Your Medicare eligibility depends on your age, disability status, and work history. Most U.S. citizens and lawful permanent residents qualify at age 65 if they or their spouse paid Medicare taxes for at least 10 years, while individuals under 65 may qualify if they have a disability and receive SSDI, or have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
Ways to Verify Eligibility
- Use Medicare.gov tools to estimate eligibility timing and potential premiums.
- Check with the Social Security Administration (SSA) online or by phone to confirm eligibility and enrollment status.
- Learn if enrollment occurred automatically. Many people receiving Social Security or Railroad Retirement Board benefits are automatically enrolled around age 65.
Key Eligibility Exceptions
- Disability: Medicare begins after 24 months of SSDI (no waiting period for ALS).
- ESRD: Eligibility may begin within 3 months of dialysis or 1 month before a kidney transplant.
- Still working: Special Enrollment Periods allow delayed enrollment without penalties if you have qualifying employer coverage.
Confirming eligibility early helps avoid late enrollment penalties and coverage gaps and allows time to compare Original Medicare and Medicare Advantage options.
Understanding the world of Medicare is equal parts challenging and essential. If you don't enroll at the right time, you risk living without valuable health benefits at a time in your life when you may increasingly need them, as well as incurring fees and penalties that further strain your finances. By checking your eligibility early, however, you can learn about the specific considerations you'll need to take into account before enrolling.
What Is Medicare and Why Eligibility Matters
Medicare is a federal health insurance program with various plans available to Americans age 65 or older. Individuals younger than 65 with disabilities or specific health conditions are also eligible for coverage. It's a valuable program that helps ensure you have the health coverage you need at a reasonable price.
If you don't determine your Medicare eligibility early, you may miss out on enrollment periods and find gaps in coverage. Gaps in your health coverage at any age can be detrimental to both your health and finances. However, it's especially risky if you need to manage an existing condition or pay for any ongoing expenses. Take the time you need to compare coverage options with confidence and select the right plan for your needs well before enrollment begins.
Medicare Eligibility Requirements
You must meet certain requirements to enroll in Medicare. The exact criteria will vary depending on your age and whether you have certain health conditions.
Age-Based Medicare Eligibility
Upon turning 65, most Americans qualify for Medicare. You must be a U.S. citizen or lawful permanent resident to be eligible.
If you're a permanent resident, there are additional criteria you have to meet. You or your spouse needs to have worked in the U.S. and contributed to Medicare payroll taxes for 10 years at a minimum (or rather, for 40 calendar quarters, though they don't need to be continuous). If you and your spouse don't meet that requirement, you need to have lived in the U.S. for at least 5 years (in this case, continuously).
Some individuals will automatically get enrolled in Medicare upon turning 65. This includes people who have already enrolled in certain benefit programs, including Social Security or Railroad Retirement Board (RRB) benefits.
Medicare Eligibility for Disabilities
Americans with disabilities are also eligible for Medicare, even if they're younger than 65. You qualify for Medicare if you're eligible for Social Security Disability Insurance (SSDI).
Once you begin collecting SSDI, you'll be eligible for Medicare, though you have to wait for 24 months before coverage begins. The 24-month waiting period doesn't begin until you actually start collecting SSDI; it doesn't include any time you spent applying and waiting for those benefits to begin. However, upon the start of the 25th month of receiving benefits, your Medicare coverage automatically begins.
Eligibility for Medicare Due to Specific Conditions
In addition, you're eligible for Medicare regardless of your age if you have one of these specific health conditions: End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gherig's disease). The process of qualifying and applying for Medicare differs if you have either of these conditions than if you have another kind of disability; the criteria are unique for each.
With ESRD, you can access Medicare when your kidneys no longer work, and you need ongoing dialysis or have had a kidney transplant. You, your spouse, or your parent upon whom you depend also must have a sufficient work history to qualify for Social Security or RRB benefits or SSDI. The date your coverage begins depends on the nature of your condition and whether you're undergoing dialysis or a transplant. Either way, you typically have a much shorter waiting period (3 months for dialysis, the month before a transplant). In some cases, you may qualify for retroactive coverage.
If you have ALS, you can get Medicare coverage as soon as you begin collecting SSDI, with no 24-month waiting period required. Similar to individuals with other disabilities or health conditions, you'll be automatically enrolled upon your application for Social Security benefits.
Medicare Enrollment Timelines You Should Know
In addition to familiarizing yourself with eligibility requirements, you should also learn more about when you can actually enroll in Medicare once you qualify.
Initial Enrollment Period (IEP)
The Initial Enrollment Period (IEP) is your first opportunity to sign up for Medicare coverage. It starts 3 months before your 65th birthday and ends 3 months after, lasting for 7 months total. For example, if you turn 65 on April 15, your IEP would start 3 months beforehand, on January 15. Your IEP would then end on July 15.
If you want Medicare coverage, it's crucial to enroll during the IEP. Not only does this ensure access to consistent health coverage, but it also means avoiding late enrollment penalties. Unfortunately, this wouldn't be a one-time fee, either. You're charged late fees as part of your monthly premiums for as long as you have that kind of coverage — meaning you could end up paying them for the rest of your life. What's more, you'll receive charges the longer you wait to enroll.
Special Enrollment Periods (SEP)
Outside of your IEP, you can apply for or make changes to your Medicare coverage during a Special Enrollment Period (SEP). You can avoid late penalties by signing up during a SEP, but these windows may be shorter than your IEP.
If you continue to work past 65, get health insurance from your or your spouse's employer, and miss your IEP, you can sign up for Medicare during a SEP. The SEP will be triggered once you either leave your job or lose your health benefits (whichever comes first) and will last for 8 months. You won't incur any late penalties if you sign up during this time.
Beyond this, certain life events can trigger SEPs, allowing you to enroll in Medicare or adjust your existing coverage. These events include:
- Moving.
- Losing Medicaid coverage.
- Being released from incarceration.
- Missing your IEP due to a natural disaster or emergency.
- Experiencing changes, reductions, or cancellations in your existing plan.
Other "exceptional circumstances" can result in opening a SEP, but are assessed on an individual basis. If a unique situation arises, it's worth inquiring about your options.
General Enrollment Period (GEP)
There is an annual General Enrollment Period (GEP) for Medicare. It starts on January 1 and closes on March 31. The GEP is the only time you can sign up for Medicare outside of your IEP and any SEPs.
Whenever you sign up during the GEP, your coverage will start on the first day of the month after your enrollment. If, for example, you enrolled on March 3, your Medicare coverage would begin on April 1.
You may be subject to late fees if you enroll during the GEP, particularly if you missed your IEP and aren't eligible for a SEP. You'll receive an additional 10% charge for medical insurance for each year you didn't sign up, but could've. These charges will appear in your monthly premium, and you'll be required to pay the late penalty for as long as you have medical insurance through Medicare.
How Medicare Advantage Eligibility Differs
There are several components to Medicare coverage, and it's essential to understand them individually, as eligibility can differ for each part:
- Part A is hospital insurance and can be used to cover expenses for inpatient care or care in facilities like hospitals and skilled nursing homes (though it can also cover home health care expenses).
- Part B is medical insurance and can cover costs for outpatient care, such as traditional doctor's visits, as well as specific medical equipment and preventive screening and testing.
- Part C refers to Medicare Advantage and bundles multiple kinds of coverage, and more (such as dental and vision insurance).
- Part D pays for prescription medications.
When Parts A and B are bundled together, that's called Original Medicare. Sometimes, Part D may also be included.
If you're interested in Part C, known as Medicare Advantage, you need to be aware of unique eligibility requirements, as well.
Basic Medicare Advantage Eligibility Rules
To qualify for a Medicare Advantage plan, you must first meet the general Medicare eligibility requirements. Additionally, you must enroll in Part A and Part B to get a Medicare Advantage plan, and live in the plan's service area.
You can sign up for Medicare Advantage even if you have a pre-existing condition or ESRD. You still need to enroll during your IEP, the GEP, or a SEP.
Medicare Advantage vs. Original Medicare Eligibility
Since Medicare Advantage and Original Medicare are different plans with unique features, they each have different eligibility criteria you need to meet to enroll.
Most Americans who are 65 and older who are U.S. citizens or lawful permanent residents can qualify for Original Medicare, as can individuals of any age with specific disabilities or health conditions. You're free to see any doctor or go to any hospital that accepts Medicare, and you don't have to worry about network restrictions. Keep in mind that you'll still have a monthly premium for your medical insurance and be responsible for certain expenses, like copays.
Private insurers provide Medicare Advantage plans, though they must be Medicare-approved. You can get coverage for all of the same products and services, as well as additional ones. However, you're restricted to the network of providers in your chosen plan and may be limited primarily to local healthcare options. And remember, you must enroll in Medicare Parts A and B and live in your plan's service area.
How To Check If You Qualify for Medicare
With all that in mind, you may be wondering how to check whether you qualify for Medicare. Luckily, it's a fairly simple process as long as you have some personal information at the ready and know which resources to use.
Information You'll Need to Verify Eligibility
There are a few pieces of information you need to keep on hand if you want to double-check your Medicare eligibility. These include:
- Your full name.
- Your age and date of birth.
- Your work history.
- Your Social Security details, including proof of citizenship or lawful residency.
You may also need to provide details about your disability or health conditions, if applicable, especially if you're applying before age 65.
Ways to Check Your Medicare Eligibility
You can determine your Medicare eligibility in several different ways. You can always directly confirm eligibility through Social Security Administration (SSA) resources. You can check online at any time by creating an SSA online account. Alternatively, you can call 1-800-772-1213 between 8 AM and 7 PM in your local time, Monday through Friday.
Medicare.gov also offers tools to help you estimate when you qualify for Medicare, as well as how much your monthly premiums might cost. You can use your Medicare.gov account to review your benefits and access further information.
Common Medicare Eligibility Questions and Misunderstandings
Accessing Medicare coverage when you need it is critical, and understanding eligibility details can be challenging, particularly if you have questions about your work and income.
Can You Qualify for Medicare If You're Still Working?
Yes, you can still qualify for Medicare even if you work past age 65. If you get health insurance from your employer and the organization has at least 20 employees, you can postpone enrolling in Part B until you either lose coverage or stop working. At this point, a SEP of 8 months will begin. As long as you enroll in this period, you won't incur any late penalties. You may also be able to drop your employer coverage once you turn 65 or even maintain coverage from both your employer and Medicare.
If your organization employs fewer than 20 employees or you're self-employed, you'll likely need to sign up for Medicare during your IEP to avoid late penalties. The same may be true if you have coverage through COBRA or another source. Because Medicare eligibility and enrollment criteria will depend on the specifics of your particular circumstances, it's best to get in touch with your current plan provider before making any changes to your coverage.
Does Income Affect Medicare Eligibility?
No, your income does not impact your ability to qualify for Medicare. However, your income may affect what you pay for Medicare.
Many people don't pay for Part A coverage. But your income can affect what you pay for Parts B and D. Generally, the more you earn, the higher your monthly costs will be. If your annual modified adjusted gross income is above a certain threshold ($218,000 if filing jointly, $109,000 otherwise), you have to pay an income-related monthly adjustment amount in addition to your premium. This helps keep Medicare costs down for lower-income individuals.
How an Enrollment Professional Can Help
Everyone's circumstances are unique, which can make it tough to know when and even if you're eligible for Medicare. Even if you know you qualify, it can be difficult to determine which plan is right for you, how much coverage will cost, and the best time to sign up.
Finding the answers to these questions can be tough, and that's why working with a Medicare enrollment professional can be beneficial. They're knowledgeable about the Medicare system and can take your specific needs and history into account. They can simplify eligibility checks, clarify enrollment timelines, and ultimately help you avoid expensive mistakes when it comes to your health coverage. Enrolling in the right plan for your needs can be quite an undertaking on your own, but having education, guidance, and personalized support can make the entire process much less stressful.
What To Do After Confirming Your Medicare Eligibility
There's still plenty of work to do once you've confirmed your Medicare eligibility. Now, it's time to start researching and making decisions about your coverage, such as deciding whether you're interested in Original Medicare or a Medicare Advantage plan. You'll also need to prepare to actually enroll, including identifying the right time to do so and gathering the information and documents you need.
Simply put, learning about how to check your eligibility is only the first part of a longer Medicare education journey. It may sound challenging, but PolicyNational is here to help each step of the way. Check out our Terms and Conditions for more details about what we can do and how we work, or fill out our web form to get started today!
Frequently Asked Questions About Medicare Eligibility
Who Qualifies for Medicare?
Most people qualify for Medicare at age 65 if they are U.S. citizens or lawful permanent residents who have lived in the United States for at least five years. Individuals under 65 may also qualify due to a disability, End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS).
How Can I Check My Medicare Eligibility Online?
You can check your Medicare eligibility online through the Social Security Administration website or by using tools available at Medicare.gov. These resources allow you to confirm eligibility based on age, work history, and disability status.
Do I Need to Be Retired to Qualify for Medicare?
No, retirement is not required to qualify for Medicare. Many people become eligible at age 65 while still working. Medicare bases eligibility on age or disability—not employment status.
Does Income Affect Medicare Eligibility?
Income does not affect whether you qualify for Medicare. However, higher-income beneficiaries may pay more for Medicare Part B and Part D premiums due to income-related monthly adjustment amounts (IRMAA).
When Should I Start Checking My Medicare Eligibility?
We recommend checking your Medicare eligibility several months before turning 65 or as soon as you begin receiving disability benefits. Early verification helps ensure timely enrollment and prevents coverage gaps or penalties.
Is Medicare Advantage Eligibility Different From Original Medicare?
Yes, Medicare Advantage plans require that you are enrolled in both Medicare Part A and Part B and live within the plan's service area. Availability and eligibility may also vary based on local plan offerings.
Can I Qualify for Medicare If I Am Still Working?
Yes, you can qualify for Medicare while still working. Whether you need to enroll right away depends on your employer's size and the type of health coverage you have.
What Happens If I Miss My Medicare Enrollment Window?
Missing your initial enrollment period may result in delayed coverage and late enrollment penalties. In some cases, you may need to wait until the General Enrollment Period to sign up.
How Do I Know If I Qualify for Medicare Due to a Disability?
Individuals who receive Social Security Disability Insurance (SSDI) typically qualify for Medicare after a 24-month waiting period. Those with ALS qualify immediately, while ESRD eligibility follows different rules.
Can a Medicare Enrollment Professional Help Me Confirm Eligibility?
Yes, a Medicare enrollment professional can help verify your eligibility, explain enrollment timelines, and guide you through the following steps. This support can be especially helpful if your situation involves disability, employer coverage, or Medicare Advantage options.
Explore more. For plan options, enrollment help, and official resources, visit Policy National. You can also read more in our blog.