Qualifying For Medicare: Eligibility & Coverage Options

Do I Qualify for Medicare?

Q. I am a fifty-five-year-old man on disability for a traffic accident I was in about eight years ago. The doctors believe that I am not permanently disabled, though I still have problems walking without a cane.

I lost my job and later my medical insurance because I could no longer afford the COBRA premiums. Do I qualify for Medicare benefits?

A. Probably not. Medicare program was initially intended to meet the medical needs of people sixty-five years or older, though there are narrowly defined exceptions:

• If you can show you have been on social security disability for 24 months or longer or
• You sufficiently worked long enough in a federal, state, or local government job and was insured by Medicare or
• You have a defined medical condition, such as End-stage Renal Disease or Amyotrophic Lateral Sclerosis. Also known as Lou Gehrig’s Disease.

Citizenship and Immigration Status to Qualify For Medicare

To qualify for Medicare, you must be:

• Be 65 or older
• Be a U.S. citizen or
• Be a permanent legal resident of the U.S for five years or more or
• Establish that you or your spouse has paid taxes for ten years

The Basics of Medicare Coverage

The Four Parts of Medicare

1. Medicare Part A – Hospital Coverage
2. Medicare Part B – Medical Coverage
3. Medicare Part C – Medicare Advantage
4. Medicare Part D – Prescription Drug Coverage

Medicare “Parts A and B”

Medicare “A and B” were parts of the original Medicare program

• Medicare Part A covers In-Hospital care, which now includes some outside home health care, including certain skilled nursing facilities.
• Medicare Part B covers services like outside doctor visits, outpatient services, X-rays and lab tests, and certain preventive screenings.

You will almost always, at some point, need the coverages of both Part A and Part B described above. However, if you are currently enrolled in health insurance through your employer or are covered on your spouse’s plan, you can delay your Medicare Part B enrollment without penalty.

Medicare “Part C” (Medicare Advantage Plan)

Single-Payer Plans

Medicare Advantage sometimes referred to as a single-payer health plan, is where the federal government contributes to the enrollee’s private health coverage.

This option is the part of Medicare that can be confusing. Private health insurance companies offer Medicare Advantage and other medical plans. Notwithstanding, when you enroll in a private Medicare Advantage plan, you still have Medicare. The difference is that the Medicare Advantage plan covers and pays for your health services instead of the Original Medicare.

Here is where it gets tricky. The Medicare Advantage plans must provide the same level of coverage as the Original Medicare plan so there is no gap in Medicare health benefits coverage. Not only is there no gap, but under private Medicare Advantage Plans, medical insurers can offer extra benefits to entice more people to enroll with their company.

Medicare “Part D”

Prescription Drug Coverage

The advantage of purchasing a Medicare Advantage plan from a private insurer is that private insurance plans usually include prescription drugs as an added benefit.

Medicare Does Not Cover Or Limits Coverage To:

• Acupuncture
• Assisted Living (Board & Care)
• Cataract Removal Surgery
• Chiropractic Services
• Colonoscopies
• Contacts or Eyeglasses
• Dental Care
• Hearing Aids
• Home Healthcare
• Hospice Care
• Routine Eye Exams
• Services Outside The U.S

How Does “Medicaid” Fit In?

Medicaid (state) and Medicare (federal) are different programs. Still, depending on the eligibility requirements based on an applicant’s state of residence, these two programs can work together to serve underserved individuals suffering from financial hardship.

Qualifying For Medicaid

Not everyone qualifies for Medicaid. Each state has its own set of qualifications. Common to all Medicaid states is that you must be 65 or older and have limited income and assets.

Medicaid Can Sometimes Offer More

Medicaid, depending on the state you are in, may cover certain services that Medicare will not. For example, in some states, Medicaid will cover:

• Dental
• Long Term Care
• Medical Transportation
• Prescription Drugs
• Vision Correction

Qualifying by Payment of Monthly Premium: People 65 or under who are otherwise eligible for Medicare Hospital Insurance can enroll in the Medicare program by paying a monthly premium. You may also qualify for Medicare if you are eligible to receive Railroad Retirement benefits but have not yet applied for them.

Should you still have questions visit our Elder Law Resource Section.