I’m Turning 65 What do I need to do for Medicare?

Turning 65 and Medicare Eligibility: A Summary of Key Considerations

Upon reaching age 65, individuals residing in the United States generally become eligible for Medicare, a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS). Eligibility and enrollment procedures vary depending on an individual’s work history, current health coverage, and disability status. The following provides a fact-based summary of the key elements associated with Medicare enrollment and coverage at age 65.

1. Eligibility Criteria

Most individuals qualify for Medicare at age 65 if they or their spouse have worked and paid Medicare taxes for at least 10 years (40 quarters). Individuals under 65 may also be eligible due to a qualifying disability or diagnosis (e.g., end-stage renal disease or amyotrophic lateral sclerosis).

2. Components of Original Medicare

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facility care (following a qualifying hospital stay), hospice care, and some home health services. Most individuals do not pay a premium for Part A if they or their spouse paid Medicare taxes for the required period.

• Part B (Medical Insurance): Covers outpatient care, preventive services, doctor visits, and durable medical equipment. Part B requires a monthly premium, which is based on income.

3. Enrollment Process and Timing

Enrollment can be automatic or require manual action depending on circumstances:

• Automatic Enrollment: Individuals already receiving Social Security or Railroad Retirement Board (RRB) benefits before turning 65 are typically enrolled in Parts A and B automatically.

• Manual Enrollment: Individuals not receiving these benefits must enroll themselves during the Initial Enrollment Period (IEP), which begins three months before the 65th birthday, includes the birthday month, and ends three months afterward (a total of seven months).

Failure to enroll in Part B during the IEP, without qualifying for a Special Enrollment Period, may result in a late enrollment penalty, which permanently increases the monthly premium.

4. Coordination with Social Security Administration

The Social Security Administration (SSA) administers Medicare enrollment. Individuals seeking to enroll in Medicare, verify eligibility, or obtain benefit information should contact their local SSA office or visit www.ssa.gov.

5. Additional Medicare Options

In addition to Original Medicare, individuals may consider:

• Medicare Advantage (Part C): Offered by private insurers, these plans combine Part A and B coverage and often include additional benefits (e.g., dental, vision, prescription drug coverage).

• Medicare Prescription Drug Plans (Part D): Available for those enrolled in Original Medicare who wish to obtain prescription drug coverage.

• Medigap (Medicare Supplement Insurance): Private insurance that helps pay costs not covered by Original Medicare, such as deductibles and coinsurance. Federal law provides a six-month Medigap Open Enrollment Period beginning the month an individual turns 65 and is enrolled in Part B. During this period, insurers cannot deny coverage due to preexisting conditions.

6. Coverage Gaps and Limitations

Original Medicare does not cover:

• Most dental, vision, and hearing services

• Long-term custodial care

• Routine foot care

• Care received outside the United States (with limited exceptions)

Beneficiaries should assess their personal health needs and financial circumstances to determine if additional coverage is required.

7. Disability and Dual Eligibility

Individuals under 65 who are receiving disability benefits may be automatically enrolled in Medicare after a 24-month waiting period. Turning 65 may confer new enrollment rights or expand eligibility for other health programs (e.g., Medicaid, Medicare Savings Programs).

Conclusion

Turning 65 marks a significant milestone in health insurance eligibility. Early planning, including contacting the SSA and consulting with a licensed Medicare professional, is recommended to ensure timely enrollment and to avoid penalties. Understanding the scope and limitations of Medicare coverage enables beneficiaries to make informed decisions regarding supplemental insurance and long-term care needs.