Medicare and Open Enrollment – Do You Qualify?

Medicare is a federal health insurance program that covers people who are 65 and older, in addition to certain younger people with disabilities or with end-stage renal disease.

If you’re 65 or older, you may qualify for full Medicare benefits if: you’re a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years; you are receiving Social Security or railroad retirement benefits or have worked long enough to be eligible for those benefits but are not yet collecting them; you or your spouse is a government employee or retiree who has not paid into Social Security but has paid Medicare payroll taxes while working.

Medicare coverage is divided into four parts – A, B, C, and D. Parts A and B cover health care that includes hospital stays, physician bills, and outpatient services. Part C consists of a variety of private health plans, known as Medicare Advantage plans (generally HMOs and PPOs) that cover Parts A and B, and often Part D services in one package. Part D helps pay the cost of prescription drugs.

Medicaid May Be Available If You Don’t Qualify for Medicare

If you don’t qualify for Medicare, Medicaid may still be a viable option. Medicaid is a federal and state program available year-round and provides health coverage in all states for certain low-income people, families and children, pregnant women, the elderly, and people with disabilities.

The income level required to qualify for Medicaid varies depending on the state in which you live. Some states have expanded their Medicaid programs to cover all people with household incomes below a certain level, while others haven’t. If your state has not expanded Medicaid, you may still qualify based on your state’s existing rules. These vary from state to state and may take into account income, household size, family status (like pregnancy or caring for young children), disability, age, and other factors.

Open Enrollment – What is it and When Does it Start?

Similar to other health plans, there is an annual enrollment period for Medicare plans. During this time, known as “open enrollment,” current Medicare users have the opportunity to assess their coverage and change their plans as needed. Open enrollment cannot be used to enroll in Part A or Part B for the first time.

The annual open enrollment period for Medicare runs from October 15 through December 7. During open enrollment, current Medicare users are able to re-evaluate the Medicare Advantage/Part C or Part D in their coverage and compare them against other plans on the market. If re-evaluating finds there may be a better fit, they can then exercise their option to switch, drop or add to those parts of their Medicare plans.

Outside of the annual open enrollment period, Medicare users can make changes to, or sign up for, coverage or benefits only if they have experienced a specific qualifying event.

What are the Qualifying Events?

There are four basic types of qualifying life events that allow Medicare users to sign up for or change their health insurance coverage outside of the open enrollment period

• Loss of health coverage: The loss of a job or qualification for Medicare or Medicaid services, or aging out of your parents’ plan
• Changes in household: A birth, adoption, death, marriage or divorce in the family
• Changes in residence: Moving to a new region outside of your current insurer’s coverage
• Other qualifying events: Becoming a U.S. citizen, leaving incarceration, joining or leaving the AmeriCorps