Ways You Can Qualify for Medicare

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Written by Guest | Last Updated February 24th, 2020
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Guest Post by Anastasia Iliou

Medicare is a government health care program for certain groups of people in the United States. While most people associate Medicare with the 65 and over generation, it’s actually much more than that.

This guide will explain the ways in which you can qualify for Medicare and how to enroll when you’re eligible.

Qualifying for Medicare by turning 65

If you age into the Medicare program, you can qualify by turning age 65. In this case, your “Initial Enrollment Period” would last from three months before your 65th birthday through three months after, for a total of seven months.

Be careful, because if you miss that seven-month window, you may face a late enrollment penalty fee (which can be up to 10 percent of your premium). That fee would stay with you for the life of your Medicare coverage. You will have other opportunities to change your coverage, but you will still face a late enrollment fee if you don’t sign up during your Medicare Initial Enrollment Period.

Some people may be able to avoid the late enrollment penalty fee. For example, if you turn 65 but choose to keep working, and you still have employer insurance, you can put off Medicare enrollment until you retire and lose your employer insurance. However, you might not need to. Since Medicare Part A has a $0 premium for those who have worked and paid taxes for at least 39 quarters, there’s really no harm in enrolling when you turn 65.

Qualifying for Medicare by disability

If you have a disability and qualify for Social Security Disability Insurance (SSDI), you may be able to qualify for Medicare. You can apply for Medicare once you’re in your 25th month of SSDI benefits.

To qualify for SSDI, you must have a severe disability that interferes with basic activities, rendering you unemployable. You must be either incapable of keeping a job or incapable of earning more than a certain amount ($1,070 in 2019). You will have to provide proof that you are unemployable to be eligible.

Some examples of disabilities that can qualify for SSDI (and potentially, Medicare) include but are not limited to the following:

  • Musculoskeletal system problems
  • Cardiovascular illness
  • Neurological/mental health
  • Cancer
  • Immunity disorders
  • Skin disorders

Diseases that qualify for Medicare

Regardless of whether you have SSDI or qualify for any other benefit programs, there are two diseases that can qualify you for Medicare: ALS (also known as Lou Gherig’s disease), and End-Stage Renal Disease (ESRD).

If you have ALS or ESRD and believe that you are eligible for Medicare, visit your local Social Security office or call Social Security (1-800-772-1213) for more information. You can also apply for Medicare online. If you get benefits from the Railroad Retirement Board, call them instead (1-877-772-5772).

ALS

ALS (Amyotrophic Lateral Sclerosis), also called Lou Gherig’s disease, for the famous baseball player who had it, is a rare disease relating to muscle neurons.

Once you receive an ALS diagnosis, you automatically become eligible for SSDI benefits. Unlike other SSDI-qualifying disabilities, those who receive SSDI due to an ALS diagnosis will automatically become eligible to enroll in Medicare. You would not have to wait for your 25th month of SSDI, as other disabled people might.

ESRD

If you have ESRD, you may qualify for Medicare regardless of age. However, according to Medicare.gov, all of the following must apply:

  • Your kidneys cannot properly function on their own
  • You have had a kidney transplant and/or require regular dialysis
  • You either:
    • Have worked and paid taxes for the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee, or...
    • Are eligible for either Social Security or Railroad Retirement benefits, or...
    • Are the spouse or dependent of a person who meets either of the two bullet points above

Medicare enrollment periods

There are five Medicare enrollment periods to be aware of. We’ve already discussed the Initial Enrollment Period, which is the time when you are first eligible for Medicare. For those turning 65, this period begins three months before your 65th birthday and ends three months after. If you qualify based on disability or disease, this Initial Enrollment Period does not really apply, and you can enroll as soon as you receive your diagnosis and are eligible.

Your Initial Enrollment Period is not the only time you can enroll.

General Enrollment Period (GEP)

If you age into Medicare and miss your Initial Enrollment Period, you can use the General Enrollment Period (January 1 through March 31). During this time, you can only enroll in Medicare parts A and B. Once you enroll, you’ll be given the chance to enroll in prescription drug coverage or a Medicare Advantage plan from April 1 through June 30. Your coverage for parts A and B will not begin until July 1.

Open Enrollment Period (OEP)

The Open Enrollment Period is new as of 2019. This is a time period where anyone who enrolled in a Medicare Advantage plan during the previous year can either drop their plan or switch to a different Medicare Advantage plan from January 1 through March 31.

Special Enrollment Period (SEP)

The Special Enrollment Period varies. There are basically two types: temporary/circumstantial and ongoing.

You can qualify for a “temporary” SEP by undergoing a major life event such as moving to a new state where different plans are available, involuntarily losing your coverage (such as if your plan is canceled), gaining a job with employer benefits, etc. If you have this “temporary” SEP, you will be granted a one-time change, which usually has to be made within 90 days or less, depending on your circumstances.

You can qualify for an “ongoing” SEP by being enrolled in a Special Needs Plan (based on income or healthcare needs), being in a Medicare Savings Program, receiving Low-Income Subsidies, or being a part of a State Pharmaceutical Assistance Program (SPAP). This “ongoing” SEP will last for the first three quarters of the year (January through September). You can make a change to your coverage once per quarter.

The fourth quarter is different because it contains the Annual Enrollment Period.

Annual Enrollment Period (AEP)

The Medicare AEP runs from October 15 through December 7 of each year. During this time, anyone with Original Medicare can make a change to their supplemental coverage (mainly Medicare Advantage and Prescription Drug plans. You can technically make a change to your Medicare Supplement plan during any time of year).

Choosing a Medicare company

Once you find out that you are eligible for Medicare, you’ll probably start getting a lot of mail, advertisements, and phone calls from companies who want to sell you a plan. Go to bestcompany.com and search “medicare” to read through reviews for Medicare companies near you.

Anastasia Iliou is the Senior Content Manager at MedicarePlanFinder.com. Medicare Plan Finder is an educational resource for those looking for a new Medicare plan. Anastasia has a B.A. in songwriting from Belmont University in Nashville and loves writing content in all forms! When she isn’t writing about Medicare, she’s probably writing songs or taking care of her two cats and two dogs.

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