Medicare Deep dive

Medicare Deep dive

Medicare Eligibility Check & Criteria?

If you’re 65 years or older in the United States, you may be eligible for Medicare coverage.

Medicare is primarily for people who meet the following eligibility requirements:

  • You’re a U.S. citizen or a permanent resident living in the United States for 5 consecutive years
  • You (or your spouse) worked 10 years and became eligible for Social Security or Railroad Retirement Benefits

Payroll taxes will only guarantee that you won’t have to pay a premium on Part A. There are no work requirements for Part B or Part D coverage.


Medicare and Social Security

The Centers for Medicare and Medicaid Services (CMS) manages Medicare. The Social Security Administration works alongside with the CMS by enrolling certain people in Medicare.  If you’re disabled and have been approved or you receive Social Security Disability Insurance benefits, you’ll also receive Medicare.

However, if you’re approved for Supplemental Security Income, you’ll receive Medicaid benefits. SSI Medicare eligibility does not start until you reach the age of 65.

Eligibility for Medicare may be available to you if:

Please note there are exceptions to this rule:

Medicare and ESRD

If you’re under the age of 65 and diagnosed with End-Stage Renal Disease (ESRD) you may also be eligible for Medicare benefits.

If you have been diagnosed with ESRD, you might qualify for Medicare if:

  • You had a kidney transplant
  • Receive dialysis treatments
  • Applied for Medicare benefits retroactively for up to 12 months AND:
    • You are SSDI eligible
    • Eligible for Railroad Retirement benefits
    • You or your spouse have paid taxes to Medicaid for a certain amount of time

If you are under the age of 65 and have ESRD, the beginning date of your SSDI is when you should apply for Medicare.

Eligibility Requirements for Medicare

  • Generally, your Medicare eligibility age is the month you turn 65. At this time, Part A and Part B will become available to you the first day of the month of your 65th birthday.

    You may also be eligible for Medicare as long as your spouse has worked and paid Medicare taxes for a minimum of 10 years and one of the following statements is true for you:

    • Currently, you’re receiving or are eligible to receive Social Security
    • Currently, you’re receiving ore are eligible to receive RRB (Railroad Retirement Board) benefits
    • Your spouse or yourself has worked for a Medicare-covered government job
    • If you or your spouse didn’t pay Medicare taxes for at least 10 years and you’re over the age of 65 you may still be eligible for purchase of Medicare.

Medicare Automatic Enrollment

  • If you receive Social Security and Medicare, you could be eligible for automatic enrollment for Part A as well as Part B.

    Automatic enrollment will not apply to those who haven’t worked enough time to receive automatic enrollment for Medicare benefits.  If you are one of these individuals, you will be required to file an application through the Social Security Administration.  Once enrolled through the SSA, you may enroll in Part A and Part B at a monthly premium rate, during an allowed Medicare enrollment period

Medicare Disability Eligibility

  • Many people in the United States receive Medicare disability coverage.

    You may qualify for Medicare Disability Eligibility under Part A and Part B coverage if you’re:

    • Diagnosed with ESRD, or ALS – you’ll automatically be enrolled in both Part A and Part B as soon as your first month of SSDI benefits is received
    • Receiving SSDI for 24 months or more, automatic enrollment for Part A and B will start at the 25th of the month following that 24th month of receiving SSDI

    For those with ESRD, your application for Medicare benefits is required. Medicare disability eligibility will be determined based on several factors.

Factors May Include:

  • Whether you’re getting regular dialysis treatments
  • If you’ve had a kidney transplant
  • If you’ve paid into taxes for Medicare sufficiently

What is dual eligibility for Medicare and Medicaid?

  • When you receive both Medicare and Medicaid, you become “dual eligible”.

    You’ll have enhanced benefits, and here’s how it works:

    • Medicare is the persons’ primary insurer
    • Beneficiaries may see any provider that accepts Medicare assignment

    Medicare supplements, as well as Medicare Advantage plans, will be your secondary insurer.

Medicare Eligibility for Nursing Home Care

  • Although Medicare does cover skilled nursing care, coverage is generally for a short-term stay. Many limitations come with Medicare Eligibility for Nursing Home Care.

    However, you may qualify for coverage if you meet the following Medicare eligibility rules:

    • You must have Part A – hospital insurance
    • You must have stayed inpatient for a minimum of 3 days in a row PRIOR to nursing home admission
    • A nursing home must be Medicare-certified
    • Your nursing home start date is within 30 days after spending 3 days in the hospital
    • Your doctor must order nursing home care and services
    • Services must be provided by skilled professionals

Medicare Savings Program Eligibility

  • The Medicare Savings Program helps with some out-of-pocket expenses, such as Part A and Part B. One of these programs can help you pay for your premiums, deductibles, copayments as well as coinsurances associated with Medicare.

    Medicare Savings Programs has 4 Types:

    • QMB – Qualified Medicare Beneficiary Program
    • SLMB – Specified Low-Income Medicare Beneficiary Program
    • QI – Qualifying Individual Program
    • QDWI – Qualified Disabled and Working Individuals Program.

    Aside from the QDWI Program, all these programs will help pay for your Part B premiums.

    Medicare Savings Program eligibility automatically qualifies you for Extra Help. The Extra Help program helps you cover the costs of prescriptions. However, if you qualify for Extra Help, that does not mean you also qualify for the Medicare Savings Program.

How to Check Medicare eligibility?

  • If you want to know how to check Medicare eligibility, contact us! (Link)

    First, make sure you have the following information in order to determine your Medicare eligibility verification:

    • First and last name
    • Medicare number
    • Date of birth of the person applying
    • Gender
  • Options for checking Medicare Eligibility:

    1. Talk to a licensed insurance agent in your state
    2. Automated phone services
    3. Several online services can assist you and prevent errors to calculate your eligibility properly
  • When you receive both Medicare and Medicaid, you become “dual eligible”.

    You’ll have enhanced benefits, and here’s how it works:

    • Medicare is the persons’ primary insurer
    • Beneficiaries may see any provider that accepts Medicare assignment

    Medicare supplements, as well as Medicare Advantage plans, will be your secondary insurer.

  • If I’m Eligible, How Much Will My Medicare Premium Be?

    Not all Medicare premiums are the same; your situation is different than the next persons and therefore the premium won’t be the same.

    If you have any questions or concerns regarding your eligibility, please contact a Medicare expert. You can reach a licensed Medicare expert by calling the phone number above or by filling out the online rate form.