Medicare Overview
Medicare Eligibility
Medicare is a nationwide federal health insurance program for American citizens and legal residents aged 65 and above, as well as some younger individuals with a qualifying disability or diagnosis.
U.S. Citizen OR Legal Resident
Legal residents must live in the United States for a minimum of 5 consecutive years, including the 5 years prior to applying for Medicare.
AND
Age 65+ OR one of the following
- 24+ months receiving disability
- Lou Gehrig’s Disease (ALS)
- End-Stage Renal Disease (ESRD)
People with Disabilities
People with disabilities become eligible for Medicare the month they receive their 25th disability check. Their IEP begins 3 months earlier and ends 3 months after that month.
Parts of Original Medicare
Medicare Part A helps pay for hospital stays and inpatient care.
Individuals cannot be denied Part A coverage. They can go to any qualified health care provider in the United States who participates in the Medicare program and is accepting Medicare patients.
Medicare Part A covers hospital stays and inpatient care, including:
| A semi-private room |
| Your hospital meals |
| Skilled nursing services |
| Care in special units, such as intensive care |
| Drugs, medical supplies and medical equipment used during an inpatient stay |
| Lab tests, X-rays and medical equipment as an inpatient |
| Operating room and recovery room services |
| Some blood transfusions in a hospital or skilled nursing facility |
| Inpatient or outpatient rehabilitation services after a qualified inpatient stay |
| Part-time, skilled care for the homebound |
| Hospice care for the terminally ill, including medications to manage symptoms and control pain |
Medicare Part B helps pay for doctor visits and outpatient care.
Individuals cannot be denied Part B coverage. They can go to any doctor or qualified health care provider in the United States who participates in the Medicare program and is accepting Medicare patients.
Medicare Part B covers doctor visits and outpatient care, including:
| Doctor visits, including in the hospital |
| An annual wellness visit and preventive services, like flu shots and mammograms |
| Lab services, like blood tests |
| X-rays and some other diagnostic tests |
| Some health programs, like smoking cessation, obesity counseling and cardiac rehab |
| Physical therapy, occupational therapy and speech-language pathology services |
| Diabetes screenings, diabetes education and certain diabetes supplies |
| Mental health care |
| Durable medical equipment for use at home, like wheelchairs and walkers |
| Ambulatory surgery center services |
| Ambulance and emergency room services |
| Skilled nursing care and health aide services for the homebound on a part-time or intermittent basis |
Enrolling in Medicare
Enrollment in Medicare occurs automatically for many Americans. But, there are cases in which you may be required to enroll manually.
Eligible recipients will be automatically enrolled in Medicare Part B if/when they meet any of the following criteria:
- Turning 65 and receiving Social Security or Railroad Retirement Board benefits
- Under 65 and receiving Social Security disability benefits for 24 months
- Diagnosed with ALS
- Turning 65 and receiving state assistance for ESRD treatment
Medicare cards are received via USPS prior to the recipient’s 65th birthday or 25th month of Disability benefits. In cases of ALS, the card will be received immediately following diagnosis. Individuals with ESRD that are NOT receiving state assistance must enroll manually, as explained in the adjacent section.
Manual Enrollment
Action needs to be taken for Medicare enrollment under the following conditions:
- Turning 65 and NOT receiving Social Security or Railroad Retirement Board benefits
- Diagnosed with ESRD and NOT receiving state assistance for treatment
- Resident of Puerto Rico seeking Part B coverage
Manual enrollment can be completed online at SSA.gov/medicare. Eligible individuals can also enroll by calling or visiting their local Social Security Office.
Late Enrollment Penalties
It’s important for individuals to enroll on time. Late enrollment (without an SEP or exception) can result in penalties, such as:
Part A: People who pay a premium (most don’t) could pay an additional 10% of the premium amount. The penalty is charged every month for twice the number of years enrollment was delayed.
Part B: You could pay an additional 10% of the premium amount for each full 12-month period enrollment is delayed. The penalty is charged every month for as long as you have Part B.
Medicare Enrollment Periods
It’s important to know when to sign up for Medicare or when to join a Medicare plan. Enrolling during these times will enable you to get the most out of your Medicare benefits and avoid late enrollment penalties.
