Are you trying to understand Medicare Part A and Part B, but feeling lost? At WHAT.EDU.VN, we break down the eligibility and enrollment requirements for these crucial parts of Medicare, making it easy for everyone to understand. We aim to provide clarity and guidance, ensuring you have the information you need to navigate Medicare confidently, so you can find information about Medicare eligibility, Medicare enrollment, and Medicare benefits.
1. What Is Medicare Part A (Hospital Insurance)?
Medicare Part A, also known as Hospital Insurance, helps cover inpatient care in hospitals, skilled nursing facilities, hospice care, and some home health care. Most people receive Part A without paying a monthly premium, but some may need to pay for this coverage.
1.1 Who Is Eligible for Premium-Free Medicare Part A?
To qualify for premium-free Part A, you must be eligible to receive Medicare based on your own earnings or those of a spouse, parent, or child. This typically involves having a certain number of quarters of coverage (QCs) through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during your working years. You must also file an application for Social Security or Railroad Retirement Board (RRB) benefits.
Alt text: An individual completes a Medicare enrollment application.
1.2 Premium-Free Medicare Part A Based on Age
To be eligible for premium-free Part A based on age, you must meet the following criteria:
- Be age 65 or older.
- Be eligible for monthly Social Security or Railroad Retirement Board (RRB) cash benefits.
If you are already receiving monthly Social Security or RRB benefits at least four months before turning 65, you will automatically get Part A at age 65 without needing to file a separate application. If you are not receiving these benefits, you must apply for Medicare by contacting the Social Security Administration.
Important Note: Part A coverage generally starts the month you turn 65, provided you apply within six months of your birthday month. If you apply later, coverage may be retroactive for six months. If your 65th birthday falls on the first day of the month, Part A coverage begins on the first day of the preceding month.
1.3 Medicare Part A for People Who Must Pay a Premium
If you do not qualify for premium-free Part A, you must pay a monthly premium to receive this coverage. To enroll, you need to:
- File an application to enroll by contacting the Social Security Administration.
- Enroll during a valid enrollment period.
- Also enroll in or already have Part B.
To maintain premium Part A, you must continue to pay all monthly premiums and stay enrolled in Part B. Coverage begins the month following the month of enrollment.
1.4 Medicare Based on Disability
If you are entitled to monthly Social Security or Railroad Retirement Board (RRB) benefits due to disability, you are automatically entitled to Part A after receiving disability benefits for 24 months. Disabled federal, state, and local government employees who are not eligible for monthly Social Security or RRB benefits may get deemed entitlement to disability benefits and automatically entitled to Part A after being disabled for 29 months.
1.4.1 Special Rule for People with Amyotrophic Lateral Sclerosis (ALS)
Individuals with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease, are entitled to Part A from the first month they are entitled to Social Security or RRB disability cash benefits. There is no waiting period.
1.4.2 Special Rule for People Claiming Child Disability Benefits
Social Security Administration (SSA) rules do not allow child disability benefits to begin before age 18. Therefore, Part A entitlement based on child disability benefit entitlement can never begin before the month the person attains age 20 (or age 18 if the individual’s disability is ALS).
1.5 Medicare Based on End-Stage Renal Disease (ESRD)
Individuals are eligible for premium-free Part A if they receive regular dialysis treatments or have had a kidney transplant, have filed an application for Medicare, and meet one of the following conditions:
- Have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.
- Are getting or are eligible for Social Security or RRB benefits.
- Are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee, or are getting Social Security or RRB benefits.
Part A coverage begins:
- The 3rd month after the month in which a regular course of dialysis begins.
- The first month a regular course of dialysis begins if the individual engages in self-dialysis training.
- The month of kidney transplant.
- Two months before the month of transplant if the individual was hospitalized during those months in preparation for the transplant.
2. What Is Medicare Part B (Medical Insurance)?
Medicare Part B, also known as Medical Insurance, covers a wide range of medical services and supplies needed to diagnose and treat medical conditions. This includes doctor’s visits, outpatient care, preventive services, and durable medical equipment. Part B is a voluntary program that requires the payment of a monthly premium.
Alt text: Doctor explaining medical information to an elderly patient.
2.1 Automatic Enrollment in Part B
Individuals already receiving Social Security or RRB benefits at least four months before being eligible for Medicare and residing in the United States (except residents of Puerto Rico) are automatically enrolled in both premium-free Part A and Part B. People who are automatically enrolled have the choice of whether they want to keep or refuse Part B coverage. People living in Puerto Rico who are eligible for automatic enrollment are only enrolled in premium-free Part A and must actively enroll in Part B to get this coverage.
2.2 Eligibility Rules for Part B
Eligibility rules for Part B depend on whether a person is eligible for premium-free Part A or whether the individual has to pay a premium for Part A coverage.
Individuals who are eligible for premium-free Part A are also eligible for enroll in Part B once they are entitled to Part A.
Individuals who must pay a premium for Part A must meet the following requirements to enroll in Part B:
- Be age 65 or older.
- Be a U.S. resident.
- Be either a U.S. citizen, OR
- Be an alien who has been lawfully admitted for permanent residence and has been residing in the United States for 5 continuous years prior to the month of filing an application for Medicare.
2.3 Enrollment Periods for Part A and Part B
Individuals eligible for premium-free Part A who are not automatically enrolled can enroll in Part A at any time after they are first eligible for the coverage.
Individuals who want premium Part A, Part B, or both may only enroll during certain enrollment periods outlined in the law. These periods include the Initial Enrollment Period (IEP), General Enrollment Period (GEP), and Special Enrollment Period (SEP).
2.4 Initial Enrollment Period (IEP)
The IEP is a 7-month period that starts three months before the month you turn 65, includes your birthday month, and ends three months after you turn 65. For those under 65 who become entitled to Medicare based on disability, the IEP begins three months before the 25th month of disability benefit entitlement, includes the 25th month, and ends three months after. The IEP for people with ESRD and ALS varies based on their situation.
Coverage will begin the month after you enroll during your IEP. Disabled individuals are automatically enrolled in Medicare Part A and Part B after receiving disability benefits from Social Security for 24 months.
Note: In most cases, if you do not enroll in Part B or premium Part A when first eligible, you may have to pay a late enrollment penalty. The Part B penalty is assessed for as long as you have Part B.
2.5 General Enrollment Period (GEP)
The GEP is a 3-month period that takes place from January 1 through March 31 of each year. Part B and premium Part A coverage will begin the month after a person enrolls during the GEP.
2.6 Special Enrollment Period (SEP)
There are specific situations where you can sign up for Part B (and Premium Part A) during a Special Enrollment Period without paying a late enrollment penalty. A Special Enrollment Period is only available for a limited time. If you do not sign up during your Special Enrollment Period, you will have to wait for the next General Enrollment Period, and you might have to pay a monthly late enrollment penalty.
Coverage will begin the month after a person enrolls during their SEP.
2.6.1 SEP for the Working Aged and Working Disabled
If you did not enroll in Part B or premium Part A when first eligible because you were covered under a group health plan based on your own or a spouse’s current employment (or the current employment of a family member, if disabled), you may enroll during this SEP.
You can enroll at any time while covered under the group health plan based on current employment or during the 8-month period that begins the month the employment ends or the group health plan coverage ends, whichever comes first.
Note: Individuals with ESRD are not eligible to enroll using this SEP.
2.6.2 SEP for International Volunteers
Individuals who do not enroll in Part B or premium Part A when first eligible because they were performing volunteer service outside of the United States for at least 12 months on behalf of a tax-exempt organization and had health insurance that provided coverage for the duration of the volunteer service may enroll using this SEP.
The SEP is a 6-month period that begins the earlier of the first day of the month following the month for which the:
- individual was no longer serving as a volunteer outside of the United States;
- organization no longer has tax-exempt status; or
- individual no longer has health insurance that provides coverage outside of the United States.
2.6.3 SEP for Certain TRICARE Beneficiaries
Individuals who enroll in Part A based on disability or ESRD but do not enroll in Part B because they were eligible for TRICARE standard or TRICARE prime may enroll using this SEP.
Eligible individuals are those who are:
- Under age 65, and
- Eligible for TRICARE Standard at the time of Part A entitlement and:
- A military retiree or military retiree family member, or
- On active duty or a family member of an active duty service member with Medicare based on ESRD.
Eligible individuals may enroll:
- If notified of Medicare entitlement during the IEP: The month after the end of the IEP, or
- If notified of Medicare entitlement after the IEP: The month of notification of Medicare entitlement.
Coverage begins:
- If notified of Medicare entitlement during the IEP:
- The month of enrollment, or
- The first month after the end of the IEP
- If notified of Medicare entitlement after the IEP:
- The month of enrollment, or
- The month Part B terminated based on the refusal.
If entitlement is based on ESRD, coverage begins:
- The month of Part A entitlement, or
- The month of enrollment, or
- The month after the end of the IEP.
2.6.4 Special Enrollment Period for Exceptional Conditions
Effective January 1, 2023, the following SEPs for exceptional conditions are available for premium Part A and Part B, respectively:
2.6.4.1 SEP for Individuals Impacted by an Emergency or Disaster
Individuals who do not enroll in Part B or premium Part A when first eligible due to having an emergency or disaster declared by a federal, state, or local government entity in their area may enroll using this SEP.
If a person is eligible because they were impacted by an emergency or disaster, they can sign up as early as the month of the emergency or disaster, or up to six months after the emergency or disaster has ended. They may also be able to use this SEP if the disaster or emergency takes place where their authorized representative, legal guardian, or person who makes health care decisions on their behalf resides.
The SEP begins the date an emergency or disaster is declared, or the start date identified in the emergency declaration, whichever is earlier. The SEP ends six months after the later of:
- The end date identified in the disaster or emergency declaration, or
- The end date of any extensions or the date when the declaration has been determined to have ended or has been revoked, or
- The date of the declaration, if such date is after the end of the disaster.
Medicare benefits will be effective the first day of the month following enrollment.
2.6.4.2 SEP for Health Plan or Employer Misrepresentation
Individuals who do not enroll in Part B or premium Part A when first eligible due to misrepresentation or reliance on incorrect information provided by their employer or group health plan (GHP), agents or brokers of health plans, or any person authorized to act on behalf of such entity may enroll using this SEP.
An eligible person must demonstrate (by documentation or written attestation) both of the following:
- They did not enroll in part B or premium Part A during an enrollment period in which they were eligible based on information received from an employer or GHP, agents or brokers of health plans, or any person authorized to act on such organization’s behalf.
- An employer, GHP, agent or broker of a health plan, or their representative materially misrepresented information or provided incorrect information relating to enrollment in part B or premium Part A.
This SEP begins the day an individual notifies the Social Security Administration and ends six months later.
Medicare benefits will be effective the first day of the month following enrollment.
2.6.4.3 SEP for Formerly Incarcerated Individuals
Individuals who do not enroll in Part B or premium Part A when first eligible because they were incarcerated may enroll using this SEP.
If a person is eligible because they are not enrolled in Medicare due to being incarcerated, they can sign up anytime within the first 12 months after their release from incarceration.
- This SEP begins the day an individual is released from the custody of penal authorities and ends the last day of the 12th month after that release.
- Individuals have the option to select a retroactive effective date (not to begin prior to their release date and not to exceed 6 months). If individuals choose this retroactive option, they will be responsible for paying Medicare premiums back to the date of coverage.
- Medicare benefits will be effective the first day of the month following enrollment or up to 6 months retroactive, if the beneficiary chooses retroactive coverage.
For additional information please visit https://www.cms.gov/training-education/look-up-topics/special-populations/incarcerated-medicare-beneficiaries.
2.6.4.4 SEP to Coordinate with Termination of Medicaid Coverage
Individuals whose Medicaid eligibility terminated may enroll using this SEP.
A person may be eligible if they have lost Medicaid entirely, missed a Medicare enrollment period, and their Medicaid coverage was terminated on or after January 1, 2023.
- The SEP begins when an individual is notified of an upcoming termination of Medicaid eligibility and ends six months after the Medicaid termination.
- Medicare benefits start the month after Medicare enrollment unless the individual elects a start date back to the first day of the month the individual lost Medicaid and agrees to pay all prior premiums.
Note: Individuals who still are eligible for Medicaid, including a Medicare Savings Program, and have not received notice of an upcoming Medicaid termination are not eligible for this SEP.
2.6.4.5 SEP for Other Exceptional Conditions
Individuals who do not enroll in Part B or premium Part A when first eligible because conditions beyond their control caused them to miss an enrollment period may enroll using this SEP. This SEP is available for individuals whose unique conditions do not qualify for other SEPs. An eligible person must demonstrate (by documentation or written attestation) that conditions outside of their control that occurred on or after January 1, 2023, caused them to miss an enrollment period.
An individual’s request for this SEP will only be granted in conditions that are truly exceptional in nature and will not be used to grant individual’s enrollment due to forgetfulness, lack of knowledge, or failure to make premium payments.
SSA will determine when this SEP begins on a case-by-case basis, but the SEP will end no less than 6 months after it begins. Medicare benefits will be effective the first day of the month following enrollment.
3. Part A and B Enrollment Forms
When enrolling in Medicare Parts A and B, you may need to complete specific forms depending on your situation. Below is a list of the common forms and their uses:
| Form | Description |
|---|---|
| CMS-18-F-5 | For individuals who do not have Part A and wish to enroll. This form can also be used to enroll in Part B simultaneously. If applying for the SEP for the Working Aged and Working Disabled, also complete the form CMS-L564. |
| CMS-40B | For individuals who have Part A but not Part B. This form is used to enroll in Part B. If applying for the SEP for the Working Aged and Working Disabled, also complete the form CMS-L564. |
| CMS-4040 | For individuals who are NOT entitled to social security or railroad retirement board benefits and wish to enroll in Part B. |
| CMS-43 | For individuals who have End-Stage Renal Disease (ESRD). This form is used to enroll in Part A and Part B. |
| CMS-10797 | For individuals who qualify for a special enrollment period due to exceptional conditions. This form is used to enroll in premium Part A and Part B. |
| CMS-L564 | For individuals who are applying for the SEP for the Working Aged and Working Disabled. This form should be completed along with the applicable Part A or Part B enrollment form. |
| CMS-1763 | For individuals who want to disenroll from Premium Part A and Part B coverage. |
Make sure to use the appropriate form based on your specific circumstances to ensure a smooth enrollment process. These forms can typically be found on the Social Security Administration’s website.
4. Termination of Enrollment
Understanding the rules for terminating your Medicare Part A and Part B coverage is essential. Here’s what you need to know:
4.1 Termination of Premium-Free Part A
Individuals entitled to premium-free Part A cannot voluntarily terminate their Part A coverage; this is not permitted by law. Generally, premium-free Part A ends due to:
- Loss of entitlement to Social Security or Railroad Retirement Board benefits.
- Death.
Special rules apply for when premium-free Part A ends for people with ESRD.
4.2 Termination of Premium Part A and Part B
Premium Part A and Part B coverage can be voluntarily terminated because premium payments are required. Premium Part A and Part B coverage ends due to:
- Voluntary disenrollment request (coverage ends prospectively).
- Failure to pay premiums.
- For individuals under age 65 (disabled and ESRD), loss of Part A entitlement (Part B terminates at the same time as Part A).
- Death.
For individuals who want to disenroll from Premium Part A and Part B coverage, use form CMS-1763.
5. Medicare Premiums
Premium Part A and Part B coverage require payment of monthly premiums.
5.1 IRMAA (Income-Related Monthly Adjustment Amount)
Individuals and married couples with an income over a certain limit must pay a higher premium for Part B and an extra amount for Part D coverage in addition to their Part D plan premium. This additional amount is called the income-related monthly adjustment amount. Less than 5 percent of people with Medicare are affected, so most people will not pay a higher premium.
5.2 Late Enrollment Penalty (LEP) for Premium Part A
If an individual did not enroll in premium Part A when first eligible, they may have to pay a higher monthly premium if they decide to enroll later. The monthly premium for Part A may increase up to 10%. The individual will have to pay the higher premium for twice the number of years the individual could have had Part A but did not sign up.
For individuals enrolling using the SEP for the Working Aged and Working Disabled, the premium Part A LEP is calculated by adding the months that have elapsed between the close of the individual’s IEP and the end of the month in which the individual enrolls. For enrollments after your IEP has ended, months where you had group health plan coverage are excluded from the LEP calculation.
For individuals enrolling using an Exceptional Conditions SEP or the International Volunteers SEP, no LEP will be applied.
5.3 Late Enrollment Penalty (LEP) for Part B
If an individual did not sign up for Part B when first eligible, the individual may have to pay a late enrollment penalty for as long as the individual has Medicare. The individual’s monthly premium for Part B may go up 10% for each full 12-month period that the individual could have had Part B but did not sign up for it.
For individuals enrolling using the SEP for the Working Aged and Working Disabled, the Part B LEP is calculated by adding the months that have elapsed between the close of the individual’s IEP and the end of the month in which the individual enrolls. For enrollments after your IEP has ended, months where you had group health plan coverage are excluded from the LEP calculation.
For individuals enrolling using an Exceptional Conditions SEP, the International Volunteers SEP, or the SEP for Certain TRICARE Beneficiaries, no LEP will be applied.
6. Frequently Asked Questions (FAQ) About Medicare Part A and Part B
| Question | Answer |
|---|---|
| What does Medicare Part A cover? | Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, skilled nursing facilities, hospice care, and some home health care. |
| What does Medicare Part B cover? | Medicare Part B (Medical Insurance) covers a wide range of medical services and supplies needed to diagnose and treat medical conditions, including doctor’s visits, outpatient care, preventive services, and durable medical equipment. |
| How do I qualify for premium-free Part A? | To qualify for premium-free Part A, you must be eligible to receive Medicare based on your own earnings or those of a spouse, parent, or child, typically involving a certain number of quarters of coverage (QCs) through payment of payroll taxes under the Federal Insurance Contributions Act (FICA). |
| What if I have to pay a premium for Part A? | If you do not qualify for premium-free Part A, you must pay a monthly premium to receive this coverage. You need to file an application with the Social Security Administration and enroll during a valid enrollment period. |
| When am I automatically enrolled in Part A and Part B? | You are automatically enrolled if you are already receiving Social Security or Railroad Retirement Board (RRB) benefits at least four months before being eligible for Medicare and reside in the United States (except residents of Puerto Rico). |
| What are the different enrollment periods for Medicare? | The enrollment periods include the Initial Enrollment Period (IEP), General Enrollment Period (GEP), and Special Enrollment Period (SEP), each with its own eligibility criteria and timelines. |
| What is the Initial Enrollment Period (IEP)? | The IEP is a 7-month period that starts three months before the month you turn 65, includes your birthday month, and ends three months after you turn 65. |
| What is the General Enrollment Period (GEP)? | The GEP is a 3-month period that takes place from January 1 through March 31 of each year. |
| What is a Special Enrollment Period (SEP)? | A Special Enrollment Period (SEP) is available in specific situations, such as being covered under a group health plan based on current employment, performing volunteer service outside of the United States, or facing exceptional conditions like an emergency or disaster. |
| How can I avoid late enrollment penalties for Part A and Part B? | To avoid penalties, enroll in Part B or premium Part A when first eligible. If you are eligible for a Special Enrollment Period (SEP), make sure to enroll during that period to avoid or reduce penalties. |
7. Need More Answers? Ask on WHAT.EDU.VN!
Navigating the complexities of Medicare Part A and Part B can be challenging. Don’t let confusion hold you back. If you have more questions or need clarification on any aspect of Medicare, we’re here to help!
At WHAT.EDU.VN, we provide a platform where you can ask any question and receive quick, accurate answers from knowledgeable experts and community members. Whether it’s about eligibility requirements, enrollment periods, coverage details, or anything else related to Medicare, we’ve got you covered.
Why choose WHAT.EDU.VN?
- It’s Free: Ask as many questions as you need without any cost.
- It’s Fast: Get answers quickly from a community of experts.
- It’s Easy: Our platform is user-friendly and straightforward.
- It’s Reliable: Benefit from a wealth of information and community support.
Don’t stay in the dark about Medicare! Visit WHAT.EDU.VN today and get the answers you need to make informed decisions about your health coverage. Our dedicated team is ready to assist you every step of the way.
Contact Us:
- Address: 888 Question City Plaza, Seattle, WA 98101, United States
- WhatsApp: +1 (206) 555-7890
- Website: WHAT.EDU.VN
Take control of your Medicare journey and get the clarity you deserve. Ask your questions now on WHAT.EDU.VN and experience the ease of finding reliable information at your fingertips.
Understanding Medicare Parts A and B doesn’t have to be overwhelming. With the right resources and support, you can navigate the system with confidence. At what.edu.vn, we’re committed to providing you with the knowledge and assistance you need to make informed decisions about your healthcare. Take the first step towards a better understanding of Medicare and ask your questions today! You may be interested in Medicare coverage, Medicare costs, and Medicare plans.
