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Medicare Eligibility

What Are Medicare Eligibility Requirements

Medicare Eligbility

Who is eligible for Medicare anyway? Medicare eligibility begins for most turning age 65. Persons who’ve been entitled to Social Security disability for at least 24 months also qualify.

 

Many people get confused about their Medicare Eligibility date with their Social Security date. They’re actually different.  For example A person may apply for full retirement income benefits at age 66. However, this doesn’t affect the age which they qualify for Medicare. Anyone that’s worked at least 40 quarters (10 years) in the U. S. during their lifetime can qualify for Medicare when they turn age 65.

 

Medicare Eligibility begins at age 65 for most people.

 

Eligibility for Medicare Part A

As mentioned above, you become eligible for Medicare Part A when you turn age 65 or if you or your spouse legally worked for at least 10 years in the U.S. During those years, whether you realized it or not, you were paying taxes toward your Medicare Part A Hospital benefits. That’s why most Americans get “Premium Free” Part A benefits when they become eligible for Medicare.  Part A basically covers your hospital stays including your care as an inpatient and room and board.

If however, you’ve not worked the required 10 years, you’ll have to pay for your Part A coverage. Contact your local Social Security office to find out what the cost will be. If you have to purchase Part A, the coverage will cost over $400/month. In some cases, however, there are lower premiums for people who have worked over 30 but less than full 40 quarters required to get “Premium Free” Part A.

 

Eligibility for Medicare Part B

You’re eligible for Medicare Part B when you turn age 65 as well. Keep in mind, you must pay a monthly premium for Part B.  Do I really need Part B?  Yes, because Medicare Part B covers outpatient medical services such as doctor visits, lab work, surgery fees, and more. See our Part B page for more information about what Part B covers.

Some people turning 65 still get their health insurance through an employer group health insurance plan. Usually group health insurance plans are very robust and provide better benefits with lower out of pocket costs to the employee because the employer is contributing toward the cost of your insurance as long as remain in the group. They can delay their enrollment into Part B in favor of their group health insurance without fearing a late penalty. However the old saying is “group is great coverage as long as your in the group”. Sometimes we see retired individuals getting charged a high monthly premium once they are no longer employed at the company, in a sense their “no longer in the group”. Sadly some employers design their group insurance plans to penalize you with higher rates once you’ve retired because you no longer contributing to the company and you bring added risk of higher than average health insurance claims because of your age. It’s sad but its true that some employers take that position and its reflected in the higher premiums some former employees have to pay to stay on the group insurance plan that they enjoyed having for many years.

Don’t get us wrong, generally we encourage people to keep their group health insurance provided through their former employer. However, if you’ve noticed the prices for it are becoming more and more unaffordable or you just want to compare contact our licensed specialist and we can help you determine if there is better coverage at lower rates available for you.

Also, should you decide to delay enrollment into Part B for any reason, consult with a licensed insurance agent who specializes in Medicare. He or she can explain the Medicare special election periods which you may use later on so that you won’t be subjected to a late enrollment penalty.

 

Eligibility for Medicare Part C

Medicare Part C is another name for the Medicare Advantage.  Medicare Advantage plans are approved by the government and have a federal contract with the Centers for Medicare and Medicaid Services.

You can enroll in Medicare Part C if you want to get your benefits through a private insurance carrier instead of Original Medicare. Part C plans must cover all of your Part A and Part B benefits and often package Part D prescription drug coverage into their plans.

To be eligible for Part C, you must first be enrolled in both Medicare Parts A and B. You must also live in the plan’s service area. Many people think that if they enroll in a Medicare Advantage plan, they can drop their Part B and escape paying Part B premiums. This is NOT the case. You must have both A and B to even be eligible to enroll in either a Medicare Advantage plan or Medigap plan. You must continue to be enrolled in Parts A and B during the entire time that you are enrolled in a Medicare Advantage plan.

 

They’re designed to reduce the out-of-pocket costs that Original Medicare doesn’t cover. However these plans generally have smaller provider networks than Original Medicare, so you’ll need to make sure all your doctors are contracted with the specific Medicare Advantage Part C Plan that you’re considering enrolling into.

Individuals enrolling in Part C under California Medicare should keep in mind that there are unique rules that only apply to this state. For example, if you enroll in a Health Maintenance Organization (HMO) plan under Part C, state and California medicare rules require that all medical providers that you want access to be part of the same medical group with some exceptions. For example, in a California Medicare HMO, if your primary care physician is in the ACME Medical group then generally you’re only allowed to see specialists that are part of the ACME Medical group. The same is true of durable medical equipment suppliers, you would only be able to get wheel chairs, oxygen, diabetes supplies and other devices from suppliers that are part of the ACME medical group. The reason is state and California medicare rules require that referrals from a primary care physician (PCP) in an HMO be made only to other medical providers in the same medical group or independent physician association (IPA) with limited exceptions. An exception to this rule may occur in remote or rural areas where there is no available specialist or medical equipment supplier that is part of the medical group or IPA.  In that case the medical group or IPA may determine or has already pre-determined which specialists outside their group may be used for those certain specialties that are necessary in order to provide their patients access to care.

So for our example under a California Medicare HMO plan, lets say that your primary care physician is in the ACME Medical group. Your doctor needs to refer you to see a cardiologist but there is not a cardiologist in ACME Medical group at all or within a reasonable distance for you to travel without creating an extreme hardship for you. In this case, California Medicare HMO rules would allow ACME Medical group to refer you to a cardiologist outside of ACME Medical group in order to give you access to care –to visit the specialist that you need for your condition. Of course, the cardiologist would have to agree to accept you as a patient and accept the terms of the HMO for payment for his or her services that they provide you.

Contact us to get more information, we’re specialist in understanding the rules that you’ll need to know about California Medicare Advantage plans.

 

Learn more about Part C Advantage plans here.

Eligibility for Medicare Part D

You’re eligible for Medicare Prescription Drug Part D coverage for as long as you are actively enrolled in either Part A and/or B. You must live in the Part D plan service area. Though Medicare Part D is not a requirement to have, we highly recommend it if you don’t have other drug coverage. Medicare Part D gives you peace of mind and provides insurance against future catastrophic medication costs. It’ll also help give you lower copays on medications you take now.

 

Find out about your Medicare Eligibility

Determining your Medicare eligibility can be is not difficult once you understand what the requirements are. We get a lot of questions about how to qualify when to enroll, or which Medicare supplement insurance plan to buy.  Though the process may seem overwhelming to you at first, our experts handle these types of questions every day. We would be more than happy to help guide you through the process.

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