Who is eligible for Medicare coverage?

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The rapid increase in healthcare costs in the United States has amplified the importance of finding quality health insurance at an affordable price. Medicare, a government healthcare program for older American citizens established in 1966 by the Social Security Administration, is a great health insurance option to help balance out massive medical bills. Most people view Medicare as an option only for Americans who are 65 and older, but eligibility is much more comprehensive.

Age Qualifications

Most Americans qualify for Medicare when they turn 65 years old if they have been an American citizen or legal resident for at least 5 years. If an individual was employed in a job for 10 years where Medicare taxes were withheld, they will receive coverage without any premiums for Part A of Medicare. It is important to note that an individual needs to have worked 10 full years or 40 quarters to qualify for premium-free coverage for Medicare Part A, not just parts of 10 years. Any individuals who have not worked for at least 40 quarters have the option to purchase Medicare coverage for a monthly premium.

Disability Benefit Qualifications

Individuals also qualify for Medicare coverage before the age of 65 if they receive disability benefits from the Social Security administration for at least 24 months. While the initial enrollment period for most Medicare recipients lasts 7 months, individuals are automatically enrolled in Medicare after 24 consecutive months of receiving disability benefits. Railroad Retirement Board disability beneficiaries are also automatically enrolled in Medicare once they have received benefits for 24 months. Both Social Security and Railroad Retirement Board disability beneficiaries can get Part A of Medicare with no premiums.

Specific Medical Condition Qualifications

Specific medical conditions also allow a person to qualify for Medicare before they reach 65. If an individual has end-stage renal disease, requiring regular dialysis treatments or a kidney transplant, they will automatically qualify for Medicare. ALS patients also automatically qualify for Medicare as soon as they begin receiving their Social Security or Railroad Retirement Board disability benefits. Both these conditions also allow individuals to avoid paying any premiums for Medicare Part A coverage.

Special Needs Plan

A Medicare Special Needs Plan (SPN), also known as Medicare part C, is also available to people with certain diseases or financial situations. A Special Needs Plan combines Medicare parts A and B into a single customized health insurance plan sold by a private insurance company. For individuals to qualify for a Special Needs Plan, they must already be enrolled in Medicare and live in the area serviced by their desired plan. Also, depending on their condition, they must have a doctor's note confirming they have the specified condition serviced by the plan, reside at least 90 days in a long-term care facility covered by the plan, or meet the state's guidelines for nursing home care at home for at least 90 days. Individuals must also have verification of their Medicare and Medicaid enrollment information.

All Medicare qualifications are subject to changes in laws and regulations implemented by the federal government. If an individual is unsure whether or not they will qualify for Medicare, they should schedule a meeting with their local social security administration field office.