What are the eligibility requirements for Medicare

As providers, we are uniquely aware of how difficult it can be to understand the inner workings of how Medicare works. Which puts us in the perfect place to help our clients when the times comes for them to understand how and if they can enroll in Medicare.


Medicare Requirements

Enrollment Dates

Medicare Penalties

How to Apply for Medicare

Patient Medicare Checker

Parts of Medicare A, B, C and D

The first hurdle in order for your patients to be eligible to receive Medicare, they will need to meet some requirements and then apply during certain periods.

First, let us go over the requirements for full coverage if your patient is 65:

  • The patient must be a U.S. citizen or a permanent legal resident for at least five continuous years.

  • Be age 65 or older and eligible for Social Security.

  • the patient or their spouse has worked long enough to be eligible for social security or railroad benefits.

  • OR

  • The patient or their spouse is a government employee or retiree who has paid Medicare payroll taxes while working.

Note: usually you will earn 40 credits through payroll taxes in a 10-year span ensuring you will not have to pay premiums

Now if the patient is under 65 years of age they may still be eligible for Medicare benefits if one of the following is true:

  • Meet certain requirements and are receiving a disability pension from the Railroad Retirement Board.

  • The patient has been entitled to Social Security disability benefits for at least 24 months. (does not need to be consecutive)

  • They have permanent kidney failure requiring regular dialysis or a kidney transplant.

  • The patient has Lou Gehrig's disease

If the patient does not meet any of the above requirements, there is still an option for your patients.

As long as they are 65 or older and either a US citizen or a legal resident for at least five years, they will have the option to buy into Medicare:

Part A premiums:

  • Meet certain requirements and are receiving a disability pension from the Railroad Retirement Board.

  • The patient has been entitled to Social Security disability benefits for at least 24 months. (does not need to be consecutive)

  • They have permanent kidney failure requiring regular dialysis or a kidney transplant.

  • The patient has Lou Gehrig's disease

Part B premiums

  • Individuals with a yearly income of $85,000 or less or those filing a joint tax return with $170,000 in income or less will be $135.50

Now let us talk about important dates of when your patients need to enroll:

If your patients are already receiving Social Security benefits or benefits from the Railroad Retirement system then they have nothing to worry about and they will be automatically enrolled in Medicare and will receive their enrollment details and information in the mail.

However, if your patients does not fall into the above category they will have to apply themselves which in our experience does cause some patients confusion where they are under the impression the process is automatic.

The truth is any individual wanting to enroll in Medicare should begin in the three month period before the month they turn 65, If you enroll during the first three months your Medicare coverage begins on the first day of the month the patient turns 65. However, if they enroll in the fourth month their coverage will be delayed a month. Generally, the longer you wait in this enrollment period the longer your coverage will take to become active.

Note:The Initial Enrollment Period begins three months before the patients 65th Birthday and three months after their 65 Birthday totaling a 7 month period.

initial enrollment period for medicare

Let’s talk about what can happen if you do not enroll in the IEP (Initial Enrollment Period)

For Part A

Your patient may find themselves in a situation where they are hit with a late-enrollment penalty. This penalty is 10% of your monthly premium. This penalty will last the patient twice the number of years they could have had Medicare, for example, if they waited a year to enroll they will now have to pay the penalty for 2 years.

For Part B

Part B is similar but the big difference is for every year you do not have it you will receive a 10% penalty which will add up, so if you waited two years to apply you will pay your premium plus 20% and this will be for as long as you have Medicare part B.

Where can my patient Apply for Medicare when the time comes?

There are three ways for your patient to apply for Medicare:

  • They can do so at Social Security Website

  • By calling Social Security at 1-800-772-1213 (TTY users 1-800-325-0778)

  • In-person at your local Social Security office.

Each option has its benefits and will depend on the individual.

How will I know if my Patient has Medicare?

You can verify Medicare eligibility of any of your patients through Episode Alert’s Medicare Eligibility Checker

We spoke all about Part A and Part B and your Patient may be confused as to what each of the Medicare Parts are. So in the following section, we will briefly go over Part A, B, C and D to give patients a better understanding of what they will be getting.

What is Part A?

Medicare Part A coverage takes effect when you admitted to the hospital or when a doctor officially makes the judgment you need to become an inpatient to the Hospital. Of course, the Hospital must cover Medicare or the Utilization Review committee* of the Hospital approves your stay (this only takes place in some instances)

Utilization Review Committee Basically, what these committees need to do is take a look at your medical records and make a judgment on whether your admittance is medically necessary. There is a lot more to this, and if you are interested we recommend you check out Utilization review here:Utilization Review Committee

What will Part A cover?

episode alerts part a coverage medicare infograph

If your wondering what type of facilities are included under Part A here are some:

  • Mental Health Care (psychiatric hospital stays are limited to 190 days in a lifetime)

  • Inpatient rehab facility

  • Qualified clinical research inpatient care

  • Long-term care hospitals

  • Critical access hospital

  • Acute care hospital

Note: You will have to pay out of pocket for a phone or television in your room, private nurse or if you want a private room (unless medically necessary)

What is Part B?

There are two types of services Part B covers:

The first is Medically necessary services which are services or supplies to treat your condition or to diagnose that meet specific standards.

The second is Preventive services used by healthcare providers to prevent illness like the flu or to identify that illness very early.

What does Part B cover?

episode alerts part b coverage medicare infograph

What is Part C?

Part C goes by another name, which is Medicare Advantage. Private insurance companies contracted to Medicare runs part C. Medicare advantage covers the same thing Part A does; it also includes Home Health Care.

Some extra benefits to Medicare Part C are:
  • Dental Care

  • Vision Care

  • Hearing Care

  • Fitness benefits

episode alerts part c coverage medicare infograph

What is Medicare Part D?

Simply put part D is the Medicare prescription drug plan. It is provided through insurance companies contracted through Medicare. You can check to see what type of prescription drugs are covered here:Part D coverage