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United Insurance
  • Home
  • GET A QUOTE
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    • Auto Insurance
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    • Medicare
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    • Request Proof of Ins
    • Medicare Guide
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How Do You Qualify for Medicare?

You are 65 or older

You are under 65 and have a qualifying disability

You are under 65 and have a qualifying disability

Most people become eligible for Medicare at age 65, regardless of whether they are still working or how much income they earn. 

You are under 65 and have a qualifying disability

You are under 65 and have a qualifying disability

You are under 65 and have a qualifying disability

You can qualify for Medicare if you are under 65 and have been receiving Social Security Disability benefits for at least 24 months. 

You have End-Stage Renal Disease (ESRD) or ALS

You are under 65 and have a qualifying disability

You have End-Stage Renal Disease (ESRD) or ALS

You can qualify for Medicare at any age if you have:

  • End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or
  • Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig’s disease).

Can green card holders get Medicare?

Yes, some green card holders (lawful permanent residents) can qualify for Medicare if they have lived in the United States as a permanent resident for at least five consecutive years, and meet the same work history or premium payment requirements as U.S. citizens.
 

Eligibility rules can be complex, so it’s always a good idea to confirm your specific situation with Social Security or Medicare directly.

The Four Parts of Medicare

Part A – Hospital Insurance

Part A – Hospital Insurance

Part A – Hospital Insurance

Think of Part A as coverage for major medical events that require facility care.


Typically helps cover:

  • Inpatient hospital stays
  • Care in a skilled nursing facility (after a qualifying hospital stay)
  • Hospice care
  • Some home health services
     

Key points:

  • Most people pay no monthly premium for Part A if they or a spouse worked and paid Medicare taxes for at least 10 years.
  • There is a deductible (for 2025, listed here as $1,676) and coinsurance amounts that apply based on the length of stay.
  • You still pay deductibles and coinsurance when you use services — it’s not “free” coverage, even if there’s no premium.
  • Part A by itself does not cover doctor visits, routine care, or prescriptions.

Part B – Medical Insurance

Part A – Hospital Insurance

Part A – Hospital Insurance

Part B is for day-to-day and outpatient medical needs.


Typically helps cover:

  • Doctor visits and outpatient services
  • Preventive care (screenings, annual wellness visits, vaccines)
  • Durable medical equipment (wheelchairs, oxygen, etc.)
  • Ambulance services
  • Certain outpatient medications given at a doctor’s office or clinic
     

Key points:

  • You pay a monthly premium (listed here as around $185/month in 2025; actual amount depends on income and year).
  • Higher-income beneficiaries may pay an additional IRMAA surcharge.
  • There is an annual deductible and then you generally pay about 20% coinsurance for most Part B services.
  • There is no annual out-of-pocket maximum under Original Medicare alone—large medical bills could mean significant 20% cost sharing.

Part C – Medicare Advantage

Part D – Prescription Drug Coverage

Part D – Prescription Drug Coverage

Medicare Advantage (Part C) plans are offered by private insurance companies that contract with Medicare.


These plans bundle your Part A and Part B coverage and often add extra benefits.


What to know:

  • You must first be enrolled in Parts A and B to join a Medicare Advantage plan.
  • Many Medicare Advantage plans also include Part D prescription drug coverage.
  • Plans may offer extras like:
    • Dental
    • Vision
    • Hearing aids
    • Gym or wellness benefits
  • Plans use networks (like HMOs or PPOs), so you often need to use doctors and hospitals in the plan’s network.
  • Each plan sets its own premiums, copays, and rules, but there is always an annual maximum out-of-pocket (MOOP) limit for in-network Medicare-covered services.
  • Many plans have a low or even $0 additional premium, beyond your Part B premium.
     

You can switch between Medicare Advantage and other types of coverage during specific enrollment periods.

Part D – Prescription Drug Coverage

Part D – Prescription Drug Coverage

Part D – Prescription Drug Coverage

Part D helps with the cost of outpatient prescription medications.


Key points:

  • Offered only through private insurers — there is no “Original Medicare” drug plan.
  • You pay a separate monthly premium, which varies by plan (an average figure here is around $55/month, but that can differ widely).
  • Part D plans have:
    • A formulary (list of covered medications)
    • Tiers, copays, and coinsurance
    • Possible deductibles (up to the maximum set each year; listed here as $590 for 2025)
  • Delaying Part D without having other creditable drug coverage can result in a permanent late enrollment penalty.
  • Starting in 2025, there is a $2,000 annual cap on out-of-pocket Part D drug costs, and the Medicare Prescription Payment Plan allows you to spread drug costs over the year instead of paying large amounts all at once.

Medigap (Medicare Supplement Insurance)

Medigap policies are offered by private insurance companies and are designed to supplement Original Medicare (Parts A and B). 

They help pay some of the costs that Original Medicare doesn’t fully cover, such as deductibles, coinsurance, and copays. 

Important basics:

  • Medigap is not another “part” of Medicare. 
  • It only works with Original Medicare – not with Medicare Advantage.
  • You cannot have a Medigap policy and a Medicare Advantage plan at the same time.

What Medigap Can Help Cover

Part A “gaps” may include:

  • Hospital deductibles
  • Coinsurance for longer hospital stays
  • Coinsurance for skilled nursing facility car
  • First three pints of blood

Part B “gaps” may include:

  • Part B deductible (though newer enrollees can’t get this covered on certain plans) 
  • The 20% coinsurance for most Part B services 
  • “Excess charges” if a provider charges more than the Medicare-approved amount (in states and situations where that applies)

Medigap plans are standardized by letter: A, B, C, D, F, G, K, L, M, and N.
Plans G and N are often popular for new Medicare beneficiaries because Plans C and F are generally not available to those new to Medicare after 1/1/2020. 

Two Common Ways People Set Up Their Medicare

Original Medicare (Parts A + B)

Medicare Advantage (Part C, usually includes Part D)

Medicare Advantage (Part C, usually includes Part D)

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  • Stand-alone Part D drug plan
  • Optional Medigap (supplement)
  • Broad flexibility in choosing doctors nationwide
  • No network in most cases (any provider that accepts Medicare)
  • Strong protection if paired with a Medigap plan, but usually higher monthly premiums
  • No built-in coverage for things like routine dental or vision (those may be added separately)

Medicare Advantage (Part C, usually includes Part D)

Medicare Advantage (Part C, usually includes Part D)

Medicare Advantage (Part C, usually includes Part D)

  •  All-in-one coverage under a private plan 
  • Often includes prescription drugs plus extras like routine dental, vision, hearing, and wellness benefits 
  • Uses a defined network of doctors and hospitals 
  • Annual maximum out-of-pocket limit for Medicare-covered services
  • Premiums can be lower, but flexibility may be more limited compared to Original Medicare with Medigap

Key Questions to Consider When Choosing a Path

  • Original Medicare + Medigap often offers broader provider access. 
  • Medicare Advantage may have tighter networks but can reduce overall costs.

  • Original Medicare doesn’t typically cover these except in limited medical situations.
  • Some Medicare Advantage plans include these extras.

  • Original Medicare offers nationwide coverage. 
  • Medicare Advantage plans may have local or regional networks but often include emergency coverage while traveling. 

  • Consider how each option impacts access to specialists, out-of-pocket costs, and prescription coverage. 

  • Delaying drug coverage without other credible coverage can add a penalty to your Part D premium for as long as you have it. 

  • Original Medicare alone has no maximum out-of-pocket limit.
  • Medicare Advantage plans include a yearly cap on out-of-pocket Medicare-covered costs.

Medicare Enrollment Windows

Knowing when you can sign up (or make changes) is just as important as knowing what Medicare covers.


Automatic Enrollment

You’re typically enrolled in Medicare Parts A and B automatically if you're already receiving Social Security benefits when you turn 65. In that case, your red, white, and blue Medicare card is usually mailed to you.


Manual Enrollment

You’ll need to actively enroll if you’re not yet collecting Social Security when you turn 65.
 

You can sign up:

  • Online through Social Security
  • By phone
  • At a local Social Security office
     

Many people choose to work with a licensed Medicare agent to make sure they enroll correctly and understand their options.


Initial Enrollment Period (IEP) – 7-Month Window

Your Initial Enrollment Period is:

  • 3 months before your 65th birthday month
  • Your birthday month
  • 3 months after your birthday month
     

If you miss this window and don’t have qualifying coverage, you may face:

  • Late enrollment penalties 
  • Delays or gaps in your coverage
     

Still Working at 65?

If you’re covered by credible employer health insurance, you may be able to delay certain parts of Medicare without a penalty. But the rules are very specific, and they depend on the size of your employer and plan type. It’s smart to:

  • Talk to your HR/benefits department
  • Confirm details with Medicare or Social Security before delaying enrollment
     

Annual Enrollment Period (AEP): October 15 – December 7

Each year during AEP, you can:

  • Switch from Original Medicare to a Medicare Advantage plan
  • Switch from Medicare Advantage back to Original Medicare
  • Change or enroll in a Part D prescription drug plan
     

Changes made during AEP usually take effect on January 1 of the following year.


Medicare Advantage Open Enrollment: January 1 – March 31

If you’re already enrolled in a Medicare Advantage (Part C) plan, you can:

  • Change to a different Medicare Advantage plan, or
  • Drop Medicare Advantage and return to Original Medicare (and, if needed, choose a Part D plan)
     

Why Deadlines Matter

Missing key enrollment periods can lead to:

  • Late enrollment penalties that may last as long as you have Medicare 
  • Gaps in medical or drug coverage
  • Fewer choices later on, especially if underwriting is involved (for Medigap in many states)

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