Who qualifies for Medicare?

Medicare is health insurance for people 65 or older who meet citizenship or residency requirements. You may qualify earlier if you have a disability, End-Stage Renal Disease, or ALS, also called Lou Gehrig's disease.

Your income and savings do not affect whether you qualify. That is the main way Medicare differs from Medicaid, which is based on financial need.

The four routes in

Turning 65 is the common one. Citizenship or residency rules apply.

Disability is the second. If you receive Social Security disability benefits, Medicare starts automatically after you have received those benefits for 24 months.

ALS is the third, and it skips the wait. If you have ALS, Medicare starts automatically as soon as your disability benefits begin.

End-Stage Renal Disease is the fourth, and it has more conditions than most summaries admit. Permanent kidney failure alone is not enough. Medicare.gov requires all of these. Your kidneys no longer work. You need regular dialysis, or you have had a kidney transplant. And one of three work-history tests must be met. You have worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee. Or you already get, or are eligible for, Social Security or Railroad Retirement benefits. Or you are the spouse or dependent child of someone who meets one of those.

Timing, and the penalty for getting it wrong

Most people sign up around their 65th birthday. Your Initial Enrollment Period runs 7 months: the 3 months before the month you turn 65, that month, and the 3 months after.

Are you already getting Social Security retirement or disability benefits at least 4 months before you turn 65? Then you are enrolled in Part A and Part B automatically. Your card arrives about 3 months before coverage starts.

Miss the window and it costs you. You may have to wait to sign up, and then pay a monthly late enrollment penalty for as long as you have Part B. The penalty grows the longer you wait. Missing it usually means waiting for the General Enrollment Period, which runs January 1 through March 31. Coverage then starts the month after you sign up. Special Enrollment Periods exist for certain situations, such as losing Medicaid coverage.

The kidney failure rules run backward

ESRD eligibility is timed differently from every other route, which catches people out during cancer care and dialysis alike.

If you are on dialysis, coverage usually starts on the first day of the fourth month of treatment. That clock runs whether or not you have signed up. Start dialysis July 1 and coverage begins October 1, even if you sign up in December.

Coverage can start in the first month instead. You must join a home dialysis training program at a Medicare-certified facility during your first three months. Your doctor must expect you to finish and dialyze at home. And you must keep up regular dialysis.

For a transplant, coverage can begin the month you are admitted to a Medicare-certified hospital. That holds if the transplant happens that month or within the next two.

If ESRD is your only route in, coverage also ends: 12 months after the month you stop dialysis, or 36 months after the month of a kidney transplant.

ESRD coverage can be backdated up to 12 months before the month you apply. So a late application is not always a lost one. Ask Social Security about retroactive coverage rather than assuming the months are gone. Our comparison of Medicare and Medicaid covers what each one pays for, and the guide to how cancer can affect your work and income explains the disability path.

Sources

• https://www.medicare.gov/basics/get-started-with-medicare
• https://www.medicare.gov/basics/get-started-with-medicare/before-65
• https://www.medicare.gov/basics/get-started-with-medicare/sign-up/when-does-medicare-coverage-start
• https://www.medicare.gov/basics/end-stage-renal-disease