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Medicare Eligibility

Who is eligible for Medicare?

  • Individuals entitled to Social Security retirement insurance and 65 years of age and older;
  • Individuals entitled to Social Security disability benefits for not less than 24 months;
  • Individuals entitled to Railroad Retirement benefits or Railroad Retirement disability benefits;
  • Individuals diagnosed with end stage renal disease;
  • Individuals with ALS;
  • A federal, state or local government employee who is not eligible for Social Security retirement or disability benefits but have worked and paid the Medicare Part A "hospital insurance" portion of your FICA taxes for a sufficient period of time. (Federal employees became subject to the hospital insurance portion of FICA in January 1983. Most newly hired state and local employees, not otherwise covered under Social Security, started paying the hospital insurance portion as of April 1986.
  • Note: Individuals who are not otherwise eligible for Medicare, but who are over age 65 may purchase Medicare coverage by paying a monthly premium.

Medicare eligibility for Social Security and Railroad Retirement beneficiaries begins on the first day of the first month in which the individual attains age 65. This is also the date upon which individuals not otherwise eligible for Medicare are entitled and may purchase coverage.

Individuals receiving Social Security or Railroad Retirement disability benefits become eligible for Medicare coverage in the 25th month of receiving those benefits. Individuals who have end stage renal disease usually become eligible on the first day of the third month of a course of renal dialysis treatments. Individuals with ALS (Lou Gehrig’s disease) become eligible when they are eligible for Social Security disability benefits, without a twenty-four month waiting period.

Application

Individuals receiving Social Security retirement or disability benefits, or railroad retirement checks, will be sent information by the Social Security Administration (SSA) a few months before becoming eligible for Medicare. Residents of one of the 50 states, Washington, D.C., the Northern Mariana Islands, Guam, American Samoa, or the U.S. Virgin Islands, will automatically be enrolled in Medicare Parts A and B by SSA. However, because there is a premium payment required for Part B coverage, beneficiaries may make the choice to turn it down.

While participation in Medicare is voluntary, one should think through the serious consequences of not applying, primarily late enrollment fees and health risks if no other health insurance is available.  The costs of premiums alone should not be an overriding factor in one’s decision to participate in the Medicare program.

NOTE: Residents of Puerto Rico must apply for Medicare.  It is not automatic.

Enrollment and Coverage

If you’re not already getting retirement or disability benefits, you may contact Social Security to sign up online for Medicare during your "Initial Enrollment Period," the three months before your 65th birthday,your birth month, and the three months after. You can sign up for Medicare even if you don’t plan to retire at age 65.

A person not entitled to Medicare by virtue of Social Security or Railroad Retirement benefits must make a separate application for Medicare and agree to pay monthly premiums. See the cost-sharing chart below for details on premiums. A person may elect not to apply for Social Security or Railroad Retirement benefits at age 65 and still be entitled to Medicare coverage. In this case a separate application for Medicare benefits is required. Application for benefits can be made at any Social Security office. Railroad Retirement beneficiaries should contact the Railroad Retirement Board to enroll.

An individual may make application to enroll in Medicare three months prior to the first month in which they would be eligible for benefits and for three months after their first month of eligibility. This period is referred to as the "initial enrollment period."

Enrollment in the first three months of the initial enrollment period will result in coverage beginning on the first day of the first month in which the individual attains age 65. Enrollment in the month in which the individual attains age 65 will result in coverage beginning in the following month. Enrollment during one of the three remaining months of the initial enrollment period will result in coverage beginning on the first day of the second month following the month in which the individual enrolls.

Example:

An individual turns 65 in May. Her initial enrollment period will be February 1, through August 31. Depending upon the month in which she enrolls her coverage period would be as follows:

Enrolls in… Coverage Begins…
February May 1
March May 1
April May 1
May June 1
June August 1
July September 1
August October 1

There is also a "general enrollment period" which occurs in the first three months of each year. An individual who fails to enroll during his initial period of eligibility can only enroll in Part B of Medicare during this general period (and may be required to pay a premium surcharge for late enrollment), unless he falls under the provisions of the working elderly discussed below. Enrollment in Part A can take place at any time and coverage can be retroactive up to six months unless the individual must purchase Part A coverage. If an individual must purchase coverage, enrollment in Part A can only occur during the initial or general enrollment period and coverage will begin on July 1 of that year. Similarly, for beneficiaries enrolling in the general enrollment period Part B coverage will not begin until July 1 of that year.

Enrollment is generally handled by the Social Security Administration through their local offices. Railroad Retirement beneficiaries should contact the Railroad Retirement Board to enroll.

Enroll Online: As of 2010, you may also enroll online at www.socialsecurity.gov (site visited September 23, 2015). Click "Online Services" and then "Apply for Benefits." The application process can take less than 10 minutes.

Working Elderly

At the time that the Medicare program was established in 1965 most people retired at 65, and automatically began their participation in the program at that age. However, as people began to work past the age of 65, and as Medicare began to try to contain costs, Medicare coverage and enrollment policy changed.

In the early 1980's several pieces of legislation were passed which made Medicare benefits secondary to benefits payable under an employer group health plan (EGHP) for employees and their spouses age 65 and older. Further, employers are now prohibited from offering a different health plan to Medicare eligible employees and their spouses than that which is offered to other employees. Employers with less than 20 employees are exempt from these new laws but may participate voluntarily.

These changes led to the establishment of an additional "special enrollment period" for the working elderly. Individuals, over the age of 65, who are covered by an EGHP by virtue of their own, or a spouses' employment, have the option to enroll in Medicare past age 65 without incurring a premium surcharge. Since their EGHP is the primary payer many workers may not want to pay for Medicare coverage which might be duplicative. Failure to enroll during this "special enrollment period" may result in a premium surcharge and the individual may not be allowed to enroll until the next general enrollment period.

Originally, the special enrollment period (SEP) began on the first day of the first month in which the employee was no longer covered by the EGHP, and ended seven months later. However, effective March 1, 1995, individuals covered under an EGHP can enroll in Medicare while still covered by the EGHP. Additionally, the period during which enrollment may occur, after EGHP coverage ends, was extended from seven to eight months.*

Under these new provisions, an individual can enroll in Medicare while still covered by an EGHP, and elect to have coverage begin in that month or any of the following three months.

Example:

Mary attained age 65 in 2013, but continued to work and be covered by an EGHP. In April 2015 she filed an application for monthly Social Security benefits and Medicare because she planned to retire on June 30, 2015. She can elect to have Medicare coverage begin either in April of 2015, or in any of the three following months. She elects to have coverage begin in July of 2015, since she has coverage under her EGHP until that time.

Mary could also have chosen to delay her application for Medicare until July 2015, the first full month she was not covered by an EGHP. This would also result in Medicare coverage becoming effective on July 1, 2015, the first day of the month that she was no longer covered by the EGHP. However, should Mary have delayed application for Medicare until August 2015, her coverage would not have been effective until September of 2015. This is because enrollment in Medicare during the seven months following the first full month in which an individual is no longer covered by an EGHP will result in coverage beginning the first day of the month after the month of enrollment. Therefore, to avoid any gaps in coverage it is advisable to enroll either in the three months before, or in the actual month your employment ends. It is important to remember that the changes in the law did not alter the fact that the Special Enrollment Period is only available to people covered by an EGHP by virtue or their own or a spouse's employment.

Failure to Enroll

There can be serious implication for individuals who fail to enroll in Medicare during their proper enrollment period. There is the surcharge of 10% per year assessed on the Part B premium for each year that an individual fails to enroll. What can be more serious, is that failure to enroll during the initial or special enrollment period will result in the individual not being allowed to enroll in Medicare Part B until the general enrollment period during the first three months of each year. Coverage for Part B benefits then would not begin until July of that year. As a result, there may be several months when an individual, having no Part B Medicare coverage, may be vulnerable to costly out-of-pocket medical expenses. It is important to note that an individual entitled to Social Security or Railroad Retirement benefits may enroll in Part A at any time and receive up to 6 months retroactive coverage without penalty. It is only Part B coverage which is subject to enrollment period restrictions and to a surcharge. An exception to this is those individuals not entitled to Part A coverage but who elect to pay the premium and participate voluntarily. They will be subject to the enrollment restrictions and the surcharge.

Appeals

A decision to deny Medicare eligibility or coverage, for whatever reason, can be appealed to the Social Security Administration or Railroad Retirement Board. When a person's enrollment rights have been prejudiced because of the action, inaction, misrepresentation or error on the part of the federal government she cannot be penalized or caused hardship. If an individual can demonstrate this to be the case, the decision to deny Medicare eligibility or coverage, or the imposition of a penalty surcharge, may be reversed. Appeals are handled by the local Social Security office. It is important if you feel you are being unfairly denied Medicare coverage that you insist on your right to an appeal.


Notes about COBRA Coverage and Medicare (all sites visted September 24, 2015)


HOW TO ENROLL IN MEDICARE IF NOT ELIGIBLE FOR SOCIAL SECURITY

The age of eligibility for full Social Security benefits is gradually increasing from 65 to 67, thus an increasing number of people will need to enroll in Medicare at age 65 without also registering for Social Security benefits. Here's how to do it:

1. Apply securely online at http://www.socialsecurity.gov/forms/apply-for-benefits.html

  • Fill out the simple questions on applying for self or other and visual impairment on the right under "to start the application process"
  • Cick the "apply for benefits" button
  • Fill out the electronic forms on the following pages.
  • The sections are divided so as to keep them short and clear. Just be sure to be accurate and complete.

OR

2. Call the Social Security 800 telephone number

  • Call 1-800-772-1213, choose prompt 1 for English, 3 for other additional services or to speak with a representative, and finally 0 to speak with a claims representative;
  • Once you are talking to a claims representative, explain that you want to enroll in Medicare but NOT Social Security. They will fill out an application for you and instruct you how to submit your birth certificate;
  • Your application will then be submitted by the claims representative;
  • Four to six weeks after the receipt of your documentation, you will receive your Medicare card and handbook in the mail.

OR

3. Visit your local Social Security office

  • Visit your local Social Security office. (You can find it online, or by calling 1-800-772-1213);
  • Once you are talking to a claims representative, explain that you want to enroll in Medicare but NOT Social Security. They will fill out an application for you and make a copy of your birth certificate;
  • Your application will then be submitted by the claims representative;
  • Four to six weeks later, you will receive your Medicare card and handbook in the mail.