Introduction to Medicare Health Insurance Eligibility

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medicare eligibility criteria
August 9, 2023 | Johanna Karlsson

Understanding Medicare

It’s easy enough to understand the basics of Medicare eligibility criteria: For most people, qualifying for Medicare means they are 65 or older, a U.S. citizen or permanent legal resident, and they’ve worked and paid Medicare taxes for at least 10 years. But it isn’t always this simple, and there are Medicare health insurance eligibility terms that enable some people to enroll before they’re 65.

If you’re wondering who can get Medicare, the Health Plus Life team is here to help you understand the rules. But first, let’s quickly recap an overview of Medicare parts, and the purpose of these plans. Medicare Part A is hospital insurance for inpatient stays, while Medicare Part B is medical insurance to cover supplies and appointments. Together, Medicare Parts A and B make up Original Medicare. Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare from a private insurer that will often include extra benefits, such as vision, hearing, dental, and prescription drug coverage. Medicare Part D is another optional plan from a private insurer to cover the cost of prescription medications.

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Basic Eligibility Criteria for Medicare

Medicare insurance eligibility is specific but fairly easy to follow. Let’s look at the basics of who can get Medicare:

  • Age: The first and most common qualification for Medicare is age. Most people become eligible for Medicare when they turn 65. However, certain circumstances can allow for earlier enrollment.
  • Citizenship or Residency Status: Medicare is available to U.S. citizens and permanent legal residents who have lived in the U.S. continuously for five years or more before applying. It’s crucial to provide proof of citizenship or legal residency status, such as a U.S. passport or a Green Card.
  • Work History: Generally, you or your spouse need to have worked and paid Medicare taxes for at least 10 years (40 quarters) to qualify for premium-free Part A, which covers hospital services. If you don’t meet these criteria, you may still be eligible for Part A, but you’ll have to pay a premium.

Age Criteria for Medicare

who is eligible for medicare

As we previously noted, for most people, eligibility for Medicare will begin when they are 65 years old, regardless of health status or pre-existing conditions. However, there are some cases when a younger person can enroll. Let’s explore some circumstances when someone under 65 who can get Medicare might be eligible.

Those under 65 who have been receiving Social Security Disability Insurance (SSDI) benefits for 24 months are eligible for Medicare. The two-year waiting period starts from the date the Social Security Administration determines the disability began, not the date when the beneficiary started receiving SSDI.

Medicare Part C, also known as Medicare Advantage, offers comprehensive coverage that combines Medicare Parts A and B benefits into a single plan. It often includes additional benefits like prescription drug coverage and may provide options for dental and vision care.

Additionally, it’s essential to be aware that people under 65 with certain medical conditions can qualify for Medicare without waiting 24 months. Individuals with End-Stage Renal Disease (ESRD), a condition of permanent kidney failure requiring dialysis or a kidney transplant, can enroll in Medicare regardless of their age.

Similarly, individuals with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease, are eligible for Medicare as soon as they begin receiving Social Security Disability Insurance (SSDI) benefits. There is no 24-month waiting period for those with this diagnosis. These provisions ensure that individuals with critical medical conditions have access to vital healthcare coverage through Medicare Part C.

Residency Criteria for Medicare

Eligibility for Medicare is straightforward in the case of citizenship or legal residency. This is who can get Medicare, and when special circumstances allow some wiggle room on the matter.

To qualify for Medicare, U.S. citizens must be aged 65 or older. However, exceptions apply to younger people with certain disabilities or medical conditions like ESRD or ALS.

Legal permanent residents, often referred to as green card holders, are also eligible for Medicare benefits if they are 65 or older. In addition, they must have lived in the United States continuously for at least five years before applying for Medicare.

Similar to U.S. citizens, legal permanent residents under 65 may also qualify for Medicare if they have been receiving Social Security Disability Insurance (SSDI) for 24 months or if they have ESRD or ALS.

It’s important to note that the residency requirements for Medicare pertain to the eligibility for premium-free Part A (Hospital Insurance). To qualify, a person or their spouse must have worked and paid Medicare taxes for at least 40 quarters (10 years).

For Part B (Medical Insurance) and Part D (Prescription Drug Coverage), which both require monthly premiums, the main requirement is that the person must be 65 or older and a U.S. citizen or legal resident.

Special Eligibility Circumstances

People under the age of 65 can qualify for Medicare if they have been receiving Social Security Disability Insurance (SSDI) benefits for at least 24 months. The 24 months begin from the time you are considered disabled and not necessarily when you start receiving benefits. Note that this rule also applies to those receiving a disability pension from the Railroad Retirement Board.

It’s also worth noting that certain medical conditions or circumstances can affect Medicare eligibility. For instance, people under 65 with disabilities, End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS) may also qualify for Medicare.

There are also specific situations where you might be eligible for Medicare even if you’re not a U.S. citizen. For instance, if you’re a lawfully admitted non-citizen who has lived in the U.S. for five years or more and you or your spouse have paid Medicare taxes while working, you’d be eligible.

As these special circumstances highlight, qualifying for Medicare can occur under different scenarios, and it’s crucial to explore all avenues of eligibility. If you believe you might qualify under one of these special circumstances but aren’t sure, you can always reach out to the Health Plus Life team for help.

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What to Do If You’re Not Immediately Eligible

Even if you don’t currently meet Medicare eligibility criteria, you may have some options to secure Medicare insurance eligibility or make sure you’re covered by some adequate health insurance policy. Let’s look at how this might work.

  • Spouse’s Eligibility: If you’re not eligible for premium-free Medicare Part A on your own work record, you may qualify based on your spouse’s work history, whether they are living, deceased, or divorced. In this case, the spouse must be at least 62 years old, and you must be at least 65. For divorced spouses, you could be eligible if you were married for at least 10 years.
  • Buying into Medicare: If you’re not eligible for premium-free Part A, and you don’t meet the requirements for eligibility based on a spouse’s work record, you can pay premiums to receive Part A coverage. This option can be particularly beneficial if you’re over 65 but don’t have the required work history. Keep in mind, though, that these premiums can be quite high.
  • Medicare Savings Programs: Depending on your income level, you may be eligible for certain Medicare Savings Programs. These programs, administered by your state, can help pay your Medicare Part A and Part B premiums, and in some cases, deductibles, coinsurance, and copayments.
  • Marketplace Plan: If you’re under 65 and don’t qualify for Medicare due to special circumstances, you can consider purchasing a health insurance plan through the Health Insurance Marketplace. Once you turn 65 or meet other Medicare eligibility requirements, you can transition from your Marketplace plan to Medicare.
  • Continuing Employer Coverage: If you’re still working and have health insurance through your employer, you may choose to delay Medicare enrollment without facing late penalties. Once your employment or coverage ends, you will have a special enrollment period to sign up for Medicare.

Checking Your Medicare Eligibility

Now that you understand the basic Medicare eligibility criteria and know some exceptions for qualifying for Medicare, let’s outline the steps you’ll want to follow to actually check your eligibility. Keep in mind the Health Plus Life team is always available to answer your questions and help you get the right Medicare coverage in place.

  1. Know the Rules: First, familiarize yourself with the basic Medicare health insurance eligibility requirements. Generally, you’re eligible for Medicare if you are a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five continuous years and you are 65 years or older; under 65 with certain disabilities; or any age with ESRD or ALS.
  2. Check Your Work History: You or your spouse need to have worked long enough in a job where you paid Medicare taxes. Typically, this is 10 years or 40 quarters.
  3. Use the Medicare Eligibility Tool: Visit the official Medicare website and use their eligibility tool. This online tool provides a personalized and comprehensive understanding of your eligibility and enrollment periods.
  4. Contact the Social Security Administration (SSA): If you’re nearing the age of 65 or have a disability, you can contact the SSA directly. They manage Medicare enrollment and can provide detailed information about your eligibility.
  5. Review Special Circumstances: If you have certain conditions such as ALS or ESRD, or if you’re not 65 but cannot work due to a disability, you may qualify for Medicare under special circumstances.
  6. Get Help: If you’re still unsure about your eligibility, consider seeking assistance from a Medicare counselor, a trusted healthcare advisor, or a social worker. They can guide you through the process and help clarify any confusion you may have. Rely on trusted resources, such as AARP, or call Health Plus Life to get answers to your questions.

Remember, understanding your Medicare eligibility is crucial to ensuring you have the coverage you need. As always, the Health Plus Life team can help you figure this all out and make sure you have the right plans and right benefits for your healthcare needs.

Frequently Asked Questions on Eligibility for Medicare Health Insurance

What are the basic eligibility criteria for Medicare?

The basic eligibility criteria for Medicare is being a U.S. citizen or legal resident who has lived in the U.S. for at least five consecutive years and is aged 65 or older. Some younger people with disabilities, or those with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS), may also qualify.

Can I qualify for Medicare if I am under 65?

Yes, individuals under 65 can qualify for Medicare if they have received Social Security Disability Insurance (SSDI) for at least 24 months, or if they have ESRD or ALS.

How does residency status affect Medicare eligibility?

You must be a U.S. citizen or a legal resident who has lived in the U.S. for at least five consecutive years to be eligible for Medicare.

What special circumstances can make someone eligible for Medicare?

Special circumstances, such as having a certain disability or illness like ALS or ESRD, can make someone eligible for Medicare. Also, receiving SSDI for at least 24 months can qualify someone under 65 for Medicare.

What can I do if I am not immediately eligible for Medicare?

If you’re not immediately eligible for Medicare, you may have options through private insurance, Medicaid, or state health insurance programs. You might also qualify for help through the Health Insurance Marketplace.

How can I check my eligibility for Medicare?

You can check your Medicare eligibility status by visiting the eligibility tool on or contacting the Social Security Administration.

Can my spouse’s eligibility affect my qualification for Medicare?

Yes, if your spouse is eligible for Medicare, you might also qualify based on their work history, even if you do not have enough work credits on your own. This is generally the case if you are at least 65 and your spouse is at least 62 and has paid into Social Security for at least 10 years.

What should I do if I still have questions about my Medicare eligibility?

If you have further questions about your Medicare eligibility, you can contact Medicare directly or speak with a trusted insurance counselor through your State Health Insurance Assistance Program (SHIP). Health Plus Life is also available to help answer any questions and guide you through the process.

Johanna Karlsson
Johanna Karlsson is a veteran health and life insurance professional licensed in 50 states. She relocated from the countryside in the south of Sweden and has not looked back. After coming to the United States to attend university, she gained her degree in Public Relations. She brought her public relations skills to a local international health insurance where she discovered a new passion in insurance. After years with that company, Johanna now joins HealthPlusLife to help build a team of licensed insurance agents ready to meet your insurance needs.