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Medicare part A - Complete eligibility guidelines
Part A – Hospital Insurance
Some of the services that Part A, hospital insurance, helps pay for include
: Inpatient hospital care
; Inpatient care in a Skilled Nursing Facility following a covered hospital stay
; Some home health care; and Hospice care.
To be eligible for premium-free Part A, an individual must first be insured based on his or her own earnings or the earnings of a spouse, parent, or child. To be insured, a worker must have a specified number of quarters of coverage (QC). The exact number of required quarters is dependent on whether he or she is filing for Part A on the basis of age, disability, or ESRD. QCs are earned through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during the individual’s working years. Most individuals pay the full FICA tax so that the QCs they earn can be used to insure them for both monthly Social Security benefits and Part A. Certain Federal, State, and local government employees pay only the Part A portion of the FICA tax. The QCs these employees earn can be used only to insure them for Part A and may not be used to insure them for monthly Social Security benefits.
Individuals Age 65 Years or Older
To be eligible for premium-free Part A on the basis of age, an individual must be age 65 years or older and either eligible for monthly Social Security or Railroad Retirement cash benefits or would be eligible for such benefits if the worker's QCs from government employment were regular Social Security QCs. Part A for the aged individual begins with the month age 65 years is attained, provided he or she files an application for Part A or for cash benefits and Part A within six months of the month in which age 65 years is attained. If the application is filed later than that, Part A entitlement can be retroactive for only six months. For Medicare purposes, individuals attain age 65 years the day before their actual 65th birthday and Part A is effective on the first day of the month upon attainment of age 65 years. For an individual whose 65th birthday is on the first day of the month, Part A is effective on the first day of the month preceding their birth month. For example, if an individual’s birthday is on December 1, Part A is effective on November 1 since for Medicare purposes, he or she attained age 65
years on November 30. Individuals who continue to work beyond age 65 years may elect to file an application for Part A only. Part A entitlement generally does not end until the death of the individual.
A second group of aged individuals who are eligible for Part A are those individuals age 65 years or older who are not insured but elect to purchase Part A coverage by filing an application at a Social Security Administration (SSA) office. Because a monthly premium is required, this coverage is called premium Part A. The individual must be a U.S. resident and either a citizen or an alien lawfully admitted for permanent residence who has resided in the U.S. continuously for the five-year period immediately preceding the month the application is filed. Individuals who want premium Part A can only file for coverage during a prescribed enrollment period and must also enroll or already be enrolled in
Individuals Under Age 65 Years with Certain Disabilities
A disabled individual who is entitled to Social Security or Railroad Retirement benefits on the basis of disability is automatically entitled to Part A after 24 months of entitlement to such benefits. In addition, disabled persons who are not insured for monthly Social Security disability benefits but would be insured for such benefits if their QCs from government employment were Social Security QCs are deemed to be entitled to disability benefits and automatically entitled to Part A after being disabled for 29 months. Part A entitlement on the basis of disability is available to the worker and to the widow, widower, or child of a deceased, disabled, or retired worker if any of them become disabled within the meaning of the Act or the Railroad Retirement Act. Beginning July 1, 2001, individuals whose disability is Amyotrophic Lateral Sclerosis are entitled to Medicare Part A the first month they are entitled to Social Security disability cash benefits. If an individual recovers from a disability, Part A entitlement ends at the end of the month after the month he or she is notified of the disability termination. However, in the case of individuals who return to work but continue to suffer from a disabling impairment, Part A entitlement will continue for at least 93 months after the individual returns to work
Individuals with End-Stage Renal Disease
Individuals are eligible for Part A if they receive regular dialysis treatments or a kidney transplant, have filed an application, and meet one of the following conditions
: Have worked the required amount of time under Social Security, the RRB, or as a government employee
; Are receiving or are eligible for Social Security or Railroad Retirement benefits
; or Are the spouse or dependent child of an individual who has worked the required amount of time under Social Security, the RRB, or as a government employee or who is receiving Social Security or Railroad Retirement benefits.
Part A coverage begins
: The third month after the month in which a regular course of dialysis begins
; The first month self-dialysis training begins (if training begins during the first three months of regular dialysis)
; The month of kidney transplant; or Two months prior to the month of transplant if the individual was hospitalized during those earlier months in preparation for the transplant.
Part A entitlement ends 12 months after the regular course of dialysis ends or 36 months after transplant
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