Medicare eligibility and enrollment rules are not complicated. The rules are largely in your favor, and if you apply for Medigap, Medicare Advantage, or a Part D plan, the carriers must strictly follow the eligibility guidelines.
That said, not following the rules can create late enrollment penalties and delays in coverage, which could have been avoided with preparation and an understanding of the Medicare enrollment process.
Medicare Eligibility Basics
You qualify for Medicare coverage on the first day of the month that you turn 65 years old. For example, if your date of birth is July 16, 1957, then your Medicare coverage can begin as soon as July 1, 2022.
One thing to note is if you are born on the 1st of a month — let’s say it was July 1, 1957 — then your Medicare coverage can begin on June 1, 2022, not July 1. For every other day of the month (July 2nd through July 31st), Medicare coverage begins on the first (July 1st).
Special Circumstances for Medicare Under 65
There are special exceptions that can allow you to be eligible for Medicare prior to turning 65. However, there are many nuances involved if you are eligible for Medicare prior to turning 65.
The three instances when a person qualifies for Medicare prior to the age of 65 are:
- Receiving Social Security Disability Insurance Benefits for 24 months
- End-Stage Renal Disease requiring dialysis
- ALS (amyotrophic lateral sclerosis) disease
Medicare Eligibility Details
Eligibility is solely determined by the Social Security Administration, which will verify if you are eligible as a result of you paying for 10 years of income taxes, or married to a spouse who has qualified. You can qualify for Medicare if your deceased spouse would have qualified. You can also qualify for Medicare if you are divorced, were married for at least 10 years, or your ex-spouse has paid 10 years of income taxes.
If you and or your spouse (living or deceased) do not qualify for Part A, then it can be purchased at either $278 or $506 a month, which are determined annually by the CMS. In addition, you may qualify for Part B if you meet the following requirements:
- Be age 65 or older
- Be a U.S. resident, a U.S. citizen, or an alien who has been lawfully admitted for permanent residence and has been residing in the United States for five continuous years prior to the month of filing an application for Medicare.
Applying for Medicare Coverage
Applying for Medicare is relatively simple. You can apply for Medicare three months prior to the day that you are eligible. For example, if you turn 65 on April 1, 2022, you can apply for Medicare as late as October 31, 2022 (three months after July ends), but there will be delays in when coverage would begin, if you apply after July 1.
For those who are already receiving Social Security benefits, you will be automatically enrolled in Part A and Part B, and the Medicare card will be sent to you automatically. Note that if you want to cancel your Part B coverage because you are covered by employer-sponsored group benefits, you can do so by completing Form CMS-1763 or calling Medicare (1-800-Medicare).
For people who are not receiving Social Security benefits and are attempting to enroll, you can do so online. You must have a login to SSA.gov — the Social Security Administration website. You will be asked separately whether you want to enroll in Part A, and another question asking if you want to enroll in Part B.
Keep in mind that sometimes complications can arise, because the actual execution can involve many steps. There can be delays in processing your application, which is administered by the Social Security Administration.
You can apply for Medicare online via SSA.gov, the official website of the Social Security Administration, but you will need to establish an SSA.gov account. You can apply for Medicare only on this website, with or without applying for Social Security benefits.
A paper application also exists and it is called Form CMS-40B, which you can transmit via mail or fax to the Social Security Administration. This application is solely for those that are enrolled in Part A only and wish to add Part B after you, or your spouse who has covered you, have retired. If you are not enrolled in Part A first, then you’ll need to enroll online or apply at a Social Security Administration office.
Note: it’s important to keep a copy of any paper applications that are submitted, along with a date and time of submission. In addition, frequent checking of your SSA.gov account will allow you to track whether or not your application has been successfully received at the SSA.
Applying After 65
If you’re applying for Medicare after the age of 65, you need to provide evidence from your employer stating that you have had health insurance (without an eight-month break in coverage) from the time that you turned 65. This is done by your employer completing Form CMS-L564. This and Form 40B can be sent to the Social Security Administration. Once you submit your application, you can check SSA.gov frequently to attempt to find a Benefits Verification Letter, to ensure that your application has been successfully processed. It will include the coverage dates for both Part A and Part B. Importantly, it will also include your Medicare ID number.
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