Who is Not Eligible for Medicare Part B Coverage?

Medicare is the federal health insurance program for seniors 65 and older and younger people with disabilities. Most Americans assume they will qualify for Medicare once they reach age 65. However, there are some circumstances that would make you ineligible for Medicare coverage.

In this comprehensive guide, we’ll explain Medicare eligibility requirements and outline the situations where you would not qualify for Medicare benefits.

Medicare Eligibility Basics

First, it helps to understand the basic Medicare eligibility guidelines. Medicare coverage includes:

• Part A – Hospital insurance
• Part B – Medical insurance
• Part D – Prescription drug coverage (optional but you pay a penalty if you delay enrollment)

You are eligible for premium-free Medicare Part A if:

• You are 65 or older, AND
• You or your spouse worked for at least 10 years and paid Medicare taxes

You must pay a premium for Part A if you don’t meet those requirements but are a legal U.S. resident 65 or older.

For Medicare Part B, you are eligible if:

• You are 65 or older, AND
• You are a U.S. citizen or permanent legal resident

Keep in mind that certain groups like federal employees may follow different rules for enrolling in Part B when first eligible.

Not a U.S. Citizen or Lawful Resident

One of the most common reasons people are not eligible for Medicare is because they are not a U.S. citizen or lawful permanent resident. You must be a U.S. citizen or have a green card to receive Medicare benefits.

Foreign visitors, temporary workers, students, and undocumented immigrants do not qualify for any part of Medicare. The only potential exception is people from countries with social insurance agreements with the U.S.

So if you were not born in the U.S. or did not complete the naturalization process, confirm your immigration status before assuming you will get Medicare coverage at 65.

Not Old Enough for Medicare

Another obvious requirement for Medicare eligibility is reaching age 65. If you have not yet turned 65, you will not qualify for Medicare coverage based on age.

Two groups that are automatically eligible for Medicare before 65 include:

• People with disabilities – You automatically get Medicare after receiving Social Security disability benefits for 24 months.
• People with ESRD – Those diagnosed with end-stage renal disease (ESRD) can get Medicare at any age if they require regular dialysis or a kidney transplant.

Barring those specific conditions, you must be at least 65 years old to enroll in Medicare. Some people confuse eligibility for Social Security with Medicare eligibility. While they often align at age 65, Social Security alone does not make you eligible for Medicare if you are under age 65.

Missed Initial Enrollment Period for Part B

While most people aged 65 and older are eligible for Part A based on work credits, you must proactively enroll in Medicare Part B during your initial enrollment period which spans 7 months around your 65th birthday.

If you missed signing up for Part B when first eligible and do not have other creditable coverage, you may have to pay a late enrollment penalty equal to 10% of the standard Part B premium for every 12 month period you delayed enrollment. You also may have limited chances to enroll until the next general open enrollment window.

Failing to enroll in Part B during your initial eligibility window is one of the most common reasons people miss out on Medicare coverage later on. Make sure to apply for both Part A and Part B as you approach your 65th birthday.

High Income with No Work History

As mentioned above, people who or whose spouses paid Medicare payroll taxes for at least 10 years are eligible for premium-free Part A benefits at 65. If you do not have at least a 10-year work history, you may have to pay for your Part A coverage.

This most commonly impacts very high-income seniors who earned most of their income from investments and non-employment sources. Since no Medicare taxes were paid through an employer, eligibility for free hospital insurance under Part A may be limited.

These individuals can still get Part A by paying monthly premiums for it, similar to Part B. So high income alone does not necessarily disqualify you from Medicare if you otherwise meet age and citizenship requirements.

Living Overseas

Generally, U.S. citizens and permanent residents who live abroad have the same Medicare eligibility and enrollment rights as those living in the 50 states or Washington D.C.

However, Medicare does not actually cover healthcare services rendered outside of the United States and its territories. You would need separate travel health insurance to get medical care overseas.

The key limitation when living abroad long-term is that it can be difficult to enroll in a Medicare Advantage or Part D prescription plan. These plans typically require you to live inside the coverage area at least 6 months per year to join.

So while Medicare eligibility remains unchanged, your options for supplemental and drug coverage may be limited if you live full-time outside of the U.S. Certain Medigap policies also restrict overseas coverage.

Incarcerated Individuals

If someone is incarcerated and serving time for a criminal conviction, they are not eligible for Medicare benefits until they are released from confinement.

Medicare will be terminated for someone who is incarcerated for a period exceeding 30 days. This applies to federal, state, and local detention facilities. Once released, Medicare can be reinstated upon request if you are otherwise eligible based on age or disability.

Prisoners who are awaiting trial or sentencing but have not yet been convicted of a crime do maintain eligibility for Medicare coverage. Medicare may cover services provided outside the prison in these cases.

Covered by Large Group Health Plan

One of the few reasons someone 65 or older would NOT enroll in Medicare Part B is if they remain actively employed and have group health coverage through that employer.

As long as the employer has 20 or more employees, Medicare will not penalize delayed Part B enrollment because other creditable insurance is in place. You have up to 8 months after retiring to sign up for Part B without penalty.

People with coverage through smaller employers, retiree plans, and Obamacare plans must still enroll in Medicare when first eligible at age 65 or risk late penalties down the road. Make sure you understand the rules before declining Part B coverage.

How Non-Eligible People Get Insurance

If you are not eligible for Medicare, you will need to seek health insurance from other sources like:

• Employer group health plans
• Individual private insurance
• Medicaid based on income
• Refugee medical assistance
• Coverage through foreign employer or government

Losing Medicare eligibility does not automatically qualify you for special enrollment in other coverage. Make arrangements for alternative insurance if it appears you will not be eligible for Medicare based on the criteria outlined above.

Having affordable healthcare is critical. Understand how Medicare eligibility works and consult an expert if your circumstances are not straightforward. With proper planning, you can ensure you have quality insurance even if Medicare is not an option.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Senior Health Advocates a Call at (386) 222-3030. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.

FAQS

Who is eligible for Medicare Part B?

A: To be eligible for Medicare Part B, you must be 65 years of age or older, and either a U.S. citizen or a legal resident who has lived in the U.S. for at least five consecutive years. You must also be eligible for Medicare Part A, which is hospital insurance.

What is the premium for Part B?

 The monthly premium for Part B varies depending on your income and when you enroll. For most individuals, the standard premium amount is set each year by the Centers for Medicare & Medicaid Services (CMS). It is important to note that the premium can change annually.

How do I qualify for Medicare Part B?

 If you are eligible for Medicare Part A, you are generally also eligible for Medicare Part B. However, you will need to sign up for Part B during your Initial Enrollment Period (IEP) if you want to activate the coverage. The IEP is a seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65.

Do I have to pay a premium for Part B?

 Yes, most beneficiaries do have to pay a premium for Part B. The premium amount is determined based on your income level. If you receive Social Security benefits, the premium will typically be deducted from your benefit payments. If you do not receive Social Security benefits, you will receive a bill for the premium.

How can I enroll in Medicare Part B?

To sign up for Medicare Part B, you can visit your local Social Security office, call Social Security at 1-800-772-1213, or apply online at the Social Security Administration’s website. It is important to enroll during your Initial Enrollment Period to avoid any late enrollment penalties.

Can I have both Medicare Part A and Part B?

Yes, you can have both Medicare Part A and Part B. Part A provides coverage for hospital stays, while Part B covers medical services such as doctor visits and outpatient care.

Can I choose a Medicare Advantage Plan instead of Part B?

Yes, instead of enrolling in Original Medicare (Part A and Part B), you have the option to choose a Medicare Advantage Plan. These plans, offered by private insurance companies approved by Medicare, provide all the coverage of Original Medicare plus additional benefits. However, you must continue to pay your Part B premium even if you choose a Medicare Advantage Plan.

What happens if I don’t enroll in Medicare Part B when I am eligible?

If you do not enroll in Medicare Part B when you are first eligible, you may have to pay a late enrollment penalty. The penalty is added to your premium for as long as you have Part B coverage. Additionally, there are limited periods during the year when you can enroll in Part B, so it is important not to miss your Initial Enrollment Period.

Are individuals under the age of 65 eligible for Medicare Part B?

In general, individuals under the age of 65 are not eligible for Medicare Part B. However, there are exceptions for individuals with certain disabilities or specific medical conditions, such as Lou Gehrig’s disease (ALS).

Can I qualify for premium-free Part A and still have to pay a premium for Part B?

Yes, it is possible to qualify for premium-free Part A and still have to pay a premium for Part B. The premium for Part B is separate from the premium for Part A, and it is determined based on your income level.