Medicare Eligibility

There are several ways individuals can become eligible for Medicare. Age, disability, and certain diagnoses can qualify someone for Medicare. Prior to enrollment, understanding how Medicare works and which plans to enroll in will ensure you get the most value. First, you’ll need to know if you are eligible to enroll in Medicare. To learn more about Missouri Medicare Eligibility read our newest blog post here.

Medicare Qualifications

Individuals who are 65 and older are eligible to receive Medicare benefits. They must be a U.S. citizen or a permanent resident who has lived in the U.S. for five consecutive years. The individual must have paid Medicare taxes for ten years to receive premium-free Part A. Enrollment is automatic if the individual has been receiving Social Security benefits.

Individuals who have been receiving disability benefits from Social Security for 24 months are also eligible for Medicare. Enrollment is automatic and will be effective on the 25th month of disability.

Finally, those with Amyotrophic Lateral Sclerosis or End-Stage Renal Disease are also eligible. ALS individuals will be enrolled in Medicare automatically, but those with ESRD must enroll themselves. Individuals with either of these conditions will receive premium-free Part A regardless of tax status.

Other Medicare Eligibility Requirements

To receive premium-free Part A, an individual must have paid Medicare taxes for ten years. A spouse who has not met that requirement but who is married to someone who has will also be eligible for premium-free Part A. Those who have not met the requirement must pay a premium for Part A.

Beneficiaries with low income may be eligible for financial assistance and may also be eligible for Medicare and Medicaid.

Beneficiaries with high income may pay a higher premium for both Part B and Part D. This added premium is calculated by using the tax return from two years ago. The added premium is called the Income-Related Monthly Adjustment Amount (IRMAA).

Disability Eligibility

Individuals who have been receiving disability benefits for 24 months will be automatically enrolled in Medicare on the 25th month. In some instances, the individual does not have to wait the full 24 months.

People with ALS will be eligible for Medicare on the month that the disability benefits begin.

Disability is determined by the Social Security Administration, not the Medicare Program.

Am I automatically
enrolled in Medicare when I turn 65?

If an individual has already been collecting Social Security benefits prior to age 65, they will be automatically enrolled in Original Medicare, unless they do not qualify for premium-free Part A.

Otherwise, 65-year-olds should enroll in Original Medicare during their unique Initial Enrollment Period. This begins three months before their 65th birthday.

Medicare enrollment can be delayed if the individual has other creditable health insurance. However, it is important to find out if your current coverage is “creditable.” All employers who have at least 20 employees have creditable coverage.

Cartoon artwork explaining Medicare and Advantage Eligibility​

Medicare Supplement Eligibility

Medicare supplement insurance plans, also known as Medigap plans which are sold by private insurance companies, require individuals to be legal U.S. citizens or permanent residents for a minimum of five consecutive years. They must also already be enrolled in Parts A and B. Most states require individuals to be 65 or older, but there are some insurance carriers that offer plans to Medicare beneficiaries who are younger than 65.

Supplement plans are standardized by the federal government. Standardization means that each plan, which is differentiated by a letter of the alphabet, is consistent across different insurance carriers. No matter which insurance company offers the plan, each Medigap plan remains the same. Since they are standardized, once you determine you are eligible it is important to compare premiums and health plan options among different carriers so you don’t have to pay more for the same coverage.

It is not possible to be enrolled in a Medicare Advantage (Part C) plan and buy a Medigap plan at the same time. The only exception can imply a situation where you’ve joined a Part C plan for the first time and wish to disenroll. In that case, you have a 1-year time period, also known as the trial right period, to join Original Medicare and buy a Medigap plan. Keep in mind Medigap policies cover only one person, so if you wish to insure your whole family, for example, you should think about researching family health plan options.

Medigap Eligibility At Age 65

Enrollment periods are time periods during which you can enroll in a Medigap plan of your choice. Adults who are already receiving Social Security benefits will be automatically enrolled In Medicare Part A upon turning 65. In some cases, this applies to Medicare Part B as well. Once you are enrolled in both parts, your unique open enrollment period for Medicare supplements begins and you can research coverage options to get the plan that best meets your needs.

When you enroll during this period of time, you have guaranteed issue rights to any Medicare supplement plan. You can not be turned away from a plan due to any health conditions or health history reports. The open enrollment period ends six months after your Part B effective date.

Medigap Eligibility Under Age 65

Medicare beneficiaries who do not meet the eligibility requirements age-wise still have a chance to enroll in Medigap but with more difficulty. Individuals who are not yet 65 do not have as many options when it comes to Medicare supplements. Some carriers offer plans in some states, but it is usually limited to Plan A, the most basic Medigap plan.

The reason for the lack of choice is that Medicare beneficiaries who are younger than 65 are on Medicare because of a disability. This means that they have higher healthcare costs and are at a higher risk for claims. This also means that the monthly premiums for Plan A are double or triple the amount that someone over 65 would pay. (This is not the case in every state.)

Individuals who hold a Medigap policy under 65 will have the opportunity to choose a new plan when they turn 65. At this time, they will still have guaranteed issue rights.

Medicare Advantage Eligibility

Eligibility for Medicare Advantage Plans

Like other aspects of Medicare, there are certain eligibility requirements for Medicare Advantage plans. Your location will be a determining factor for which plans are available for you. We are going to discuss Medicare Advantage eligibility so that you can determine if you qualify for one of these plans.

Qualification for Medicare Advantage Plans

To qualify for a Medicare Advantage plan, individuals must first be enrolled in Original Medicare – Parts A and B. This includes people younger than 65 who are eligible for Medicare for some other reason than age. Next, you must be current on payments of your Part B premiums. (Even if you choose to enroll in a Medicare Advantage plan, you must continue to pay the Medicare Part B premium.) Lastly, you must live in an area where Medicare Advantage plans are offered.

There are separate qualifications for financial assistance. Low-income individuals or those who qualify for both Medicare and Medicaid may be able to get help paying for the premiums, deductibles, copayments, and coinsurance expenses.

Individuals who have been diagnosed with End-Stage Renal Disease (ESRD) are eligible for Medicare Advantage plans, but their options are more limited. There are also Special Needs Plans available for those with chronic issues.

Regardless of your qualifications, Medicare Advantage plans are not available in all areas of the country. There may be none available in some areas, while others just have limited choices.

Eligibility Checklist for Medicare Advantage Plans

There are three things you must do to become eligible for a Medicare Advantage plan.

  1. Enroll in Medicare Parts A and B and have your Part B effective date
  2. Have your Medicare ID number
  3. Live in the plan’s service area

If you are unsure if you qualify for a Medicare Advantage plan, one of our licensed agents can assist you.

Rules and Requirements for Medicare Advantage Plans

Since Medicare Advantage plans are sold by private insurance companies, they will all come with their own rules and regulations. Not all Medicare Advantage plans are created equal, so it is very important that you understand how your plan works.

Most of the time, you will need to receive care from a doctor that is within your plan’s network. Going outside of the network will cause you to incur higher out-of-pocket costs, sometimes even the entire bill for services. You will likely also need to get a referral to see a specialist. Failure to do so may mean that the plan will not cover those expenses, regardless of whether the specialist is in your network or not.

Medicare Advantage Enrollments and Applications

As long as you are eligible for Medicare and have enrolled in Medicare Parts A and B, you can enroll in a Medicare Advantage plan if one is available in your area. Not all counties have these plans available, so this is one of the first things to check before you continue your enrollment.

There are several enrollment periods associated with Medicare Advantage plans. This first one you will be eligible for is your Initial Enrollment Period which begins around the time of your Part B effective date. One of the most important enrollment periods is the Annual Enrollment Period, which occurs every fall from October 15 to December 7.

You may also qualify for a Special Enrollment Period if you have a qualifying life event. One thing that can qualify you for a Special Enrollment Period is if your current Medicare Advantage plan leaves your area of residence. This gives you the right to switch policies when that occurs. You also have the ability to try a Medicare Advantage plan. During your trial period, you can decide if you’d like to keep the plan or switch back to Original Medicare. The trial period lasts for 12 months.

The easiest and most effective way to submit an application for a Medicare Advantage plan is through an insurance agent. The agent will make sure the plan you’ve chosen fits your needs and will assist you with all the necessary paperwork. They will also submit the application on your behalf, and follow up with you to make sure you have received your enrollment package.


Savings Program

The Medicare Savings Program will help eligible beneficiaries pay for some of their out-of-pocket expenses, like those associated with Medicare Parts A and B.

There are four Medicare Savings Programs.


Qualified Medicare Beneficiary Program


Specified Low-Income Medicare Beneficiary Program


Qualifying Individual Program


Qualified Disabled and Working Individuals Program

If an individual qualifies for one of these programs, they will also qualify for Extra Help, which is a program that offers financial assistance for prescriptions.

Learn more about

Medicare Eligibility

If you have any questions or concerns regarding your eligibility, please contact a Missouri Medicare Advisor today.

Questions to be advised on:

The Missouri Medicare Advisor website character Nathan Mueller discussing Questions to be advised on.
Individuals at least 65 years of age, individuals who have been on disability for at least 24 months, and individuals with either ALS or ESRD are eligible for Medicare.
Unless you become eligible due to disability or you get diagnosed with ALS or ESRD, you will become eligible for Medicare at age 65.
You must be 65 to enroll in Medicare unless you qualify because of disability or because you have been diagnosed with ALS or ESRD.

You must be a legal U.S. citizen or a permanent resident for at least five years to be eligible for Medicare.

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