Medicare Benefits

Medicare Benefits

Medicare provides a national health care system for seniors of 65 and over. Some people older than 60 can be eligible for Medicare, including disabled individuals with permanent kidney problems. These subsidies help cover the medical costs, but they don't cover most long-standing costs, or all medical costs. It's your choice to have Medicare covered.

You can obtain your own Medicare Supplement insurance from a private company to pay for your premium. These "bundled" plans include Medicare Part A (Hospital Insurance) Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Related Resources Getting care & drugs in disasters or emergencies Find out who to call about Medicare options, claims and more.

How does Medicare work?

Medicare allows people to pick and choose what coverage is offered. When a patient enrolls they have to decide how they are eligible to be covered by Medicare. After you are enrolled, they will send you a Welcome to Medicare packet in the mail with your Medicare card.

You will also receive the Medicare & You handbook, with important information about your Medicare coverage choices. Medicare prescription drug coverage (Part D) Medicare drug coverage helps pay for prescription drugs you need.

What Medicare health plans cover Medicare health plans include Medicare Advantage, Medical Savings Account (MSA), Medicare Cost plans, PACE, MTM Preventive & screening services Part B covers many preventive services. Most Medicare Advantage Plans include drug coverage (Part D). In most cases, you'll need to use health care providers who participate in the plan's network.

Who is eligible for Medicare?

Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).

Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:

• You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
• You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
• You or your spouse had Medicare-covered government employment.

To find out if you are eligible and your expected premium, go the Medicare.gov eligibility tool.

If you (or your spouse) did not pay Medicare taxes while you worked, and you are age 65 or older and a citizen or permanent resident of the United States, you may be able to buy Part A. If you are under age 65, you can get Part A without having to pay premiums if:

• You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months. (Note: If you have Lou Gehrig's disease, your Medicare benefits begin the first month you get disability benefits.)
• You are a kidney dialysis or kidney transplant patient.

While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.

Prescription Drug Coverage

Since January 1, 2006, everyone with Medicare, regardless of income, health status, or prescription drug usage has had access to prescription drug coverage. For more information, you may wish to visit the Prescription Drug Coverage site. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicare's coverage rules.

Medicare Based on End-Stage Renal Disease (ESRD)

Individuals are eligible for premium-free Part A if they receive regular dialysis treatments or a kidney transplant, have filed an application for Medicare, and meet 1 of the following conditions:

• Have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee; or
• Are getting or are eligible for Social Security or RRB benefits; or
• Are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee; or are getting Social Security or RRB benefits.

Part A coverage begins:

• The 3rd month after the month in which a regular course of dialysis begins; or
• The first month a regular course of dialysis begins if the individual engages in self-dialysis training; or
• The month of kidney transplant; or
• Two months prior to the month of transplant if the individual was hospitalized during those months in preparation for the transplant.

Medicare Part A (Hospital Insurance)

Most people get Part A for free, but some have to pay a premium for this coverage.

To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits.

The exact number of QCs required is dependent on whether the person is filing for Part A on the basis of age, disability, or End Stage Renal Disease (ESRD). QCs are earned through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during the person's working years. Most individuals pay the full FICA tax so the QCs they earn can be used to meet the requirements for both monthly Social Security benefits and premium-free Part A.

NOTE: Certain Federal, State, and local government employees pay only the Part A portion of the FICA tax. The QCs they earn can be used only to meet the requirements for premium-free Part A; they may not be used to meet the requirements for monthly Social Security benefits.

To be eligible for premium Part A, an individual must be age 65 or older and be enrolled in Part B. Enrollment in premium Part A and Part B can only happen at certain times. (The section titled Enrollment Periods and When Coverage Begins explains the times when someone can enroll).

More Information on Enrolling in Part A

Individuals already receiving Social Security or RRB benefits at least 4 months before being eligible for Medicare and residing in the United States (except residents of Puerto Rico) are automatically enrolled in both premium-free Part A and Part B. People living in Puerto Rico who are eligible for automatic enrollment are only enrolled in premium-free Part A.

Individuals who are not receiving a Social Security or RRB benefit are not automatically enrolled. These individuals must apply by contacting Social Security. 

Medicare Part B (Medical Insurance)

The eligibility rules for Part B depend on whether a person is eligible for premium-free Part A or whether the individual has to pay a premium for Part A coverage.

Individuals who are eligible for premium-free Part A are also eligible for enroll in Part B once they are entitled to Part A.  Enrollment in Part B can only happen at certain times.

Individuals who must pay a premium for Part A must meet the following requirements to enroll in Part B:

• Be age 65 or older;
• Be a U.S. resident; AND
• Be either a U.S. citizen, OR
• Be an alien who has been lawfully admitted for permanent residence and has been residing in the United States for 5 continuous years prior to the month of filing an application for Medicare.

NOTE: Part B is a voluntary program which requires the payment of a monthly premium for all months of coverage.

More Information on Enrolling in Part B

Individuals already receiving Social Security or RRB benefits at least 4 months before being eligible for Medicare and residing in the United States (except residents of Puerto Rico) are automatically enrolled in both premium-free Part A and Part B. People who are automatically enrolled have the choice whether they want to keep or refuse Part B coverage. People living in Puerto Rico who are eligible for automatic enrollment are only enrolled in premium-free Part A; they must actively enroll in Part B to get this coverage.

Individuals who are not receiving a Social Security or RRB benefit are not automatically enrolled. Individuals who previously refused Part B, or who terminated their Part B enrollment, may enroll (or re-enroll) in Part B only during certain enrollment periods. In most cases, if someone does not enroll in Medicare Part B (Medical Insurance) when first eligible, they will have to pay a late enrollment penalty for as long as they have Part B.

This coverage is offered by insurance companies and other private companies approved by Medicare. . In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan.