Getting Started with Medicare

Age 65 or older

The most common way people become eligible for Medicare.

Under 65 with a disability

People receiving qualifying Social Security or Railroad Retirement Board disability benefits generally receive Medicare after 24 months of disability benefits. Supplemental Security Income (SSI) alone does not qualify someone for Medicare.

ALS

People with amyotrophic lateral sclerosis, also called Lou Gehrig’s disease, generally receive Medicare when their qualifying disability benefits begin, without the usual 24-month Medicare waiting period.

End-Stage Renal Disease

People with permanent kidney failure requiring regular dialysis or a kidney transplant may qualify at any age if Medicare’s requirements are met. Application and coverage-start rules differ from the usual age-65 rules.

Some people receive Medicare automatically

If you receive qualifying Social Security or Railroad Retirement Board benefits at least four months before turning 65, you generally receive Parts A and B automatically. Qualifying disability benefits can also trigger automatic enrollment.

Check your Medicare card for both Part A and Part B effective dates. Do not assume having a card means both parts are active. People living in Puerto Rico or outside the United States generally need to actively enroll in Part B.

Others must sign up

If you are not receiving those benefits, you generally need to apply. You can enroll in Medicare without starting your Social Security retirement benefits.

Apply through Social Security online, call 1-800-772-1213 (TTY 1-800-325-0778), or contact your local office to arrange assistance. Railroad beneficiaries should contact the Railroad Retirement Board at 1-877-772-5772.

Hospital insurance

• Inpatient hospital care: covered room, meals, nursing, and hospital services after a qualifying admission.
• Skilled nursing facility care: qualifying, short-term skilled care or rehabilitation, not unlimited nursing home care.
• Hospice: eligible end-of-life care and support.
• Home health: certain eligible skilled services when Medicare’s conditions are met.

Most people pay no Part A premium because of their or a spouse’s qualifying work history. Deductibles and other cost sharing still apply.

Hospital status matters: An overnight stay can still be outpatient observation. Ask whether you are formally admitted as an inpatient; this can affect billing and skilled nursing eligibility.

Medical insurance

• Doctor and specialist visits, outpatient treatment, and eligible surgery.
• Medically necessary tests, imaging, and lab services.
• Preventive screenings, vaccinations, and wellness visits under applicable rules.
• Durable medical equipment, such as eligible walkers, wheelchairs, and oxygen.
• Covered ambulance, mental health, and certain home health services.
• Some medications, including certain drugs administered in a medical setting.

You pay a monthly premium. For many covered services, you generally pay 20% of the Medicare-approved amount after the annual deductible. Many preventive services have no cost sharing when requirements are met and the provider accepts assignment.

Medicare Advantage

A Medicare-approved private plan that must cover all medically necessary services covered by Original Medicare. Most plans include Part D, and some offer additional benefits. Original Medicare pays for the hospice benefit even when you remain in Medicare Advantage. You remain enrolled in Parts A and B and continue paying your Part B premium.

Prescription drug coverage

Helps pay for covered prescriptions through a stand-alone drug plan or a Medicare Advantage plan with drug coverage. Each plan has its own medication list, pharmacy network, and costs.

Premium

The amount you pay regularly to keep coverage, whether or not you use healthcare services.

Deductible

The amount you must pay for applicable covered services before coverage begins paying its share.

Copayment

A set amount you pay for a covered service or prescription, such as a fixed charge for a visit.

Coinsurance

A percentage of a covered service’s cost that you pay. The usual Part B share is 20% after the deductible.

Medicare-approved amount

The amount Medicare recognizes for a covered service or item. It can differ from the provider’s billed charge.

Creditable drug coverage

Prescription coverage expected to pay, on average, at least as much as standard Medicare drug coverage. Keep the written notice from the coverage provider.

What “accepting assignment” means

The provider accepts the Medicare-approved amount as full payment for the covered service. You remain responsible for applicable deductibles and coinsurance, unless other coverage helps pay them.

What to confirm before care

• Does this provider accept Medicare and assignment?
• Is the service covered for my circumstances?
• Are medical necessity or other requirements met?
• What deductible or coinsurance will I owe?
• If I choose Medicare Advantage, is this provider in that plan’s network?

Routine dental, vision & hearing

Most dental care and dentures, routine eye exams for glasses, and hearing aids or fitting exams are generally excluded. Certain medically related services may be covered under specific rules.

Long-term custodial care

Ongoing help with bathing, dressing, eating, or other daily activities is generally not covered when it is the only care needed. This differs from qualifying short-term skilled care.

Most retail prescriptions

Parts A and B cover certain drugs in specific settings, but generally do not provide comprehensive retail prescription coverage. Part D addresses this separate need.

Other exclusions

Routine physical examinations, most cosmetic surgery, and most care outside the United States are generally excluded. Medicare wellness visits differ from a full routine physical.

Medicare Savings Programs

State-administered programs may help pay Medicare premiums. Some also help with deductibles, copayments, and coinsurance. Eligibility varies by program and state; contact your state Medicaid office to apply or ask about eligibility.

Extra Help

This program helps eligible people with Part D premiums, deductibles, and prescription cost sharing. Some people qualify automatically; others apply through Social Security. You do not pay a Part D late enrollment penalty while receiving Extra Help.

Prescription Payment Plan

This optional payment arrangement spreads covered Part D out-of-pocket drug costs across the calendar year. It can help manage the timing of bills, but does not reduce your total drug costs. Ask your health or drug plan how to participate.

Track your application.

Keep a copy of your application and follow up with Social Security on its status.

Review your Medicare card.

Confirm your name and both Part A and Part B start dates.

Check additional coverage.

Confirm any drug, Supplement, or Advantage coverage and its effective date.

Coordinate existing insurance.

Verify who pays first and arrange end dates to avoid an unintended gap.

Prepare for your first visit.

Give providers the applicable cards and confirm participation.

Review bills and notices.

Check Medicare Summary Notices or plan explanations of benefits for unfamiliar services or errors.