Who is Not Eligible for Medicare Coverage?

Medicare is the federal health insurance program that provides healthcare coverage primarily for Americans aged 65 and older. Medicare also covers certain younger people with disabilities and end-stage renal disease (ESRD).

But not everyone is eligible for Medicare. There are situations where you may not qualify for Medicare coverage when you turn 65 or have a disability. Let’s look at who is not eligible for Medicare and reasons for Medicare ineligibility.

Turning 65 Does Not Automatically Qualify You for Medicare

Simply turning 65 years old does not by itself make you eligible for Medicare coverage. To qualify for premium-free Part A hospital insurance at 65, you must also meet one of the following criteria:

You receive or are eligible for Social Security retirement benefits
You receive Railroad Retirement Board benefits
Your spouse receives Social Security or Railroad Retirement Board benefits

If you do not collect Social Security or equivalent retirement benefits, you would need to purchase Part A coverage. The premium for Part A in 2023 is up to $506 per month.

To get Part B medical insurance, you must sign up and pay a monthly premium during your initial enrollment period when you turn 65. Most people over 65 who are citizens or permanent residents for 5+ years are eligible to enroll in Medicare Part B by paying this monthly premium.

Lacking Work Credits Can Make You Ineligible for Part A

To qualify for premium-free Medicare Part A hospital coverage at 65, you must have accumulated a sufficient number of work credits under Social Security or the Railroad Retirement Board.

In 2023, you need 10 years of work credits (40 credits) to qualify for premium-free Part A. People without enough work credits would need to purchase Part A coverage.

However, anyone 65 or older can get Part B by paying the monthly premium, regardless of work history. Only Part A eligibility depends on having earned enough work credits through your or your spouse’s employment history.

Medicare Eligibility With Disability

People under age 65 can qualify for Medicare coverage based on disability, if they meet Social Security’s definition of disability and have received Social Security Disability Insurance (SSDI) benefits for at least 24 months.

SSDI benefits are administered by the Social Security Administration and require you to have a medical condition that prevents substantial work and is expected to last at least one year or result in death.

If you have not earned enough work credits to qualify for SSDI based on your own employment history, you would not be eligible for Medicare coverage based on disability.

Additional Requirements for Disabled Adult Children

People aged 18-64 who qualify for Social Security disability benefits based on a parent’s work history have additional requirements to meet in order to qualify for Medicare.

They must have a disability that began before age 22 and been receiving SSDI benefits on a parent’s record for at least 24 months to establish Medicare eligibility.

End-Stage Renal Disease (ESRD) Medicare Eligibility

People of any age who have permanent kidney failure requiring dialysis or a kidney transplant can qualify for Medicare coverage based on ESRD.

To be eligible, you must be on dialysis for more than 3 months to get Medicare ESRD benefits or have a kidney transplant without the 3 month wait. Simply having chronic kidney disease does not establish Medicare eligibility.

Other Health Conditions Not Sufficient for Medicare Eligibility

Certain other health conditions do not automatically make someone eligible for Medicare coverage. For example:

Dementia, Alzheimer’s, or other cognitive disorders
Parkinson’s disease
Autoimmune disorders
Cancer or tumor diagnoses
Legally blind or low vision
End stage renal disease

Unless someone with these conditions is over 65, receives Social Security disability benefits, or has ESRD, they would not qualify for Medicare based solely on their diagnosis or disability.

Medicare Eligibility Denials

There are certain situations where someone may have their Medicare eligibility denied when they believe they qualify, including:

Applied for SSDI but were denied or are appealing a denial
Were previously on SSDI but lost benefits after a continuing disability review
Live in Puerto Rico (limited Medicare coverage available)
Have employer or union coverage that precludes Medicare enrollment before 65
Missed initial enrollment or special enrollment periods after becoming eligible
Are not a U.S. citizen or do not have lawful permanent resident status for 5+ years

In these cases, speak with a Medicare advocate or Social Security to understand eligibility and enrollment options. Do not go without health coverage.

How Ineligible People Can Get Health Coverage

People who do not qualify for Medicare coverage still have options for affordable healthcare, such as:

Employer group health insurance (active or retiree coverage)
Individual private insurance plans
COBRA temporary continuation coverage
Medicaid coverage in some states
Health insurance marketplace plans

Make sure you have comprehensive insurance if Medicare is not an option so you can get needed medical care.

Takeaways

While Medicare covers most Americans over 65 and millions more under 65 with long-term disabilities, not every person is eligible. Make sure you understand the qualifying criteria so you can enroll successfully when initially eligible to avoid penalties or coverage gaps.

FAQS

How do I sign up for Medicare if I’ve been getting Social Security disability benefits? If you’ve been receiving Social Security disability benefits for 24 months, you’ll be automatically enrolled in Medicare Parts A and B. However, be sure to also sign up for Medicare Part D drug coverage when you’re first eligible to avoid paying penalties later.

When do I need to enroll in Medicare Part B? If you’re eligible for premium-free Part B, you generally have a 7-month initial enrollment period that includes the 3 months before your 65th birthday month, the month of your birthday, and the 3 months after. Enrolling anytime during this period means your Part B coverage will begin on your birthday month.

I’m over 65 but still working, do I need to sign up for Medicare? If you or your spouse is still actively working and you’re covered by employer group health plan coverage through that job, you may be able to delay enrolling in Medicare Parts A and B without penalties as long as you have that group coverage based on current employment.

Who’s eligible for premium-free Medicare Part A? You’re eligible for premium-free Medicare Part A if you’re aged 65 or older and you or your spouse paid Medicare taxes while working for at least 10 years. This generally means you don’t need to pay a monthly premium for Part A coverage.

Can people under 65 with disabilities qualify for Medicare? Yes, people under 65 with long-term disabilities may qualify for Medicare if they receive Social Security disability benefits for at least 24 months. Their Medicare coverage will then begin the month they achieve 24 months of entitlement to disability benefits.

Do I need to enroll in Part B if I have a Medicare Advantage Plan? Yes, enrollment in Medicare Part A and Part B premium is required to join a Medicare Advantage Plan. These private plans provide all of your Medicare health and drug coverage, but you must still be enrolled in Original Medicare to be eligible for the Advantage plan.

When should a person with ALS become eligible for Medicare? People diagnosed with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s Disease, can generally qualify for Medicare if they receive Social Security disability benefits. The disability determination process is often expedited and they can receive Medicare coverage within 1-2 months after becoming entitled to benefits.

Do people living in Puerto Rico qualify for Medicare? US citizens living in Puerto Rico must pay the same Part A premium as those living in the 50 states if they aren’t otherwise entitled to premium-free Part A coverage. However, Puerto Rico residents are not eligible for Medicare premium for Part B and D enrollment and coverage.

If I have creditable coverage will I be charged a late penalty to enroll in Part D? No, if you have drug coverage through a former group health plan that is considered creditable, meaning comparable to standard Part D coverage, you won’t be penalized for signing up for Medicare Part D outside of your initial enrollment period.

Will I be automatically enrolled in Medicare if I have Medicare based on my spouse’s work record? If you’re at least 65 years old and eligible for Medicare based on your spouse’s current employment and coverage through their group health plan, you won’t automatically be enrolled in Medicare Parts A and B. You must proactively enroll when the group coverage ends to avoid any potential late enrollment penalties.

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