Who is not eligible for Medicare coverage? Eligibility Requirements

Medicare is a federal health insurance program that covers most people who are 65 or older, as well as some people who are younger than 65 and have certain disabilities or medical conditions. Medicare has four parts: Part A, Part B premium, Part C, and Part D. Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services. Part B covers outpatient medical services, such as doctor visits, lab tests, preventive care, and durable medical equipment. Part C, also known as Medicare Advantage, is an alternative way to get your Medicare benefits through a private insurance company that contracts with Medicare. Part D covers prescription drugs and is offered by private companies that work with Medicare.

However, not everyone qualifies for Medicare eligibility or Medicare enrollment. There are some groups of people who may not qualify for Medicare based on their age, work history, citizenship status, or health condition. In this article, we will explain who is not eligible for Medicare coverage and what options they may have to get health insurance.

Who is Not Eligible for Medicare Based on Age?

The most common way to qualify for Medicare is by reaching the age of 65. However, not everyone who is 65 or older is automatically eligible for Medicare. You also have to meet one of the following criteria:

You are a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years.
You or your spouse has worked and paid Medicare taxes for at least 10 years (40 quarters).
You are eligible for Social Security or Railroad Retirement Board benefits based on your own or your spouse’s work history.
You are a government employee or retiree who has not paid into Social Security but has paid Medicare payroll taxes.

If you do not meet any of these criteria, you may not be eligible for premium-free Part A coverage, which means you will have to pay a monthly premium for Part A if you want to enroll in it. The premium amount depends on how many quarters of work you have. For example, in 2023, the Part A premium was $511 per month if you had less than 30 quarters of work, and $259 per month if you had 30 to 39 quarters of work. However, you may still be eligible for Part B coverage if you are 65 or older and a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years. You will have to pay a monthly premium for Part B, which was $170.10 in 2023.

Who is Not Eligible for Medicare Based on Disability?

Another way to qualify for Medicare is by having a disability that prevents you from working and earning a substantial income. However, not everyone who has a disability is automatically eligible for Medicare. You also have to meet one of the following criteria:

You have been receiving disability benefits from Social Security or the Railroad Retirement Board for at least 24 months.
You have amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, and you are entitled to Social Security disability benefits based on your own or your spouse’s work history.
You have end-stage renal disease (ESRD), which is a permanent kidney failure that requires dialysis or a kidney transplant, and you meet certain work and insurance requirements.

If you do not meet any of these criteria, you may not be eligible for Medicare based on disability. However, you may still be eligible for Medicare based on age if you are 65 or older and meet the criteria mentioned above. Alternatively, you may be eligible for Medicaid, which is a joint federal and state program that provides health coverage for low-income individuals and families. Medicaid eligibility rules vary by state, but generally you have to meet certain income and asset limits to qualify. You can find out more about Medicaid eligibility and how to apply in your state by visiting [Medicaid.gov] or contacting your State Health Insurance Assistance Program (SHIP).

Who is Not Eligible for Medicare Based on Citizenship Status?

Another factor that affects your eligibility for Medicare is your citizenship status. As mentioned above, you have to be a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years to qualify for Medicare based on age or disability. However, there are some exceptions to this rule:

If you are under 65 and have ESRD, you may be eligible for Medicare regardless of your citizenship status if you are the spouse or dependent child of a U.S. citizen or permanent legal resident who meets the work and insurance requirements.
If you are under 65 and have ALS, you may be eligible for Medicare regardless of your citizenship status if you are entitled to Social Security disability benefits based on your own or your spouse’s work history.
If you are a refugee, asylee, or other humanitarian immigrant who has been granted legal status in the U.S., you may be eligible for Medicare if you meet the age or disability criteria and have lived in the U.S. for at least five years.

If you do not meet any of these exceptions, you may not be eligible for Medicare based on your citizenship status. However, you may still be eligible for other health insurance options, such as:

A health insurance plan through the Health Insurance Marketplace, which is a website where you can compare and buy private health insurance plans that meet the minimum standards set by the Affordable Care Act (ACA). Depending on your income and household size, you may qualify for financial assistance to lower your monthly premiums and out-of-pocket costs. You can find out more about the Health Insurance Marketplace and how to enroll by visiting [HealthCare.gov] or calling 1-800-318-2596.
A health insurance plan through your employer, your spouse’s employer, or a former employer if you are retired. Depending on the type and size of the employer, you may be able to get health insurance coverage that meets your needs and budget. You can find out more about your employer-sponsored health insurance options by contacting your human resources department or benefits administrator.
A health insurance plan through a professional association, a union, a religious group, or another organization that offers group health insurance to its members. Depending on the type and size of the organization, you may be able to get health insurance coverage that meets your needs and budget. You can find out more about your group health insurance options by contacting the organization that offers it.

Who is Not Eligible for Medicare Based on Health Condition?

The last factor that affects your eligibility for Medicare is your health condition. As mentioned above, you have to have end-stage renal disease ESRD or ALS to qualify for Medicare based on disability before age 65. However, there are some other health conditions that may affect your eligibility for Medicare in different ways:

If you have ESRD and are enrolled in a Medicare Advantage Plan, you may not be able to switch to another Medicare Advantage Plan or return to Original Medicare (Part A and Part B) unless you have a special enrollment period or a trial right. However, you may be able to join a Medicare Special Needs Plan (SNP) that specializes in serving people with ESRD if one is available in your area. You can find out more about Medicare SNPs and how to enroll by visiting [Medicare.gov] or calling 1-800-MEDICARE (1-800-633-4227).
If you have ESRD and are enrolled in Original Medicare, you may not be able to join a Medicare Advantage Plan unless you have a special enrollment period or a trial right. However, you may be able to join a Medicare Cost plan, which is a type of Medicare health plan that is offered by private companies in certain areas of the country. Unlike Medicare Advantage Plans, Medicare Cost plans allow you to keep your Original Medicare coverage and use any provider that accepts Medicare. You can find out more about Medicare Cost plans and how to enroll by visiting [Medicare.gov] or calling 1-800-MEDICARE (1-800-633-4227).
If you have ALS and are enrolled in Original Medicare, you may not be able to join a Medicare Advantage Plan unless you have a special enrollment period or a trial right. However, you may be able to join a Medicare SNP that specializes in serving people with ALS if one is available in your area. You can find out more about Medicare SNPs and how to enroll by visiting [Medicare.gov] or calling 1-800-MEDICARE (1-800-633-4227).
If you have dementia and are enrolled in Original Medicare or a Medicare Advantage Plan, you may not be eligible for certain services or benefits that require prior authorization or medical necessity determination. For example, you may not be eligible for home health care services if you do not have a skilled need or a home bound status. However, you may be eligible for other services or benefits that can help you manage your condition and improve your quality of life. For example, you may be eligible for cognitive assessment and care planning services, which are covered by Part B once per year for people with cognitive impairment. You can find out more about the services and benefits that are available for people with dementia by visiting [Medicare.gov] or calling 1-800-MEDICARE (1-800-633-4227).

Conclusion

Medicare is a federal health insurance program that covers most people who are 65 or older, as well as some people who are younger than 65 and have certain disabilities or medical conditions. However, not everyone is eligible for Medicare coverage. There are some groups of people who may not qualify for Medicare based on their age, work history, citizenship status, or health condition.

FAQS

When should I enroll in Medicare Part B?

You should sign up for Part B during your initial enrollment period when you first become eligible, or you may have to pay a premium surcharge later.

Who qualifies for Medicare based on disability?

People under 65 can receive Medicare if they have received Social Security disability benefits for at least 24 months. Those with disabilities like ALS also qualify.

What if I’m still working at 65 – should I enroll in Medicare?

Yes, you should still enroll in Medicare when you turn 65 even if you have group health coverage through your job. You can delay Part B without penalty.

When does Medicare coverage begin?

For most who qualify, Medicare coverage begins on the first day of the month you turn 65, as long as you enroll in Part B when first eligible.

Do I have to pay a Part A premium for Medicare?

Most don’t pay a premium since they paid Medicare taxes while working. You may pay a premium if you did not pay taxes for at least 10 years.

Who qualifies for premium-free Part A Medicare?

Citizens and permanent residents 65+ who paid Medicare taxes for 10 years while working qualify for premium-free Part A.

Can I get Medicare if I’m under 65 and on disability?

Yes, after receiving Social Security disability benefits for 24 months, people under 65 become eligible for Medicare coverage.

Does Medicare cover people with dementia?

Yes, people over 65 with dementia are entitled to Medicare. Coverage should not be denied because someone has dementia.

What if I have other health insurance when I turn 65?

You should still enroll in Medicare when first eligible at 65 even if you have coverage through an employer or retirement plan.

When does Medicare coverage end?

Medicare does not end as long as you keep Part A and B and pay premiums. It ends if you drop Medicare or lose eligibility.

Who is Not Eligible for Medicare Coverage?