Original Medicare:
Eligibility and Enrollment

Title XVIII of the Social Security Act provides health insurance to qualified individuals under Medicare Part A (hospital insurance), Part B (voluntary supplementary medical insurance), Part C (managed care), and Part D (prescription drug coverage). This law is codified in the United States Code, and the rules governing the law are codified in the Code of Federal Regulations. 

HAP Resources

Tool: Enrollment Periods

Eligibility

Individuals qualify for Medicare who are age 65 and older and:

• Who are eligible for Social Security retirement, survivor benefits, or railroad retirement benefits; or
• Who are United States citizens or have been legal permanent residents for five or more years. 
  

Individuals under age 65 qualify for Medicare:

• Who have received Social Security or railroad retirement disability benefits for a minimum of 24 months; or
• Who have lost their Social Security Disability Insurance (SSDI) and Medicare coverage after regaining employment; or
• Who receive Social Security Disability Insurance (SSDI) as a result of being diagnosed with Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease); or
• Who have end stage renal disease (ESRD), are in need of dialysis or a kidney transplant, and have worked 40 or more quarters. (Note: A parent or spouse’s work quarters may count toward this eligibility requirement. Check with the local Social Security office.)

See Soc. Sec. Act §1811; 42 U.S.C. § 426; 42 C.F.R. § 406, et seq. ; 42 C.F.R. § 407, et. seq.

 (back to the top) 

Enrollment

Medicare Part A Enrollment

The following groups are automatically enrolled in Medicare Part A:

• Individuals already receiving retirement benefits
  Those who are already receiving Social Security or railroad retirement benefits will automatically receive Part A coverage upon turning 65. These individuals do not need to file a separate application—coverage begins on the first of the month in which the beneficiary has his/her 65th birthday. These individuals will receive a “Welcome to Medicare” packet in the mail. Contact the Social Security Administration if a beneficiary has not received a packet in advance of their birth month.
  
  
• Individuals already receiving disability insurance benefits
  Those who qualify for Medicare based on receipt of Social Security Disability Insurance or railroad retirement disability benefits will automatically receive Medicare Part A. They are not required to take any action. For most individuals, Medicare will begin on the first day of the 25th month of entitlement to disability benefits. Individuals with Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease) receive Medicare concurrent with their receipt of disability benefits. To find out an individual’s Medicare enrollment status, contact the Social Security Administration. 
  
  People who are not automatically enrolled must apply for Medicare by visiting their local Social Security office or by calling Social Security’s national toll-free telephone number at 1-800-772-1213.
  

The following groups are not automatically enrolled: 

• Individuals approaching age 65 who are not receiving retirement benefits 
  Individuals who are eligible for Social Security Retirement but who have chosen to delay receiving benefits until age 65 or older should apply for Medicare coverage close to their 65th birthday to avoid a late enrollment penalty. This is also true for individuals who will not qualify for retirement benefits until after age 65 (as the initiation date for Social Security benefits is gradually pushed back to age 67). An application must be filed in the time period between three months before and three months after the beneficiary’s birthday month or during the annual general enrollment period (GEP). For more information, see HAP’s Enrollment Periods for Original Medicare.
  
  
• Working individuals with a continuing disability who have lost premium-free Medicare coverage
  Individuals must apply in the seven months following notice of termination or during the annual general enrollment period (GEP). For more information, see HAP’s Enrollment Periods for Original Medicare.
  
  
• Individuals not otherwise entitled to Medicare seeking to voluntarily enroll in Medicare Part A based on their age and citizenship or legal permanent resident status
  
  
• People seeking Medicare coverage who have end stage renal disease (ESRD) and are on kidney dialysis or have had a kidney transplant                                         
  (Unlike other Medicare eligibility categories, an application for enrollment may be filed after the beneficiary’s death by family members or other interested parties.)

See Soc. Sec. Act § 1818 - 1818A; 42 U.S.C. §§ 426, 426-1; 42 C.F.R. §§ 406.6, 406.7, 406.21.

 (back to the top)

Medicare Part B Enrollment

• Unless they specifically decline Medicare Part B coverage, individuals who automatically receive Medicare Part A will also automatically receive Part B. This process is referred to as “passive enrollment.”
• All other eligible individuals may enroll in Part B by visiting or phoning their local Social Security office during the same initial enrollment period required under Part A. People who do not enroll during this time may enroll during the general enrollment period (GEP). This period is January 1-March 31, with coverage effective July 1. Individuals may enroll during a special enrollment period if they qualify (e.g., had coverage under a qualifying employer group health plan). See HAP’s Enrollment Periods for Original Medicare.
  

See 42 C.F.R. § 407, et. seq.

Premiums

Medicare Part A Premiums

• For most Medicare beneficiaries, there is no monthly cost for hospital insurance under Medicare Part A.
• A Part A monthly premium is required only if a person is not entitled to Social Security retirement or disability benefits, railroad retirement or disability benefits, or end stage renal disease benefits.
• The cost of the monthly premium changes each September and may be reduced in the case of an individual who has 30 or more work quarters under Social Security but is not eligible for Social Security benefits.
• Some beneficiaries with lower incomes and assets may qualify for assistance in paying their monthly Part A premium. This financial assistance, provided through state Medicare Savings Programs, may reduce or eliminate the monthly premium paid by the beneficiary. See Cost Sharing for more information.

See, Soc. Sec. Act §1818; 42 C.F.R. § 406, et seq.; 42 C.F.R. § 407, et. seq.

Medicare Part B Premiums

• All Medicare beneficiaries are required to pay a monthly premium in order to receive medical insurance coverage under Medicare Part B.
• Although most individuals pay their monthly Part B premiums by way of automatic deduction from their retirement benefits or through state payment of premiums, some may choose to be billed.
• Some beneficiaries with lower incomes and assets may qualify for assistance in paying their monthly Part B premiums. This financial assistance, provided through state Medicaid programs and Medicare Savings Programs, may reduce or eliminate the monthly premiums paid by these beneficiaries.                                          
• The monthly premium cost may be higher for some individuals. People who enrolled in Part B after their initial enrollment period passed may be charged a penalty in the form of a permanently increased premium. Additionally, Medicare beneficiaries with higher incomes may pay higher premiums that are based upon their income. Exceptions and waivers apply under some circumstances in both cases. See Cost Sharing for more information.
  

See, Soc. Sec. Act § 1839]; 42 C.F.R. § 408 et. seq.

Penalties

Late Enrollment Penalties

Part A

• Individuals who enroll in Medicare Part A 12 or more months after they are initially able to enroll will be charged a 10 percent higher premium. This increased premium will be charged to the Medicare beneficiary for two times the number of years that the beneficiary was late in enrolling. (e.g. Mr. Lowry was one year late in enrolling, so he will pay increased premiums for two years.)

Part B

• Individuals who enroll in Medicare Part B after their initial enrollment period, and who do not qualify for enrollment during a special enrollment period, will be charged a 10 percent surcharge on their monthly premiums for every 12-month period they are late in enrolling. This surcharge is permanent, resulting in monthly premiums that are higher than other Medicare beneficiaries who enrolled in a timely manner.
  

See, Soc. Sec. Act. § 1839; 42 C.F.R. § 408.22; 42 C.F.R. § 406.33

(back to the top)