Eligibility for Medicare: Beneficiaries

Individuals are eligible for Medicare based on personal earnings or on those of a spouse, parent or child. There are three categories of individuals who are eligible to be insured by Medicare.

• Aged
• Disabled
• Those with end-stage renal disease

The Social Security Administration (SSA) handles entitlement, enrollment and premiums for the Medicare program. The SSA office issues the Medicare cards. Medicare Part B is a voluntary program for which the insured must pay a monthly premium.

Some individuals are eligible for Medicare under Railroad Retirement Benefits. The Railroad Retirement Board (RRB) will issue Medicare cards to individuals eligible for those benefits.

Medicare Eligibility for Age 65 or Older
To be eligible for premium-free Part A on the basis of age:

• A person must be age 65 or older; and
• Be eligible for monthly Social Security or Railroad Retirement Board (RRB) cash benefits

An individual who is receiving monthly Social Security or RRB benefits at least four months prior to turning age 65 does not need to file a separate application to become entitled to premium-free Part A. In this case, the individual will get Part A automatically at age 65.

An individual who is not receiving monthly Social Security or RRB benefits must file an application for Medicare by contacting the Social Security Administration.

Part A coverage begins the month the individual turns age 65, provided he or she files an application for Part A (or for Social Security or RRB benefits) within six months of the month in which he or she becomes age 65. If the application is filed more than 6 months after turning age 65, Part A coverage will be retroactive for six months.

NOTE: For an individual whose 65th birthday is on the first day of the month, Part A coverage begins on the first day of the month preceding their birth month. For example, if an individual's birthday is on December 1, Part A begins on November 1.

More Information for People Age 65 or Older who Must Pay a Premium for Part A
People who must pay a premium for Part A do not automatically get Medicare when they turn 65. They must:

• File an application to enroll by contacting the Social Security Administration;
• Enroll during a valid enrollment period; and
• Also enroll in or already have Part B

To keep premium Part A, the person must continue to pay all monthly premiums and stay enrolled in Part B. This means that the person must pay both the premiums for Part B and premium Part A timely to keep this coverage.  

Premium Part A coverage begins prospectively, based on the enrollment period the person uses to apply for coverage.

Medicare Eligibility Based on Disability
A person who is entitled to monthly Social Security or Railroad Retirement Board (RRB) benefits on the basis of disability is automatically entitled to Part A after receiving disability benefits for 24 months. Disabled Federal, State and local government employees who are not eligible for monthly Social Security or RRB benefits may get deemed entitlement to disability benefits and automatically entitled to Part A after being disabled for 29 months.

Special Rule for People with Amyotrophic Lateral Sclerosis (ALS) (Lou Gehrig’s Disease)
Individuals whose disability is Amyotrophic Lateral Sclerosis (ALS) are entitled to Part A the first month they are entitled to Social Security or RRB disability cash benefits. There is no waiting period.

Special Rule for People Claiming Child Disability Benefits
SSA rules do not allow for child disability benefit to begin earlier than age 18. Therefore, Part A entitlement based on child disability benefit entitlement can never begin before the month the person attains age 20 (or age 18 if the individual’s disability is ALS).

The Social Security Administration (SSA) handles entitlement, enrollment and premiums for the Medicare program. The SSA office issues the Medicare cards.

Medicare Eligibility Based on End-Stage Renal Disease (ESRD)
Individuals are eligible for premium-free Part A if they receive regular dialysis treatments or a kidney transplant, have filed an application for Medicare, and meet 1 of the following conditions:

• Have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee; or
• Are getting or are eligible for Social Security or RRB benefits; or
• Are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee; or are getting Social Security or RRB benefits

Part A coverage begins:

• The third month after the month in which a regular course of dialysis begins; or
• The first month a regular course of dialysis begins if the individual engages in self-dialysis training; or
• The month of kidney transplant; or
• Two months prior to the month of transplant if the individual was hospitalized during those months in preparation for the transplant

When a Medicare patient comes to your office, we recommend that you make a copy of his oe her Medicare card. Failure to indicate the beneficiary’s name and identification number exactly as it appears on the Medicare card may result in a claim delay/denial. You may also want to establish a process by which insurance information is verified at the beginning of each year and at certain intervals to ensure that the information has not been changed. If a change has occurred, your patient’s records will need to be updated to reflect the most current information.

References

• The official government Web site for 'people with Medicare' (beneficiaries): www.medicare.gov/
• Medicare handbook for beneficiaries: Medicare & You

Other Resources

• Original Medicare (Part A and B) Eligibility