How is Medicare Eligibility Determined?

There are complex formulas to determine some forms of Medicare eligibility, but it’s fairly easy to understand the broad strokes. Most people who are 65 or older get Medicare if they are US permanent residents or citizens. Residents or citizens younger than 65 may qualify if they have certain disabilities or end stage renal disease. Others will probably not qualify for Medicare, but it’s always worthwhile to check.

The matter gets a little complicated because Medicare comes in different parts. Most people who are 65 will get what is called hospital or Part A Medicare at no charge if they’re eligible to receive social security benefits or if they’re the spouse or widow/widower of someone who had/has this eligibility. Medicare eligibility works the same when people receive railroad retirement benefits. People who have been disabled and received railroad or social security payments for at least two years are likely to be able to get Part A without paying for it.

People who are 65 and legal residents in the US for at least five years can also get Part A benefits. The difference is that they will pay for this if they don’t qualify for social security or railroad retirement. In contrast, others who qualify through social security retirement or railroad retirement eligibility may get Part A for free.

While Part A covers some of the costs of hospitalizations, it doesn’t cover most doctor’s visits or wellness care. For this, people need to check Medicare eligibility for Part B. Essentially, most people who qualify for Part A will also be able to get Part B. One of the differences is that everyone pays for Part B, unless a person has an extremely low income, in which case some costs for payment might be deferred by signing up for Medicaid.

In place of Part B, people can choose a variety of healthcare plans called Medicare Advantage plans, and these might cover costs for prescription drugs. Should people not have chosen an Advantage Plan, their eligibility for Part A and B also means they must sign up for Medicare Part D, which is prescription drug coverage. Other people chose Medigap plans, often through company retirement offers, that help to meet some of the costs Medicare doesn’t meet.

Since each person’s case can be different, it helps to get advice on Medicare eligibility. A good place to look for information is medicare.gov, the US government run website. There are quick calculators to determine eligibility, lists of frequently asked questions, and information regarding how to contact the government to determine Medicare eligibility or to ask specific questions pertaining to each individual situation.