Medicare Advantage plans may have lower out-of-pocket costs than Original Medicare.
Medical Savings Account (MSA) plans are another option. These plans combine a high deductible health insurance plan with a savings account. Medicare deposits money into the savings account; the money in the account can then be used to pay for health care services during the year.
Medicare Supplement Plans (Medigap)
Upon Medicare eligibility, the future applicant’s mailbox will most likely start to fill up with offers from private insurance companies offering Medicare Supplement insurance (or Medigap) coverage. It is advisable to talk with an agent to 1) gain a better understanding of what Medicare covers, and doesn’t cover, and 2) understand what a Medigap policy covers and what the monthly premium is.
Though Original Medicare (Part A and Part B) covers many expenses, it doesn’t cover everything. Issued by a private provider, a Medigap policy will pay costs that aren’t covered under Parts A and B, such as coinsurance, copayments and deductibles.
Note that you can only get a Medigap plan if you already have Original Medicare. It’s not available for Medicare Advantage plans.
Unlike most private health insurance plans, Medigap plans are “guaranteed issue,” meaning an insurer cannot deny someone coverage due to a pre-existing medical condition. They also have a “guaranteed renewal” clause, meaning the insurer cannot cancel the policy due to new medical conditions arising after the policy is issued. The insurer may, however, issue a policy with a six-month waiting period before pre-existing conditions are covered.
Because Medicare Supplement plans do not include prescription drug coverage, it’s important to enroll in Medicare Part D, which does cover many prescription drugs. Part D enrollment should be done when enrolling in Part A and Part B to avoid any financial penalties incurred by not signing up during the seven-month enrollment period.
If the enrollee chooses to enroll in a Medicare Supplement plan and then later chooses to cancel it and enroll in Part D, there may be a waiting period before they can enroll, as well as an increased cost because of “late enrollment.” There may also be a “lifetime premium penalty.”
Medigap policies also do not cover some common healthcare expenses such as long-term care, vision, dental care or hearing aids.
Working With Multiple Insurers
If an individual has both Medicare and other health insurance or coverage, each of the organizations responsible for coverage is called a “payer.” When there is more than one payer, “coordination of benefits” rules go into effect and will decide which one pays first.
The “primary payer” pays what it owes on the insured’s bills first, then the secondary payer will be responsible for the balance if the expenses are covered. Though it is rare, in some cases, there may also be a third payer.
There are major differences between payers regarding how payment for benefits are calculated. They are:
- The insurance that pays first, the primary payer, pays up to the limits of its coverage.
- The second payer will only pay the medical expenses which the primary insurer didn’t cover.
- The secondary payer, which may be Medicare, may not pay all of the uncovered costs. They only will pay according to what is specifically covered in the plan’s documentation.
- If an employer’s insurance plan is the secondary payer, an individual may need to enroll in Medicare Part B before the employer’s insurance plan will pay.
If the insurance company doesn’t pay the claim promptly, usually within 120 days, a doctor or other provider may bill Medicare. Medicare sometimes will make a conditional payment to pay a hospital or doctor’s bill, and then later recover the payments the primary payer should have made.
If an individual is retired and has both Medicare and group health plan (retiree) coverage from a former employer, Medicare will generally pay first for the health care bills, and group health coverage will pay second.
The Consolidated Omnibus Budget Reconciliation Act (COBRA), signed by former President Ronald Reagan in 1985, mandates employers to give some employees the ability to continue health insurance coverage if they’re laid off or have to work reduced hours. If a former employer files for bankruptcy protection or goes out of business, federal COBRA rules may provide protection if any other company within the same corporate organization still offers group health plans to its employees. That plan is required to offer COBRA continuation coverage. If a person can’t get COBRA continuation coverage, they may have the right to buy a Medigap policy even if it is no longer the Medigap Open Enrollment Period.
If you have COBRA by the time you’re eligible for Medicare, your COBRA plan will typically end once your Medicare plan starts.
Ready to Enroll? Get a Free Quote:
If you’re eligible for Medicare and want to enroll today, you can compare your options and get a free quote here:
After having enrolled, you’ll receive a “Welcome to Medicare” packet. Included in this packet is the Identification Card (I.D. card), which you’ll need to present when visiting a doctor’s office or hospital.
As can be seen, there are many things to be considered when someone is at, or near, their Medicare eligibility period. Consulting with a professional is recommended to avoid costly errors resulting in a period of having no insurance coverage, or having to pay additional, ongoing penalties for having missed the enrollment window.
Current Medicare users can always re-evaluate their coverage during the annual Open Enrollment Period, from October 15 to December 7.
The Daily Caller is devoted to showing you things that you’ll like or find interesting. We do have partnerships with affiliates, so The Daily Caller may get a small share of the revenue from any purchase.