Generally speaking, anyone under 65 will likely not have access to Medicare. Other people who may fall short of Medicare eligibility criteria include:
- Undocumented immigrants
- People with disabilities who have received SSDI benefits for under two years
- Incarcerated individuals who cannot keep up on monthly premiums
To receive premium-free Medicare Part A, you must have worked and paid your fair share of taxes for at least 10 years. While people who worked less than this can still secure coverage at age 65, they must pay a monthly Part A premium. Other people can secure Medicare early 65 by receiving 24 months of SSDI or having end-stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
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How Does Medicare Eligibility Work?
Medicare eligibility hinges on several factors, including age, employment history, and health status.
General Medicare Eligibility
Traditionally, only U.S. citizens and lawful residents 65 or older can secure Medicare. To gain premium-free Medicare Part A eligibility, you must have worked and paid payroll taxes for at least 10 years (40 quarters). Seniors below this threshold can still secure Medicare Part A, albeit for a monthly premium relative to their lifetime tax contributions.
Some individuals who typically would not qualify for premium-free Part A can still receive it based on their current, former, or deceased spouse’s tax history. Likewise, tax contributions from your parents or children can also swing your eligibility. However, regardless of work history, everyone must pay a monthly premium to maintain Medicare Part B.
Special Medicare Eligibility
People under age 65 can often secure Medicare after 24 months of monthly Social Security or Railroad Retirement Board (RRB) benefits for a qualifying disability. Likewise, people with ESRD (permanent kidney failure) or ALS (Lou Gehrig’s disease) typically gain access to Medicare coverage.
For example, if you’ve had a kidney transplant or are currently receiving dialysis and have worked the appropriate time required by the Social Security Administration, the Railroad Retirement Board, or the federal government, you should gain access to benefits. Coverage will begin on the first month of admission to a hospital for a transplant or four months after your first dialysis treatment.
What If You Do Not Fall Into Either Category?
If you cannot secure Medicare due to the above circumstances, carefully review Medicare’s eligibility guidelines and exceptions and discuss your options with a certified Medicare agent. For example, some ESRD patients with insufficient tax history can still receive Medicare benefits based on a parent or spouse’s credentials.
Medicare Eligibility Without Free Part A Coverage
While most Medicare beneficiaries receive premium-free Part A, individuals in the following categories will likely have to pay a monthly premium to maintain coverage:
- You are 65 or older and did not work or pay at least 10 years of Medicare taxes
- Neither you nor your current or former spouse paid sufficient taxes
- You do have eligibility for retirement or disability benefits from Social Security or the Railroad Retirement Board
If any of these situations apply to you, you can still secure Medicare Part A by paying a monthly premium of either $278 or $506 relative to your tax credentials.
How Do You Know If Your Medicare Application Was Denied?
Most people who fall below Medicare eligibility will receive a notice of their application denial in the mail. If you applied online, you can also check your enrollment status on Medicare’s website. While it may take some time to hear back, call 1-800-MEDICARE and follow up every few weeks to ensure everything has processed smoothly.
What Is a Disapproved Claim?
If you applied for Medicare without the appropriate credentials, you might receive a Disapproved Claim letter from the Social Security Administration. A Disapproved Claim is an official notice verifying your ineligibility for Medicare Part A.
This notice typically applies to applicants who did not work enough hours to qualify for Social Security and premium-free Part A coverage. You must have worked for at least 10 years and paid 40 quarterly Social Security tax credits to qualify for both. If you disagree with Medicare’s determination, you have 60 days from the post date on your Dissaproved Claim letter.
What Is a Notice of Award?
Conversely, a Notice of Award is an official letter from the Social Security Administration informing someone of their eligibility for Social Security benefits and premium-free Medicare Part A. This document will illustrate your projected monthly benefits and state which of the following coverage combinations you will receive:
- Medicare Part B and premium-free Part A
- Only premium-free Part A coverage
- Only Part B coverage
All applicants who have worked enough to qualify for free Medicare Part A will receive this letter, regardless of their decision to enroll in Part B coverage.
Can You Lose Medicare Eligibility If You Do Not Apply In Time?
While missing your Medicare Enrollment window cannot result in lost eligibility, it can lead to any of the costly penalties illustrated below:
Medicare | Enrollment window | Penalty Added if Missed | How long |
|---|---|---|---|
Part A | Initial Enrollment Period: 3 months before and three months after you turn 65 | 10% | Twice the number of years you didn’t sign up when eligible |
Part B | Initial Enrollment Period | 10% for each year you could have signed up but didn’t | Permanent |
Part D | Initial Enrollment Period | 1% for each uncovered month without Part D or creditable coverage. | Permanent |
However, some exceptions exist. For example, if you have employer-sponsored health insurance, you can enroll in Medicare during an 8-month Special Enrollment Period that begins after you or your spouse retire.
Can You Appeal Your Denied Medicare Application?
Sometimes, Medicare applications get denied due to common paperwork errors, improper documentation, or bureaucratic miscommunication. If any of these situations apply to you, you can contact the Social Security Administration to appeal their determination. This process involves four steps:
- Reconsideration request
- Hearing with an administrative judge
- Reviewing decision with the appeals council
- Filing district court action
Each level of appeal requires specific paperwork, guidelines, and deadlines. For example, you have 60 days to request non-medical reconsideration. Likewise, if you want to file a disability reconsideration, Medicare will allow you to submit new or updated medical information online.
Are Immigrants Eligible For Medicare?
Immigrants can receive Medicare if they have a federally-approved green card proving their lawful presence in the country. Eligible immigrants must meet the following criteria for both parts of Original Medicare:
- Part A: As with US nationals, premium-free coverage requires 40 members to have gained 40 quarterly payroll credits through at least 10 years of employment.
- Part B: Only eligible for lawfully admitted aliens residing within US borders for 5 consecutive years or longer.
However, illegal immigrants cannot secure Medicare. Though these individuals can occasionally secure private insurance coverage, they often must pay for medical care out-of-pocket or seek sliding-scale services from community health clinics.
How To Prevent Your Medicare Application From Being Denied
Follow these steps to ensure you receive Medicare coverage where you deserve it:
- Understand the eligibility requirements: Review Medicare’s enrollment criteria pertaining to age, employment history, and qualifying disabilities.
- Apply during your Initial Enrollment Period (IEP): Your 7-month IEP starts three months before your 65th birthday month and ends three months afterward.
- Keep documents handy: Organize all relevant documents that might help prove your citizenship, identification, employment, and medical status.
- Double-check your application: Ensure all your application information aligns with the documents you provided.
- Seek assistance: Call 1-800-MEDICARE, your local Social Security office, or State Health Insurance Assistance Programs (SHIPs) for any questions or concerns surrounding Medicare enrollment.
- Follow-up: If you do not hear back promptly about your coverage status, regularly contact Medicare or the SSA to ensure everything runs smoothly.
Your Coverage Options If Your Medicare Application Was Denied
If Medicare denies your application, consider the following alternatives:
- Marketplace coverage: Many individuals ineligible for Medicare can still secure subsidized private health insurance through the online Marketplace.
- Medicaid: If you fall below 138% of the federal poverty level, you can likely receive free or low-cost health care through your state.
- Short-term health plans: Though these temporary plans often exclude coverage for pre-existing conditions, they can still protect against emergencies.
- Employer plans: Larger companies must legally offer affordable healthcare to all full-time employees.
Remember that due to the high cost of healthcare, unexpected emergencies and terminal illness can quickly result in immense debt. If you cannot secure Medicare, all these alternatives will still help prevent you and your family from paying for bills entirely out-of-pocket.
What This Means For You
Unfortunately, not everyone will meet Medicare’s various eligibility requirements. However, if you cannot secure premium-free Medicare Part A due to your employment history, you can likely still secure coverage for a relative premium relative to your lifelong tax contributions. Likewise, while Medicare typically only applies to seniors over 65, some individuals who receive SSDI or have ESRD or ALS can secure benefits earlier.
Carefully review Medicare’s guidelines and exclusions to ensure you waste no time on your application. Likewise, ensure you enroll during the proper windows to avoid late penalties and call 1-800-MEDICARE for any questions or concerns surrounding your eligibility. If the SSA denies you coverage, you can appeal the determination within 60 days of receiving the notice.