Medicare Questions & Answers: Eligibility
Eligibility Q&A
Showing 50 questions
I'm retiring next year - do I need to do anything with my Medicare?
1. Determine Your EligibilityMost people become eligible for Medicare at age 65. If you are retiring and will turn 65 next year, you should begin the enrollment process as early as three months before your 65th birthday. If you are already 65 or older, you may need to evaluate how your retirement affects your current Medicare enrollment.
2. Understand How Retirement Affects Coverage
If you’re retiring and currently have health insurance through your employer, that coverage will likely end when you stop working. You’ll need to ensure that you have Medicare Parts A (hospital insurance) and B (medical insurance) to avoid gaps in coverage. Even if you’re already enrolled in Part A, you’ll still need to sign up for Part B if it hasn't been done yet.
3. Enroll During the Special Enrollment Period (SEP)
For individuals retiring after age 65, retirement triggers a Special Enrollment Period (SEP), during which you can sign up for Medicare Part B without incurring late penalties. The SEP begins the month your employer coverage ends and lasts for eight months.
4. Consider Additional Coverage Options
Beyond Parts A and B, you may want to explore:
• Medicare Part D: Prescription drug coverage to help lower medication costs.
• Medigap: Supplemental insurance to cover costs not paid by Original Medicare, such as copayments and deductibles.
• Medicare Advantage Plans (Part C): An alternative to Original Medicare that combines Parts A and B, and often Part D, into a single plan.
5. Know Key Deadlines
Avoid gaps in coverage or penalties by knowing when to enroll:
• Initial Enrollment Period (if turning 65): Starts three months before your 65th birthday and ends three months after.
• Special Enrollment Period: Applies if you had employer-provided coverage and are retiring after age 65.
6. Contact Medicare or a Licensed Insurance Agent
Reach out to Medicare (1-800-MEDICARE) or your local Insurance Agent for personalized guidance on your specific situation.
Can I switch from a Medicare Advantage plan to a Supplemental/Medigap plan during the Annual Enrollment Period without answering health questions?
Maybe. How long did you have a Medicare Advantage plan?If you are still in your first year of Medicare Advantage coverage and you previously had a Medicare Supplement plan that you dropped to join the Medicare Advantage plan, you may exercise your 'Trial Right' Special Enrollment Period to return to your Medicare Supplement plan with no medical questions. If that plan is no longer available, you may choose another Medicare Supplement insurance company and enroll without Medical Underwriting, within certain guidelines.
If you enrolled directly into a Medicare Advantage plan during your Initial Enrollment Period and are leaving that plan within the first 12-months of coverage, you may also choose to return to Original Medicare and enroll with a Medicare Supplement plan without Medical Underwriting, again, subject to certain guidelines.
This process can be a bit tricky because you must first drop the Medicare Advantage plan and return to Original Medicare before you may enroll for a Medicare Supplement plan, and this can take some time. The Annual Enrollment Period is from October 15 - December 7 each year, and it is a very busy time of year for Social Security and Medicare, as most Medicare beneficiaries need to review and make changes to their plans during that time of year. It is possible that you could leave your Medicare Advantage plan and go back to Original Medicare only to have your Special Enrollment denied by the insurance company and find yourself without a Supplement plan while also outside of the Annual Enrollment Period, so also unable to re-enroll in your Medicare Advantage plan. If you want to do this, be prepared to start the process in October to allow enough time for the disenrollment and re-enrollment. You do not want to wait until the end of November or beginning of December to start this process.
Am I eligible for a Special Enrollment Period if I lose employer coverage?
Yes — losing employer or union-based health coverage does indeed qualify you for a Medicare Special Enrollment Period (SEP). Specifically, if you delay enrolling in Original Medicare (Parts A and/or B) because you were covered by current employment-based group health insurance, you have an eight‑month SEP to sign up once that coverage ends or your employment ends—whichever comes firstHowever, for enrolling in or changing a Medicare Advantage (Part C) plan or a stand-alone Part D prescription drug plan, you have only a two‑month SEP that begins immediately after the month your employer coverage ends
Do I have to answer health questions when switching from one Supplemental/Medigap plan to another?
Medigap plans are underwritten in most states once you’re outside your initial enrollment window (usually 6 months after you turn 65 and enroll in Part B). That means:• Insurance companies can ask about your health
• They can deny coverage, charge more, or exclude pre-existing conditions
You don’t need to go through underwriting if:
1. You’re in your Medigap Open Enrollment Period (the 6-month window after you enroll in Medicare Part B).
2. You qualify for a guaranteed issue right, such as:
• Your current Medigap plan ends or stops covering your area
• You move out of your plan’s service area (for Medicare SELECT)
• You lose other creditable coverage (like employer or union coverage)
• You’re within 12 months of trying a Medicare Advantage plan and want to switch back to Medigap (the “trial right”)
If you’re switching Medigap plans just because of cost or benefits, and you’re outside of those protected periods, expect to answer health questions — and possibly be declined.
I'm turning 65 in three months but still working with employer coverage. Do I need to sign up for Medicare right now or can I wait?
The real answer depends on one specific detail: how many employees your company has.If it's 20 or more, your employer coverage is considered primary, and you can generally delay Medicare Part B without any penalty — as long as you sign up within eight months after you eventually leave that job or the coverage ends, using what's called a Special Enrollment Period.
If your employer has fewer than 20 employees, Medicare typically becomes primary at 65 whether you're still working or not, which usually means you do need to enroll on time to avoid a gap in coverage.
One thing almost everyone should still do, regardless of employer size: sign up for Part A, since it's usually premium-free and can run alongside your employer coverage. The one exception is if you're contributing to a Health Savings Account — enrolling in any part of Medicare stops those contributions, so that's worth planning around.
Before you decide anything, check with your HR or benefits department to confirm your employer's size and whether your coverage is considered "creditable" — that one conversation determines whether waiting is actually safe for your situation, or whether it's setting you up for a penalty later.
At the same time, meet with a trusted independent Medicare agent like myself who will give you guidance about the best steps forward.
I applied for a Medigap plan and got denied because of my health history-how is that even legal when I've paid into Medicare for years?
Medigap plans, also known as Medicare Supplement Insurance, are private insurance policies designed to cover healthcare costs not included in Original Medicare. While Medicare itself is a federal program with standardized benefits, Medigap plans are offered by private insurers, and their rules can vary depending on state laws and circumstances.Medical Underwriting Outside Guaranteed Periods
If you apply for a Medigap plan outside your guaranteed issue period (when you turned 65), insurers are generally allowed to use a process called "medical underwriting." Medical underwriting enables them to evaluate your health history and decide whether to approve your application, decline coverage, or adjust premiums. This practice is permitted under federal law because Medigap plans are private insurance products, and insurers have the right to assess risk when determining eligibility outside federally protected periods.
State Regulations
While federal law sets the baseline for Medigap protections, states may have additional regulations that expand consumer rights. For example, some states prohibit medical underwriting entirely or allow open enrollment periods for Medigap plans beyond the federally mandated timeframe. If you were denied coverage, it may be worth investigating whether your state offers extended protections.
What You Can Do
If you have been denied a Medigap plan due to your health history, here are steps you can take:
• Check whether you were within a guaranteed issue period at the time of your application. If so, you may be able to appeal the denial.
• Consult your state’s Department of Insurance to learn about any state-specific rules that might apply.
• Look for alternative forms of coverage, such as Medicare Advantage plans, which may provide similar benefits without medical underwriting.
• Seek advice from a licensed Medicare counselor or broker who can help you navigate your options.
Who qualifies for Medicare coverage if they are under 65?
Individuals under 65 can qualify for Medicare if they have been receiving Social Security Disability Insurance (SSDI) benefits for at least 24 months, or if they have Amyotrophic Lateral Sclerosis (ALS) or End-Stage Renal Disease (ESRD). Some individuals with ALS may be automatically enrolled in Medicare, while those with ESRD need to actively sign up.Elaboration:
Social Security Disability Insurance (SSDI):
If you are under 65 and have been receiving SSDI benefits for 24 months, you are eligible for Medicare Parts A and B, according to the Centers for Medicare & Medicaid Services (CMS).
Amyotrophic Lateral Sclerosis (ALS):
Individuals with ALS are automatically enrolled in Medicare Parts A and B the month their disability benefits begin, says the CMS.
End-Stage Renal Disease (ESRD):
If you have ESRD, you are eligible for Medicare Parts A and B regardless of age, but you need to actively enroll when you first become eligible, states the Centers for Medicare & Medicaid Services.
If I have been on disabilty due to an accident, do I qualify for Medicare Insurance?
If you're on disability due to an accident, you'll be eligible for Medicare after receiving disability/SSDI payments for 24 months. The clock starts when you begin receiving disability payments, not on the date of the accident.In month 25, you're enrolled in part A and part B automatically, and you'll get your card in the mail a few months before your Medicare start date. And there's a couple of exceptions: If you have ALS (Lou Gherig's Disease), Medicare starts immediately. And if you have end stage renal disease (ESRD) the timing can be sooner, depending on treatment.
Quick example: If your disability/SSDI payments began in June of 2025, your Medicare would begin in June of 2027.
Can I get a Medigap plan with Guaranteed Issue if I'm losing my employer coverage?
Often, yes, but it depends on what type of employer coverage you are losing and whether you have (or are enrolling in) Medicare Part B.If you are losing employer/union coverage that supplements Original Medicare (including many retiree plans or COBRA): You generally have a federal Medigap “guaranteed issue” right. That means you can buy a Medigap policy without medical underwriting, and you typically must apply within 63 days of the coverage ending (or the date you are notified it is ending, depending on timing).
If you are losing active employer coverage and you are enrolling in Part B now: You may not be using “guaranteed issue,” but you typically get a 6‑month Medigap open enrollment period starting when Part B becomes effective, during which you can usually buy any Medigap plan sold in your state without underwriting.
If you are voluntarily dropping employer coverage that you could keep: You often do not get a guaranteed issue right.
Also, Medigap generally requires that you have Original Medicare (Part A and Part B), and guaranteed issue rights and plan availability can vary by state.
Can Medicare drop me for health reasons?
No, Medicare cannot drop you because of your health. If you have Medicare, your coverage continues even if you have health problems or develop a new illness.Original Medicare (Parts A and B) is a government health insurance program, so once you’re enrolled, you’re guaranteed coverage (assuming you remain eligible, such as by age or disability status).
The following are a few details to know:
Original Medicare (Parts A & B): You cannot be denied or dropped based on your health.
Medicare Advantage (Part C): These are private insurance plans, but they must accept anyone who’s eligible for Medicare and who lives in their service area, regardless of health. The only exception is for people with end-stage renal disease (ESRD) — until recently, plans did not have to accept those patients, but this has now changed, and nearly all plans accept ESRD.
Medicare Supplement (Medigap): When you first become eligible (your 6-month Medigap Open Enrollment Period), you’re guaranteed acceptance regardless of health. Outside that window, insurance companies in most states can ask health questions, but once they accept you, they cannot drop you as long as you pay your premiums.
In summary, while your plan options may vary based on when and how you apply, once you have Medicare coverage, the program cannot drop you for health reasons.
Do I have to apply for Medicare if I am still working past 65?
Probably yes, but there are a lot of details that go into this decision that you need to consider.If you work for a small employer with less than 20 employees, Medicare will become your Primary coverage once you’re eligible and your plan at work will only pay what Medicare does not cover - usually deductibles and the 20% coinsurance. Some employer plans will only pay the secondary portion even if you never signed-up for Medicare, and that would potentially leave you responsible for 80% of the bill on your own if you have not signed-up for Medicare Parts A & B.
If you have an HSA that you or your employer puts money into, you must stop adding money to that account once you’re eligible and have Medicare - even if you only have Medicare Part A. For this reason, you might choose to delay enrollment into Medicare.
If you are paying a part of the premium for your health plan at work or if you have a high deductible, you may want to take Medicare instead of your coverage at work. It may cost less and/or cover more.
There are so many different scenarios that require careful consideration when you work past age 65 and become eligible for Medicare. You should speak with an expert before making decisions to be sure you’re doing everything correctly for the outcomes you want and to avoid penalties later.
I have Medicare Part A and B since 06/01/2006 because of disability. My husband retired on 4/1/2024, and I now have no other coverage except for Medicare Parts A and B because I missed open enrollment for insurance coverage. Note: SS dropped SSI and changed it to straight SS. Please help.
Got it — since we’re now in October 2025, your situation changes a bit, but there are still options.Here’s what’s happening:
Because your husband retired back in April 2024, your Special Enrollment Period (SEP) for losing employer coverage has already expired. (That SEP lasts 8 months after losing group coverage — so it would’ve ended around December 2024.)
But the good news is — you’re now in Medicare’s Annual Enrollment Period (AEP), which runs October 15 through December 7 every year. During this time, you can:
Enroll in a Medicare Advantage (Part C) plan, which combines hospital, medical, and often prescription coverage.
Or enroll in a standalone Part D (prescription drug) plan if you want to stay on Original Medicare.
Your new coverage would start January 1, 2026.
Since you mentioned you only have Parts A and B right now, you should definitely look into adding at least a Part D plan — otherwise, you could face a late enrollment penalty later on. You might also qualify for Extra Help or a Medicare Savings Program depending on your income, especially since your SSI changed to standard Social Security. Those programs can help lower your premiums and copays.
So right now, you’re in the perfect window to fix this — just make sure you act before December 7, 2025.
Would you like me to help you figure out what type of plan (Advantage or Supplement + Part D) might work best for your health needs and budget?
What if I missed my window to sign up?
There are a LOT of moving parts to this question. For the sake of simplicity I am assuming you’re saying you missed the 7 month window (3 months before your birth month, your month of birth, and 3 months after) to sign up for Medicare.You can call Social Security anytime to sign up for Part A as long you qualify for premium-free Part A (you’ve worked and paid into the system for at least 40 quarters, or 10 years).
For Part B, there’s a General Enrollment Period (GEP) from January 1st to March 31st each year, with Part B starting July 1st. If you were eligible this year, and signed up in GEP 2027, you will pay a 10% monthly penalty ($20.25 at the 2026 rate) per year you missed. It’s cumulative, so if you didn’t sign up until GEP 2028, you’d pay 20%, etc. It’s also permanent, so you pay that penalty as long as you have Part B coverage.
If you don’t qualify for premium free Part A, the same GEP applies, and the 10% penalty applies, but it only lasts for twice as long as you went without coverage. So the part A penalty is finite, the Part B penalty follows you forever.
However, if you have employer coverage or spousal coverage that can be considered creditable (VA coverage, COBRA, and ACA coverage are not creditable) then you have a different situation.
Your best bet is to talk to agent to review your situation in detail to see if any special election periods apply that can help you.
What is Guaranteed Issue for Medicare Supplement plans, and when does it apply?
Guaranteed Issue (GI) for a (Medigap/Medicare Supplement) plan means an insurance company must sell you a policy, cannot deny you coverage, cannot charge you more because of health conditions, and cannot impose waiting periods for pre-existing conditions. Medigap works alongside **Original Medicare** to help cover out-of-pocket costs like deductibles and the 20% Part B coinsurance. The strongest GI protection occurs during your one-time, six-month Medigap Open Enrollment Period, which begins when you are age 65 or older and enrolled in Medicare Part B.You may also qualify for Guaranteed Issue in certain special situations, such as losing employer coverage, your **Medicare Advantage** plan leaving Medicare or your service area, or exercising a 12-month “trial right” after first joining Medicare Advantage. In these cases, you typically have 63 days to apply for certain standardized Medigap plans without medical underwriting. Outside of these protected periods, insurers in most states can require health screening and may deny coverage or charge higher premiums.
I'm a green card holder who's been in the US for 4 years and turning 65 soon. Am I eligible for Medicare?
No, as a green card holder with only 4 years in the US, you are not yet eligible for Medicare. To qualify for Medicare, you need to have been a lawful permanent resident (green card holder) and lived in the US continuously for 5 years.Here's a more detailed explanation:
Lawful Permanent Resident: You need to hold a green card, which grants you permanent residency in the US.
Continuous US Residence: You must have lived in the US for 5 years continuously, meaning you've maintained your primary residence in the US during that time.
Age: You need to be 65 years old or older.
In your case, you're 4 years into your US residency and haven't met the 5-year requirement. You'll need to wait until you've been a green card holder and lived in the US for 5 continuous years to be eligible for Medicare.
What happens when you're eligible:
You'll need to apply for Medicare, which can be done through the Social Security Administration or online.
You may need to pay a monthly premium for Medicare Part A (hospital insurance) if you haven't worked in the US for the required 40 quarters (10 years).
If you do have the required work history, you can enroll in Medicare Part A (hospital insurance) and Part B (medical insurance).
You can also enroll in Medicare Part D (prescription drug coverage) if you have Part A and/or Part B.
What happens if I am unable to provide creditable coverage?
If you go without creditable coverage for too long, you could face a late enrollment penalty when you sign up for Medicare Part B or Part D.Part B (Medical Insurance) – If you don’t have creditable coverage and delay enrolling, your premium may go up 10% for every 12 months you were eligible but didn’t sign up. This penalty is permanent.
Part D (Prescription Drug Coverage) – If you go 63 days or more without creditable drug coverage, you may pay an extra monthly penalty for as long as you have Part D.
Creditable coverage means your existing insurance is at least as good as Medicare’s standard coverage. If you’re ever unsure whether your plan is creditable, ask your insurer for a written notice—keep it in your records in case Medicare ever asks for proof.
If I live part of the year abroad, do I still have to pay for Medicare if I don’t use it?
If you plan to live outside the United States for an extended period, you may have the option to disenroll from Medicare Part B and avoid paying the monthly premium while you are abroad. However, this decision should be made carefully. When you return to the U.S., you may need to demonstrate to the Social Security Administration that you had qualifying health coverage or met specific enrollment requirements to avoid a late enrollment penalty. Depending on your circumstances, you could also experience a delay before your Part B coverage becomes effective again.For many individuals who travel or reside overseas part-time, maintaining Medicare Part B coverage may provide greater flexibility and peace of mind. One option is to enroll in a $0 premium Medicare Advantage plan (while continuing to pay the Part B premium) that offers worldwide emergency and urgent care benefits. While Medicare Advantage plans are generally designed for use within the United States, certain plans can help cover emergency medical situations that occur abroad—something Original Medicare typically does not cover.
Before making any changes to your Medicare coverage, it’s important to evaluate how long you expect to be outside the country, whether you maintain a U.S. residence, your access to healthcare overseas, and the potential impact of future enrollment rules and penalties. Consulting with a Medicare specialist can help ensure you make the choice that best fits your travel and healthcare needs.
Note: Individuals living abroad generally do not automatically qualify for a Special Enrollment Period simply because they reside outside the United States. Eligibility to reenroll in Part B without penalty typically depends on meeting specific Medicare enrollment rules, such as having qualifying employer group health coverage. Always verify your situation with the Social Security Administration before dropping Part B.
Do I qualify for SEP if my health dramatically gets worse out of nowhere?
A sudden worsening of health, even with hospitalization, generally does not give you a Medicare Special Enrollment Period (SEP) to change coverage mid-year.What can create a Medicare SEP that sometimes relates to a health change is one of these situations:
- You qualify for a Chronic Condition Special Needs Plan (C‑SNP): If you are diagnosed with a qualifying chronic condition and a C‑SNP is available where you live, you may be able to join that plan using an SEP.
- You enter, live in, or leave an institution: If you are in a skilled nursing facility, nursing home, or similar facility, you may have an SEP to change Medicare Advantage/Part D coverage.
- You gain or lose Extra Help (LIS) or Medicaid: These programs can allow plan changes outside the usual enrollment periods.
- You move or lose other coverage: Moving out of your plan’s service area or losing creditable drug/employer coverage can trigger SEPs.
- Your plan changes materially: Certain plan terminations or other CMS-approved circumstances can trigger an SEP.
If none of those apply, your main options are usually:
- Annual Enrollment Period (AEP): Oct 15–Dec 7 (changes effective Jan 1).
- Medicare Advantage Open Enrollment Period (MA OEP): Jan 1–Mar 31 (only if you are already in a Medicare Advantage plan).
- State Medigap switching rules (where available): If you have a Medigap (supplement) policy, some states give extra opportunities to switch plans without medical underwriting, such as California and Oregon's “birthday rule,” which can allow a switch to a Medigap plan with equal or lesser benefits around your birthday (subject to state timing and requirements).
Should I worry about my income effecting my Medicare eligibility?
No, income does not affect your eligibility for Medicare, however, if your income is above a certain threshold, an IRMAA (Income Related Monthly Adjustment Amount) will be applied to your Part B & Part D monthly premiums. The IRMAA is determined by your tax returns from 2 years ago- 2026 will be determined by your 2024 tax returns. There is an appeal form on the Social Security website ssa.gov. I recommend checking to see if an appeal category applies to your situation.
What happens to my Medicare coverage if I move to a U.S. territory like Guam or the Virgin Islands?
Medicare is available in US territories, including the District of Columbia, Puerto Rico, the US Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. If you have an Advantage plan or a Part D drug plan, you would need to sign up for a new plan. If you have original Medicare with a Medigap plan, simply notify the plan of your move.
I’ll be turning 65 in April. I have full VA coverage and good hospital and doctor coverage through Eisenhower here in the desert. The VA doesn’t provide dental care. Do I still need to enroll in Medicare, and if so, which part makes sense for my situation?
Congratulations on approaching your 65th birthday! With VA coverage and additional hospital and doctor coverage through Eisenhower, you have a solid foundation for your healthcare needs. Since the VA doesn't provide dental care, you'll want to consider how Medicare can complement your existing coverage.*Do you need to enroll in Medicare?*
While VA coverage is excellent, Medicare can help fill gaps, including potential out-of-pocket costs and additional benefits. Enrolling in Medicare can provide more comprehensive coverage and financial protection.
*Which part of Medicare makes sense for you?*
Consider the following:
- *Medicare Part A*: Covers hospital stays, which might overlap with your existing VA coverage. However, Part A typically has no premium if you've worked and paid Medicare taxes.
- *Medicare Part B*: Covers doctor services, outpatient care, and some preventive services. This might complement your existing coverage.
- *Medicare Part D*: Covers prescription medication. If you have medication costs not covered by the VA, Part D might be beneficial.
- *Medicare Advantage (Part C)*: Combines Part A and Part B coverage, often with additional benefits like dental, vision, or hearing. Some plans might offer dental coverage, which could be valuable given the VA's limitations.
*Key considerations:*
- *VA coverage and Medicare coordination*: Understand how your VA coverage and Medicare will work together. In some cases, Medicare may be the primary payer, while the VA coverage supplements it.
- *Out-of-pocket costs*: Consider potential costs associated with Medicare, such as premiums, deductibles, and copays.
- *Dental coverage*: If dental care is a priority, explore Medicare Advantage plans that offer dental benefits or consider standalone dental insurance.
*Next steps:*
- *schedule a consultation with me
Does everyone over the age of 65 qualify for Medicare?
To be eligible for Original Medicare Part A and Part B, you must be age 65 or have been entitled to Social Security Disability insurance for 24 months (two exceptions to this: disabled due to end stage renal disease ESRD or ALS).Part A is hospital insurance and comes with a zero dollar premium if you are insured (e.g. paid FICA tax for 10 years) for Social Security benefits. Many people sign up for Part A, even if they are continuing to work since it is a benefit they have earned and does not cost anything extra. It simply provides extra coverage.
Part B is medical insurance and in 2026 comes with a $202.90 monthly premium for most individuals (some high earners pay pay more for their Part B). If you are still working at age 65 and covered by an employer group health plan (EGHP), many people hold off on signing up for Part B, due to the cost of the premium. There is also no penalty for filing after age 65, if you are covered by an EGHP that is creditable. You should ask your Human Resources Department if your EGHP is creditable before deciding not to take Part B at age 65.
If you have not worked and paid into Social Security and are not insured for benefits, you can get Part A and Part B, but you would owe the monthly premiums for both. For Part A, the monthly premiums may range from ~$300 to over $500 monthly. For Part B, the monthly premium will be $202.90.
I also recommend working with a local Medicare expert at least 4-6 months before your 65th birthday. Additionally, if you are on Social Security Disability, reach out 4-6 months before you are eligible for Medicare. Medicare experts will be able to educate you on all your Medicare options (e.g. Original Medicare, Medicare Advantage Plans, Dental, Vision, Hearing etc...), as well as ensure that you avoid costly late enrollment penalties.
I am a resident in another country outside of America, will I still be covered living abroad?
No you will not. Medicare does not generally cover healthcare outside of the United States except in limited medical emergencies in a foreign country that is closer than the nearest U.S. hospital. If you are living abroad you should still consider keeping your Medicare though if you plan to return to the United States to avoid penalties. However it may not be worth the cost if you do not plan to return and plan to live abroad permanently and will not travel very frequently.
How to enroll in Part D plan for RX coverage?
You can enroll in a Medicare Part D plan through the Medicare.gov website. You will want to be careful and make sure you verify that all of your medications are covered and compare your out-of-pocket costs between plans as they will vary. Also make sure your preferred Pharmacy is in network as well. Even though the insurance carriers no longer compensate Medicare Health Insurance Agents to enroll Medicare beneficiaries into their Part D Plans, some agents may be willing to offer their time and expertise in finding a plan that fits your needs. This process can be time consuming if you have a lot of prescriptions, so start early and be sure to have an organized list of your prescriptions and the dosages ready to enter when you do your research. Remember, not signing up for Medicare Part D when you are eligible even if you don’t have any prescriptions will result in a late penalty when you sign up later on down the road.
Can eligibility for certain Medicare Advantage plans depend on where I live?
Yes — eligibility for Medicare Advantage plans can absolutely depend on where you live.Here’s why location matters:
Medicare Advantage plans are county-based
Medicare Advantage plans are approved and offered by county, not statewide or nationwide. That means a plan available in one county may not exist in the neighboring one.
Provider networks are local
Most Medicare Advantage plans use local doctor and hospital networks (especially HMOs and PPOs). If you live outside the service area, the plan can’t guarantee access to in-network care, so you wouldn’t be eligible.
Benefits and costs vary by area
Premiums, copays, extra benefits (like dental, vision, transportation, or fitness), and even plan types can change based on your ZIP code or county.
Moving can affect your plan
If you move to a different county or state:
Your current Medicare Advantage plan may no longer be available
You may qualify for a Special Enrollment Period to choose a new plan
Medicare Advantage vs. Original Medicare
Original Medicare works the same nationwide, but Medicare Advantage plans are location-specific, which is a key difference to keep in mind if you travel or relocate often.
Can I be turned down for a Medicare Advantage plan because of my health?
You generally cannot be turned down for a Medicare Advantage plan because of your health, as long as you’re eligible for Medicare Parts A and B and live in the plan’s service area.Enrollment and health conditions
Medicare Advantage plans (Part C) are required to accept you regardless of pre‑existing conditions; they must follow the same “no health underwriting” rule as Original Medicare for eligibility.
Since 2021, people with End‑Stage Renal Disease (ESRD) can also enroll in most Medicare Advantage plans, which used to be a major exception.
Plans also cannot drop you from coverage later just because your health gets worse, as long as you keep paying premiums and meet basic plan rules.
When a plan can say “no”
A Medicare Advantage plan can’t deny you based on health, but it can deny enrollment for non‑medical reasons such as:
You don’t have both Part A and Part B.
You don’t live in the plan’s service area or network county.
You try to enroll outside of an allowed enrollment period (Initial Coverage Election Period, Annual Enrollment Period, or a qualifying Special Enrollment Period).
You are enrolled in certain types of other coverage that are incompatible with that plan (for example, another Medicare Advantage plan at the same time).
Coverage limits vs enrollment denial
Even though you can’t be turned down for health reasons, the plan can have rules about which doctors you can see (network), which drugs are covered (formulary), and when you need prior authorization or step therapy.
A plan must cover all services that Original Medicare covers and cannot refuse medically necessary care, but it may deny particular services if it decides they are not medically necessary under Medicare rules, in which case you have appeal rights.
Medicare Advantage vs Medigap (important distinction)
Medicare Supplement (Medigap) plans are different: outside of your first Medigap open‑enrollment or certain guaranteed‑issue situations, a Medigap insurer can use medical underwr
If I qualify for both Medicare and Medicaid, how does that eligibility work together?
If you qualify for both Medicare and Medicaid, you are considered dual eligible. This means you can receive benefits from both programs, helping reduce your healthcare costs and improve access to care.Medicare is your primary health insurance and generally pays first for covered medical services, including hospital stays, doctor visits, and prescription drug coverage (depending on your plan).
Medicaid works alongside Medicare and may help pay for:
Medicare premiums
Deductibles and copayments
Services Medicare doesn't fully cover, such as certain long-term care services and supports
Many dual-eligible beneficiaries choose a Dual Eligible Special Needs Plan (D-SNP), a type of Medicare Advantage plan designed specifically for people who qualify for both programs. These plans often provide additional benefits and help coordinate care.
Because Medicaid eligibility and benefits vary by state, it's important to review your options annually to make sure you're receiving all available assistance.
If you think you may qualify for both Medicare and Medicaid, a licensed insurance agent experienced in Medicare can help you understand your choices and determine which coverage best fits your needs.
This information is for educational purposes only and is not a complete description of benefits. Eligibility for Medicare, Medicaid, and D-SNP plans varies. Contact your state Medicaid office for specific eligibility requirements.
How do I apply for Medicare if I qualify because of a disability?
You cannot apply for Medicare due to a disability directly; you must first be approved for SSDI through the Social Security Administration (SSA). You can submit your application online using the SSA Disability Benefits Portal.To get Medicare due to a disability before age 65, you must first qualify for and receive Social Security Disability Insurance (SSDI) for 24 months. You will then be automatically enrolled in Medicare Parts A and B starting in your 25th month.
Because you are under 65, your Medicare enrollment is usually automatic. You will receive a Welcome Packet and your official Medicare Card in the mail approximately 3 months prior to your 25th month of SSDI benefits.
For more details/guidance, go to: https://www.ssa.gov/benefits/disability/qualify.html
Will I lose my Medicare benefits if I get married?
So the question is, will I lose my Medicare benefits if I get married?
Regarding your Medicare benefits, you will not lose your Medicare benefits. Meaning that say if you have Part A, Part B, and a supplemental and drug plan, once you get married your coverage will stay the exact same. When you are married, Medicare coverage is completely separate, so there are no group plans. There's no plans that you can add on to your life. Sometimes plans give a household discount, but everybody is on their own individual plan.
The only thing that you can possibly lose is if you are getting extra assistance through the state, through your state's Medicare Savings Program, as we have here in Connecticut. There are different income thresholds. So for instance, if you are making $2,600 a month from your Social Security and a small pension, and you're single, you would most likely qualify for that Medicare Savings Program in Connecticut. However, if you get married to your spouse and they happen to have a larger income, say if they're making $3,500 a month, you would be over the threshold, which is about $3,600 to $3,800 as a couple to be on that savings program.
So you won't lose Medicare, but you would lose that extra assistance from the state. Hope this helps.
How does divorce affect my Medicare eligibility, premiums, or benefits?
Great Question: Divorce can affect Medicare in a few important ways, but your eligibility for Medicare itself is usually not affected if you're already entitled to it based on your own work history or your former spouse's work history.If you're eligible based on your own work record (typically 40 quarters/10 years of Medicare-covered employment), divorce does not change your Medicare eligibility.
If you're relying on a former spouse's work record to qualify for premium-free Medicare Part A, you may still qualify if:
The marriage lasted at least 10 years.
You are currently unmarried.
You are age 65 or older.
Your former spouse is eligible for Social Security retirement or disability benefits.
After a divorce, if you don't have enough work credits yourself, you may still receive premium-free Part A through your ex-spouse if the 10-year marriage rule is met.
Divorce does not automatically change your Medicare Advantage or Medigap coverage.
However, if you were covered under a spouse's employer health plan before Medicare, losing that coverage due to divorce may trigger a Special Enrollment Period, allowing you to make Medicare coverage changes.
Are Medicare Advantage plans guaranteed issue?
Medicare Advantage plans are guaranteed issue, meaning you cannot be denied coverage or pay more for your plan based on preexisting conditions, recent diagnosis or your current health condition. However, you can only enroll in plans within your service area, have Medicare Part A and B, and enroll during valid enrollment periods.If you're concerned about managing costs during a health crisis or illness, here are some things to consider when selecting a Medicare Advantage Plan:
- look for a lower maximum out of pocket amount. This can help reduce costs for medical services that use original Medicare billing such as radiation, chemotherapy, and infusions.
- understand what services you will use or need most frequently and estimate how many visits you may need in a plan year. Then, compare copays from different plans.
- ensure that all of your providers are in network and your prescriptions are on the plan's formulary.
- $0 premium plans might not always be the best option. Plans with a premium may have lower copays for services you use the most, saving you money even with paying a monthly premium.
An experienced broker who knows your area's network of providers and plans can guide you through finding the right plan for you.
What's the difference between Medicare and Medicaid?
One of the most common questions I hear is:“What’s the difference between Medicare and Medicaid?”
While the names sound similar, they are actually two very different programs.
Medicare is primarily health insurance for:
• People age 65 and older
• Certain younger individuals with disabilities
• People with End-Stage Renal Disease (ESRD) or specific qualifying conditions
Medicare is generally based on age or disability status — not income.
Medicaid, on the other hand, is a needs-based program designed to help individuals and families with limited income and resources. Medicaid rules can vary from state to state.
Here’s a simple way to think about it:
• Medicare = Age or disability-based health coverage
• Medicaid = Income and asset-based assistance program
Some people qualify for BOTH Medicare and Medicaid at the same time. These individuals are often referred to as “dual eligible” beneficiaries.
When someone qualifies for both programs, Medicaid may help pay for things like:
• Medicare premiums
• Copays and deductibles
• Additional healthcare services
• Long-term care support in some situations
This is why proper guidance matters so much. Many seniors don’t realize they may qualify for additional assistance programs that could potentially save them thousands of dollars each year.
I spend a lot of time helping seniors and families understand these programs, review their options, and connect them with resources that may help — always at no cost.
Chuck Winslow
US Marine Veteran 🇺🇸
Retirement & Legacy Planner
Contact me.
If I don't have a primary physician will my new carrier assign me to one?
Yes — in many cases, if you enroll into certain Medicare plans, especially HMO plans, the insurance carrier may automatically assign you a Primary Care Physician (PCP) if you do not select one during enrollment.However, you usually still have the ability to change your assigned doctor afterward if you would prefer someone else who is in-network and accepting new patients. I always recommend reviewing the provider network carefully to make sure the doctor, specialists, hospitals, and medical groups are a good fit for your healthcare needs and location.
I also partner with senior-focused healthcare networks and medical groups that offer strong support for Medicare beneficiaries, including access to quality primary care physicians, quicker new-patient appointments, coordinated specialist care, wellness resources, and senior activities. My goal is not only to help clients select a plan, but also help connect them with healthcare resources and support systems that can improve their overall experience and quality of care.
What is the cost and value of a supplemental plan, and what plans are available?
This is a big question with a LOT of variables.First, there are two pathways for supplemental medicare coverage: a medigap plan, or a medicare advantage plan. Which option is right for you depends on a lot of factors. But in general:
Cost:
Medigap plans will always have a premium tied to them. What the premium is depends on several factors and on the plan you choose. A high deductible plan G will have a much lower premium than a standard plan G, for example.
Medicare advantage plans are USUALLY (but not always) premium free so there could be no additional cost beyond your part B Premium.
In both cases you must continue to pay your part B premium in addition to any plan premiums to remain eligible.
Value:
The value of a Medigap plan is flexibility. There are no networks, so if a doctor accepts medicare, they accept your medigap plan. What your copayments or coinsurance would be depends on the plan you select. For example, if you choose a standard plan G, you pay the Medicare Part B deductible ($283 in 2026) and the plan pays the rest of your medical expenses. The coverage is simple. You do need to pick up a standalone Medicare Part D plan for prescription drug coverage, and there is no preventive dental, vision or hearing coverage.
A medicare advantage plan will typically include your part D coverage, as well as basic dental, hearing and vision coverage. Often you will get some comprehensive dental, a copay or stipend for hearing aids, and a stipend for eyewear. You will have a medical network (an HMO or PPO) which means you have to work with doctors in that network, and while there’s typically no premium, you will have copays for most services and those will vary by carrier and by plan within a carrier.
What plans are available?
This is going to depend on your location. Most areas have the same medigap plans available, but medicare advantage options differ by county. So, you would need to talk to an agent or go to medicare.gov to see all your options.
Barson Financial / Kellogg Insurance Group/ Integrity Insurance Company/ Kellogg Insurance Group • Las Vegas, NV
Does life insurance affect my Medicare eligibility or premiums?
The short answer — No.Life insurance has absolutely no effect on your Medicare eligibility or your monthly premiums. The two are completely separate and do not interact with each other in any way.
Here's what actually determines your Medicare premiums:
Part A (Hospital Insurance)
Most people pay $0 for Part A if they or their spouse worked and paid Medicare taxes for at least 10 years.
Part B (Medical Insurance)
Your Part B premium is based on your income — specifically your Modified Adjusted Gross Income (MAGI) from two years prior.
For 2026, the standard premium is $202.90/month. Higher earners pay more through what's called IRMAA.
Part C (Medicare Advantage) & Part D (Drug Plans)
Premiums vary by plan, carrier, and your location — not by your life insurance coverage.
Can You Be Denied a Medicare Advantage Plan?
As long as you apply for a plan during a valid election period and you meet the eligibility requirements, you can't be denied.To qualify for a Medicare Advantage plan, you must have both part A and part B of Medicare. Some plans have additional requirements such as plans designed for people who have a chronic condition such as diabetes or heart conditions. There are also plans designed specifically for people who also have Medicaid and may contain additional requirements that look into the level of Medicaid or state wavers. It's always best to work with an experienced agent to help guide you through the process of choosing and enrolling into a plan.
What if you have Medicare and SSI or you have both Medicare and Medicaid how do you qualify for LIS or Extra Help?
If you have Medicaid, SSI, or a Medicare Savings Program, you typically qualify automatically for Extra Help (Low-Income Subsidy) with your Medicare Part D drug costs. This means your premiums, deductibles, and copays for prescriptions are significantly reduced. You usually do not need to apply separately because the benefit is assigned automatically through the Social Security Administration. If someone does not automatically qualify, they can apply directly through Social Security based on income and asset limits. Extra Help can substantially lower prescription drug costs for eligible Medicare beneficiaries.How to sign up for A & B?
You can sign up for Medicare Part A and Part B online through the Social Security Administration (SSA) website during your 7-month Initial Enrollment Period (3 months before to 3 months after your 65th birthday). The process takes about 10 minutes, and you will need to create a login.gov account.Several ways to Enroll:
- Online, visit SSA.gov and click "Sign up for Medicare".
- Phone: Call Social Security at 1-800-772-1213
- In-Person: Visit your local Social Security office.
Can you get Medicare if you never worked or didn't pay into the system?
Yes, you can get Medicare if you never worked or didn't pay into the system, but you will likely have to pay a monthly premium for Part A (hospital insurance). To get it for free, you generally need 10 years (40 quarters) of work or qualify for low income Medicaid!
Can I have both Medicare and Medicaid at the same time?
Yes. You can have both Medicare and Medicaid at the same time. Individuals who qualify for both are called dual-eligible beneficiaries.* Medicare is your primary health insurance.
* Medicaid helps pay Medicare costs, such as premiums, deductibles, copays, and coinsurance, and may also cover services like dental, vision, hearing, transportation, and long-term care.
Many dual-eligible individuals enroll in a Dual Eligible Special Needs Plan (D-SNP), which combines Medicare benefits with extra services such as prescription drug coverage, dental, vision, hearing, OTC allowances, transportation, care coordination, and, on some plans, grocery or utility benefits.
To qualify, you must:
1. Be eligible for Medicare, and
2. Meet your state’s Medicaid income and eligibility requirements.
Medicaid assistance may include Full Medicaid or a Medicare Savings Program (QMB, SLMB, QI, or QDWI), depending on your eligibility.
Do I need to enroll in Medicare if I already have VA health benefits?
That's a trick question and relies heavily on what your goals or even your benefit level with the VA is. If you live near a VA location or maybe you have Tricare the answer could be no you dont need to enroll in medicare. However if you receive limited benefits and do not have easy access to a VA location or maybe you want more private access to doctors and specialist versus government employees, you may want to get Medicare parts A and B and potentially even enroll into a Part C or medicare advantage plan. This doesn't remove your ability to go to the VA for care or prescriptions but can actually enhance your healthcare benefits and provide some really important benefits you may not be getting like dental, vision, gym memberships and so on all at no cost in most cases.What is the CMS-L564 form and when do I need it for Medicare enrollment?
Seniors who are still working and covered by a large group plan can delay starting part B and enroll, without penalty, if they've maintained proof of continuous creditable coverage.The CMS-L564 form is used to document creditable coverage, it is signed by a representative of the employer, and is submitted with the application for part B.
For many seniors, it can make sense to delay starting part B, and the CMS L564 form helps avoid part B late enrollment penalties by documenting continuous creditable coverage.
Does moving to a new state let me switch from Medicare Advantage to Medigap without health questions?
Moving to a new state opens a Special Enrollment Period (SEP) for your move where you can switch with what's called . The moving process is a bit involved. First, you will need to stop your Advantage Plan and go back to Original Medicare. Once you are back in Original Medicare, you can apply for a Medigap Plan.Keep in mind that moving from Medicare Advantage to Medigap does not cover prescriptions. You will need to add a separate Prescription Drug Plan (Part D) with your Medigap Policy. Don't forget to check and see if your medications are covered.
You’ll have up to two months to get a Part D prescription plan, and you’ll qualify for a Medigap guaranteed issue period that lasts up to 63 days after your Medicare Advantage coverage ends. During this time, you can purchase most Medigap plans regardless of existing health problems.
Although the Medigap Plans offer the same coverage, premiums are not the same price. Also, different sates have their own rules for Medigap policies. For instance, New York, Connecticut, and Massachusetts offer enrollment at anytime, without the need for a Special Enrollment Period. Check with a licensed Medicare Broker in your new home town to help you with the specific rules in your new hometown.
I'm over 65, not enrolled in Part A or B, and leaving active coverage through an employer with 20+ employees for six months of COBRA.
No, once your active employer coverage ends, your 8-month Special Enrollment Period starts immediately, and COBRA doesn't extend or pause it. So even if you elect 6 months of COBRA, you still need to enroll in Part A and B within 8 months of your active coverage ending, not 8 months from when COBRA runs out. Waiting until COBRA ends would put you outside the SEP window and risk a late enrollment penalty plus a potential gap in coverage.
Do I need Medicare Part B if I have VA benefits?
VA benefits and TRICARE are treated very differently when it comes to Medicare Part B.VA benefits are a separate health care system. Medicare gives the veteran more flexibility outside the VA system, but Part B is not technically required just because someone has VA benefits.
TRICARE is different. For most Medicare-eligible TRICARE beneficiaries, Medicare Part B is required in order to keep TRICARE active.
Even with VA benefits, I would still strongly consider enrolling in Medicare Part B in most cases.
The reason is simple. VA benefits and Medicare do not work together the same way employer insurance and Medicare do. If you receive care through the VA, the VA generally covers care provided within the VA system. But if you go outside the VA system, Medicare may be what gives you access to non-VA doctors, hospitals, outpatient services, specialists, and medical equipment.
If you have both Medicare and VA benefits, you can use either program, but they generally do not pay for the same service at the same time. That is why Part B is often an important planning decision, even though it is not technically required for VA benefits.
Unless you are enrolled in TRICARE For Life, you may also want to consider how you would cover the costs that Medicare Part B does not fully pay if you receive care outside the VA system. For some people, that may mean reviewing a Medicare Supplement plan to help cover Original Medicare cost-sharing. For others, it may mean reviewing a Medicare Advantage plan as an alternative way to receive Medicare benefits.
If there is a chance you may need or want care outside the VA system, Medicare Part B should be strongly considered. You may also want to review whether a Medicare Advantage plan or Medicare Supplement plan makes sense to help cover the Medicare Part B cost-sharing that VA benefits may not cover outside the VA system.
Can I cancel or drop Medicare Part B if I move abroad?
Yes, you can drop Medicare Part B if you move abroad, since Medicare generally doesn’t cover care outside the U.S. To do this, you must contact the Social Security Administration and submit a request to disenroll.Keep in mind, if you later return to the U.S. and want Part B again, you may face a late enrollment penalty and have to wait for an appropriate Enrollment Period.
Before dropping Part B, make sure you’ll have adequate health coverage in the country you’re moving to.
In NC, I’m on my husband’s active employer plan with 20+ employees. Since it’s credible coverage, can I delay Medicare, including Part D?
Yes, since your husband's employer plan covers 20+ employees, it counts as creditable coverage for both Medicare and Part D. So you can delay enrolling in Part A, Part B, and Part D without a late enrollment penalty as long as that coverage stays in place. Once the employer coverage ends, you'll get an 8-month Special Enrollment Period to sign up for Part A and B, and a separate 2-month window to enroll in a Part D or Medicare Advantage plan with drug coverageCan my employer force me to take Medicare when I turn 65?
It depends on your individual situation, which feels like a bit of a cop-out. If your employer is considered a small employer (less than 20 employees) they can force you to enroll in Medicare. Smaller employers do not have to operate by the same federal rules as larger companies. Medicare Part A & B will become your primary coverage.If your employer is over 20 people, the employer cannot legally force you to enroll into Medicare. People with larger employers have three choices for their insurance. First, just stay on your employers plan. You can delay Medicare without penalty but make sure to notify Social Security of your intent to delay. The second option is to enroll in Medicare Part A, defer Part B, and stay on your employer coverage. Last, you could drop the employer plan and enroll in Medicare Part A&B.
Make sure and review your options with your employer's HR department to verify you are taking are taking a correct action. They may even be able refer you to a Medicare agent that can review Advantage and Supplement Options.
if you defer Medicare you can visit the Social Security website at this link: https://www.ssa.gov/medicare/sign-up/part-b-only. If you don't like doing things online, you can call SSA directly for assistance at 1-800-772-1213.
Do you automatically get Medicare if you're on Social Security Disability?
The question is, do you automatically get Medicare if you're on Social Security disability?
The way Social Security disability works is that you will qualify for Medicare A and B two years after you're found to be disabled. This is different for everybody. If you win a favorable decision, you can start collecting Social Security disability income. A lot of times you get your Medicare card sent to you automatically because you were found to be disabled years before. If for some reason they found you to be disabled maybe a year before you get your favorable decision, again, you have to wait to that two year mark to start getting Medicare benefits.
A couple things to think about is that a lot of times if you did win a case for Social Security and then you get your Medicare card automatically, you don't always have to keep the Medicare. More importantly, if you have a spouse that has group coverage. Now the caveat to that is normally for most folks turning 65, you could opt out of Medicare for now if you have an employer with 20 or more employees. However, with Social Security disability under 65 Medicare, that company has to have more than 100 employees.
So if you have a spouse that works for an employer that has more than 100 employees and the insurance is better for you, I always say hold off, don't go on Medicare. However, when that time comes, maybe if your spouse retires or if they lose their job, at that point if you do not have insurance through your spouse's employer, you would have to go on Medicare at that time.
Hope that helps.
How do eligibility rules differ for those on TRICARE or Veterans Affairs (VA) benefits?
For Medicare in 2026, eligibility itself doesn’t change for people with military benefits, but the rules around enrollment and coordination do. Those eligible for TRICARE must enroll in Medicare Parts A and B at age 65 to keep coverage, at which point they move into TRICARE For Life, with Medicare as the primary payer and TRICARE acting as secondary “wraparound” coverage—skipping Part B can mean loss of TRICARE and permanent penalties. In contrast, Veterans Affairs (VA) health benefits are based on military service rather than age and do not require Medicare enrollment; however, VA and Medicare generally do not coordinate for the same care, so veterans often enroll in Medicare (especially Part B) to avoid late penalties and to have access to non-VA providers. In short, Medicare enrollment is mandatory to keep TRICARE but optional (though strongly recommended) for those relying on VA benefits.Browse Other Questions & Answers
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