Who Is Not Eligible for Medicare at Age 65?

As you approach age 65, you may begin to think about Medicare eligibility and when to apply for coverage. While most people are eligible, some circumstances may prevent you from qualifying. Understanding the specific eligibility requirements—and why you may not be eligible—can help you avoid surprises and plan for your healthcare needs. This article breaks down who might not qualify for Medicare at age 65 and what steps to take if you're in this situation.

Basic Eligibility Requirements

To qualify for Medicare, you need to meet three basic criteria: age, citizenship or legal residency, and work history. Generally, you must be 65 or older. You must also be a U.S. citizen or legal permanent resident who has lived in the U.S. for at least five years.

Medicare Part A, which covers hospital services, requires that you’ve worked for 10 years (40 quarters) under Social Security or the Railroad Retirement Board to qualify for premium-free coverage. If you haven’t met this requirement, you may still be able to purchase Medicare Part A, but you won’t qualify for it without paying premiums. Learn more about Medicare Part A.

Common Reasons for Ineligibility

Some people may not be eligible for Medicare due to insufficient work history, non-citizenship or residency status, or failure to enroll on time. If you haven’t worked 40 quarters (10 years) under Social Security or the Railroad Retirement Board, you won’t qualify for premium-free Medicare Part A. Additionally, if you’re not a U.S. citizen or legal permanent resident, you won’t be eligible for Medicare at age 65.

Another common reason for ineligibility is failing to enroll during your Initial Enrollment Period (IEP), which begins three months before you turn 65 and lasts seven months. Missing this period can result in late enrollment penalties, which can increase your premiums for Medicare Part B and Part D. If you don’t enroll when first eligible, you may experience a gap in coverage, meaning you may not be covered for essential services until you can enroll in the next available period.

Special Enrollment Periods (SEPs)

If you delay enrolling in Medicare due to employer coverage, you may qualify for a Special Enrollment Period (SEP).

• Eligibility: If you or your spouse have had employer-sponsored insurance and delayed Medicare enrollment, you can sign up during the SEP, which applies to those who delayed enrollment because they were covered by a group health plan. Learn more about the Special Enrollment Period.

• Duration: The SEP lasts for 8 months after your employment or group health coverage ends, whichever comes first. If you miss the SEP, you may have to wait for the next General Enrollment Period (GEP), which could result in coverage delays and penalties. Learn what to do if you miss Medicare enrollment.

Alternatives for Those Not Eligible

If you’re not eligible for Medicare, you can explore other health coverage options. You may qualify for plans through the Health Insurance Marketplace, which offers affordable coverage depending on your income and needs. Some states also provide assistance programs for residents who don’t qualify for Medicare. These programs can help provide low-cost health insurance or assist with finding coverage that fits your financial situation.

Next Steps

To confirm your eligibility, check your work history and residency status. If you’re eligible, be sure to enroll during your Initial Enrollment Period to avoid penalties and delays. If you’re not eligible, consider alternative coverage through the Marketplace or state programs. For help navigating your options, contact the Social Security Administration or a licensed Medicare agent.

Need Help Navigating Medicare Eligibility? Contact us today at 1-855-870-0077

Understanding your Medicare eligibility is key to ensuring that you have the right healthcare coverage when you turn 65. If you have questions about eligibility, enrollment, or need assistance in making the right choice for your healthcare needs, contact Unified Health today. We’re here to help you through the process and find the best options for your coverage.

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