Here are the requirements needed to be eligible to receive Medicare Part A and/or B.
- Age 65 or older,
- ESRD, or
- Lou Gehrig’s disease or ALS.
Age 65 & Older
The majority of those who are first eligible for Medicare will fall into the category of age 65 or older. In the insurance industry when someone is turning 65, these individuals are often referred to as T-65, which means turning 65. When someone is turning 65 no matter what their current insurance is at that time, they have the option to enroll into Medicare Part A and/or B.
Simple requirements for Medicare at 65 or older
Here are the only requirements that CMS has in place when someone is turning 65 or older:
- The individual is age 65 or older,
- The individual is a U.S. resident,
- The individual is a U.S. citizen, and
- The individual is an alien who has been lawfully admitted for permanent residence and has been residing in the U.S for five continuous years prior to the month that they apply for Medicare.
The last scenario of requiring permanent residence in the U.S. for the last five years is typically when a family moves a parent over from another country to live with them permanently in the U.S. Once that family member is admitted for permanent residence, it will be five years before they can buy into Medicare. This would be a good example of an individual that would fall into the one percent of having to pay for their Medicare Part A.
To get Medicare prior to the age of 65, you must qualify based on permanent disability. An individual must apply with Social Security and be granted what is known as SSDI, which means that they are asking the federal government to pay them a benefit each month because they are permanently disabled and can no longer work.
Determination for Disability
Social Security will only pay out benefits if they have determined that an individual cannot work due to a disability for at least one year or it will result in the individual’s death. Social Security will use the following basic requirements to determine if someone could qualify:
- Are you working?
- Is your condition severe?
- Is your condition found in the list of disabling conditions?
- Can you do the work you did previously?
- Can you do any other type of work?
Payments & Permanent Disability
This is a lengthy process as the doctors and disability specialists must be involved in ensuring that the individual is unable to work and perform the basic duties of lifting, standing, walking, sitting, or the individual has cognitive issues that affects their impairment. Social Security does not offer short-term disability, but they do offer total permanent disability. They are making the decision to financially take care of the impact the individual will have because they can no longer contribute to the workforce.
Medicare Is Not Immediate
Once someone is granted permanent disability, they will begin to receive SSDI benefits each month after a five-month waiting period. The SSDI will be paid on the sixth full month after the date that the disability was approved. Medicare, however, will not be automatic for the individual that first month when they start receiving their SSDI payments.
Social Security Waiting Period
Social Security has what they call a Medicare waiting period of 24 months of SSDI benefits before someone will qualify for Medicare Part A and B. Once someone has received SSDI benefits for at least 24 months, their Medicare Part A and B will start automatically on the 25th month. The Medicare card will arrive in the mail about three months prior to the effective date of the 25th month of SSDI benefits. The individual does not need to apply for their Medicare.
End Stage Renal Disease
Someone will qualify for Medicare if they have ESRD that results in permanent kidney failure, which requires dialysis or a kidney transplant. An individual that meets these requirements will need to apply for Medicare Part A and B. It will not be automatic just because they received the diagnosis of ESRD.
Here are the general guidelines and rules to get Medicare started when an individual meets the ESRD requirements:
- If an individual is receiving dialysis at an inpatient or outpatient facility for at least three months, they are eligible for Medicare on the 1st day of their fourth month of treatment.
- If an individual decides to begin at home dialysis, they may be eligible for Medicare on the 1st day of the month that their program begins.
- If an individual is receiving a kidney transplant, they are eligible for Medicare starting the 1st day of the month that they will be admitted to the hospital for the transplant. If the kidney transplant is successful, their Medicare will end 36 months after they have the kidney transplant.
Lou Gehrig’s Disease
Amyotrophic lateral sclerosis or ALS is most referred to as Lou Gehrig’s disease, which would be considered a permanent disability according to Social Security. An individual would still have the five-month waiting period before receiving their SSDI benefit payments.
LGD - No Waiting Period
What is different with this type of permanent disability, is that the 24-month waiting period for Medicare is waived. Medicare will start the first month that the individual begins to receive their SSDI benefit payments.