What is Medicare and How Can You Qualify?

What is Medicare?

We explain what Medicare is, how you can qualify for Medicare, and how the Affordable Care Act affects Medicare.

Medicare is a federal health insurance program that most people pay into while working and all citizens can access when they turn 65.

Medicare is funded by two trust funds held by the US Treasury: the Hospital Insurance Trust Fund and the Supplementary Medical Insurance Trust Fund. Together they are known as the Medicare Trust Funds.

Both Medicare and the Affordable Care Act are overseen by the Department of Health and Human Services. You can visit the Health and Human Services website here.[1]

Is Medicare Part of the Affordable Care Act?

Although Medicare is not part of the Affordable Care Act, and Medicare-eligible Americans do not use the Marketplace during Open Enrollment to enroll (they enroll through a private insurer or directly through Medicare), it is affected by the Affordable Care Plan laws.

Medicare has a complex open enrollment system, but in general, once a person is on Medicare they are subject to some significant ACA benefits (through Medicare).

ACA benefits for Medicare include preventive services like colonoscopies, mammograms, and an annual wellness visit without charge.

Also, the “donut hole” deductible for Part D brand-name prescription drugs is scheduled to be closed by 2020. Until then, you get an automatic 60% discount on covered drugs.

The ACA also extended the Medicare Trusts to 2029. This 12-year extension was made possible by cost savings included in the ACA.

How to Get Medicare

You need to be an American citizen or legal permanent resident for at least five continuous years before being eligible to enroll. You also need to have been paying Medicare taxes unless you have a Social Security recognized disability.

You can get Medicare once you turn 65, have been collecting Social Security Disability for two years with some exceptions, or have either end-stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) and meet some other requirements.

You do not have to enroll in Medicare if you have ESRD or ALS and you want a Marketplace plan. There are distinct Initial Enrollment Periods that you can find on Medicare.gov.[2]

Medicare has several parts. Part A covers hospital care, skilled nursing facility care, nursing home care (but not custodial care), Hospice, and some home health services.

Part B covers preventive services, diagnostic services, and some prescription drugs. It is important to know that you should sign up for Part B when you sign up for Part A.

If you delay Part B, you may pay a late enrollment penalty for the duration of your coverage.

If you have A and B, you can enroll in Part C, Medicare Advantage Plans, and Part D, Medicare Prescription Plans.

Part D is also subject to a late enrollment penalty.

Medicare Advantage plans are sold by and run by private health insurance companies.

How Do I Qualify For Medicare?

You may qualify for Medicare as a spouse when you are 65 if you are married to someone who has turned 62 and worked at a job paying Medicare taxes for ten years.

If your spouse is younger than you are and you are relying on their payment of Medicare tax quarters to qualify for Medicare, you will need to wait until they turn 62 before you can qualify.

You are eligible for premium-free Part A Medicare if you have collected benefits from Social Security or the Railroad Retirement Board for 24 months or if you or your spouse is 62 or older and has worked in Medicare-covered employment for 40 quarters.

If you paid Medicare taxes for 30 quarters or less, you could buy Medicare Part A for a 2017 cost of $413 a month. If you paid taxes into Medicare for 30-39 quarters, your premium would be $227 a month. If you cannot afford your prescription drug costs, you can apply for Extra Help from Social Security here.[3]

You can contact Social Security at ssa.gov or 1-800-772-1213 (TTY is 1-800-325-0778) Monday through Friday or the Railroad Retirement Board at secure.rrb.gov or 1-877-772-5772 (TTY is 312-751-4701) Monday through Friday.

You can contact the Medicare program at the Medicare.gov website.[4] You can also call 1-800-633-4227 (TTY is 1-877-486-2048).

Article Citations
  1. hhs.gov
  2. Initial Enrollment Periods
  3. Extra Help Available
  4. Medicare.gov

Author: Linda DeSolla Price

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