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 health conditions. Medicare has four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage). Most people are eligible for Medicare if they meet the following criteria:
- They are U.S. citizens or permanent residents who have lived in the U.S. for at least five years.
- They or their spouse have paid Medicare taxes for at least 10 years while working, or they are eligible for Social Security or Railroad Retirement Board benefits based on their work history.
- They are 65 or older, or they have a disability or a health condition that qualifies them for Medicare, such as end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
However, not everyone who meets these criteria is automatically enrolled in Medicare or eligible for all parts of Medicare. Some people may have to sign up for Medicare, pay a premium for certain parts of Medicare, or wait for a certain period of time before they can receive Medicare benefits. Some people may not be eligible for Medicare at all, depending on their situation and circumstances. 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 Part A?
Medicare Part A is the part of Medicare that covers inpatient hospital services, skilled nursing facility care, hospice care, and some home health care services. Most people do not have to pay a premium for Part A if they are eligible for premium-free Part A, which means they or their spouse have paid Medicare taxes for at least 10 years while working, or they are eligible for Social Security or Railroad Retirement Board benefits based on their work history.
However, some people may not be eligible for premium-free Part A, such as:
- People who are 65 or older but do not have enough work credits to qualify for Social Security or Railroad Retirement Board benefits, and do not have a spouse who has enough work credits to qualify them for premium-free Part A.
- People who are younger than 65 and do not have a disability or a health condition that qualifies them for Medicare, such as ESRD or ALS.
These people may still be able to enroll in Part A, but they will have to pay a monthly premium for it. The premium amount depends on how many work credits they have. In 2021, the monthly premium for Part A is $471 for people who have less than 30 work credits, and $259 for people who have 30 to 39 work credits. The premium amount may change every year based on inflation and other factors.
Some people may choose not to enroll in Part A if they have to pay a premium for it, especially if they have other health insurance that covers their hospital costs. However, if they decide to enroll in Part A later, they may have to pay a late enrollment penalty that increases their premium by 10% for each 12-month period that they could have had Part A but did not sign up for it.
Who is Not Eligible for Medicare Part B?
Medicare Part B is the part of Medicare that covers outpatient medical services, such as doctor visits, lab tests, preventive care, and durable medical equipment. Most people have to pay a monthly premium for Part B, which is $148.50 in 2021. The premium amount may change every year based on inflation and other factors. Some people may pay more or less than the standard premium depending on their income and whether they receive certain benefits from other programs.
Most people who are eligible for Medicare Part A are also eligible for Medicare Part B. However, some people may choose not to enroll in Part B if they have other health insurance that covers their medical costs. However, if they decide to enroll in Part B later, they may have to pay a late enrollment penalty that increases their premium by 10% for each full 12-month period that they could have had Part B but did not sign up for it.
Some people may not be able to enroll in Part B at all, such as:
- People who live outside the U.S. and its territories and do not have a U.S. address.
- People who are incarcerated and do not have a release date within the next two months.
- People who are enrolled in Medicaid and do not qualify for any of the programs that help pay for their Part B premiums, such as the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, the Qualifying Individual (QI) program, or the Qualified Disabled and Working Individuals (QDWI) program.
These people may still be able to get health care through other sources, such as their home country’s health system, their state’s Medicaid program, or their correctional facility’s health services.
Who is Not Eligible for Medicare Part C?
Medicare Part C is also known as Medicare Advantage, which is a type of Medicare health plan that is offered by private insurance companies that contract with Medicare. Medicare Advantage Plans provide all the benefits of Part A and Part B, and often include additional benefits such as prescription drug coverage, vision, dental, hearing, and wellness programs. Medicare Advantage Plans may have different costs, benefits, networks, and rules than Original Medicare (Part A and Part B).
Most people who are eligible for Medicare Part A and Part B are also eligible for Medicare Part C. However, some people may not be able to enroll in a Medicare Advantage Plan, such as:
- People who have ESRD and are not already enrolled in a Medicare Advantage Plan or a Special Needs Plan (SNP) that accepts people with ESRD. However, starting in 2021, people with ESRD may be able to enroll in any Medicare Advantage Plan that is available in their area.
- People who live outside the service area of any Medicare Advantage Plan that is available in their state or territory.
- People who are enrolled in certain types of health plans that are incompatible with Medicare Advantage, such as the Program of All-Inclusive Care for the Elderly (PACE), the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), or the Federal Employees Health Benefits Program (FEHBP).
These people may still be able to get health care through Original Medicare or other sources, such as their home country’s health system, their state’s Medicaid program, or their employer’s health plan.
Who is Not Eligible for Medicare Part D?
Medicare Part D is the part of Medicare that covers prescription drug costs. Medicare Part D is optional, and most people have to pay a monthly premium for it. The premium amount depends on the plan they choose and their income. Some people may pay more or less than the standard premium depending on whether they receive certain benefits from other programs or whether they have to pay a late enrollment penalty.
Most people who are eligible for Medicare Part A or Part B are also eligible for Medicare Part D. However, some people may not be able to enroll in a Part D Plan, such as:
- People who live outside the U.S. and its territories and do not have a U.S. address.
- People who are incarcerated and do not have a release date within the next two months.
- People who are enrolled in certain types of health plans that provide prescription drug coverage that is at least as good as Medicare’s, such as a Medicare Advantage Plan that includes drug coverage, an employer-sponsored health plan, a union-sponsored health plan, a military health plan (such as TRICARE), or a Veterans Affairs health plan.
These people may still be able to get prescription drug coverage through their other health plans or sources, such as their home country’s health system, their state’s Medicaid program, or their correctional facility’s health services.
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 health conditions. However, not everyone who meets these criteria is automatically enrolled in Medicare or eligible for all parts of Medicare. Some people may have to sign up for Medicare, pay a premium for certain parts of Medicare, or wait for a certain period of time before they can receive Medicare benefits. Some people may not be eligible for Medicare at all, depending on their situation and circumstances. If you want to learn more about your eligibility for Medicare, you can visit the official website of Medicare, or read some of the articles from the web search results above .
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FAQs
Who is not eligible for Medicare coverage?
Not everyone is eligible for Medicare coverage. To be eligible for Medicare, you must meet certain criteria such as being 65 years old or older, or having certain disabilities.
What are the eligibility requirements for Medicare?
The eligibility requirements for Medicare include being 65 years old or older and either being a U.S. citizen or a legal permanent resident who has lived in the U.S. for at least five years. You may also qualify for Medicare if you have certain disabilities or if you have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
Do I automatically get Medicare when I turn 65?
If you are already receiving Social Security or Railroad Retirement Board benefits, you will be automatically enrolled in Medicare Part A and Part B when you turn 65. If you are not receiving these benefits, you will need to sign up for Medicare during your initial enrollment period.
What is the initial enrollment period for Medicare?
The initial enrollment period for Medicare is a seven-month period that begins three months before the month you turn 65 and ends three months after the month you turn 65. It is important to enroll during this period to avoid any late enrollment penalties.
Can I enroll in Medicare if I am under 65?
While the majority of people become eligible for Medicare at age 65, you may also be eligible for Medicare if you have certain disabilities or if you have been receiving Social Security disability benefits for at least 24 months.
Do I have to pay a premium for Medicare Part A coverage?
Most people do not have to pay a premium for Medicare Part A coverage if they or their spouse has paid Medicare taxes while working. However, if you do not qualify for premium-free Medicare Part A, you may still be able to purchase it by paying a monthly premium.
Do I have to pay a premium for Medicare Part B coverage?
Yes, most people have to pay a premium for Medicare Part B coverage. The amount of the premium is based on your income. If you qualify for a Medicare Savings Program or have certain other types of coverage, you may be eligible for assistance with your Part B premium.
Can I delay enrolling in Medicare Part B if I have other health insurance?
If you have health insurance coverage through your employer or union, you may be able to delay enrolling in Medicare Part B without facing a penalty. However, it is important to speak with your employer or insurance provider to determine how your current coverage works with Medicare.
Can I qualify for premium-free Medicare Part A?
You may qualify for premium-free Medicare Part A if you or your spouse has paid Medicare taxes while working for at least 10 years (40 quarters). If you have not worked long enough to qualify for premium-free Medicare Part A, you may still be able to purchase it by paying a monthly premium.
Can people with disabilities get Medicare?
Yes, people with certain disabilities can qualify for Medicare, regardless of age. If you have been receiving Social Security disability benefits for at least 24 months, you may be eligible for Medicare coverage.