The information in this booklet describes the Medicare Program at the time this booklet was printed. Changes may occur after printing. Visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users should call 1-877-486-2048.

“Enrolling in Medicare Part A & Part B” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

You have the right to get the information in this booklet in an alternate format. Visit Medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html, or call 1-800-MEDICARE for more information.

Contents

Section 1—The Medicare Program

What’s Medicare?

Medicare has different parts

Medicare Part A (Hospital Insurance)

Medicare Part B (Medical Insurance)

Can I get Part B if I don’t have Part A?

How do I know if I have Part A or Part B?

Medicare Part C (also known as Medicare Advantage)

Medicare Part D (prescription drug coverage)

For more information

Section 2—Part A & Part B Enrollment

When can I sign up?

Getting Part A and Part B automatically

Signing up for Part A and Part B

Turning 65 and you or your spouse is still working

Medicare and End-Stage Renal Disease (ESRD)

Retiree coverage

Can I still get Medicare at 65?

Veterans’ benefits

I have Health Insurance Marketplace coverage

I have coverage through a health savings account (HSA)

Living outside the U. S.

Section 3—For More Information

Where to get more information

Medicare publications

Section 4—Definitions

Section 1—The Medicare Program

What’s Medicare?

Medicare is health insurance for:

People 65 or older

Under 65 with certain disabilities

People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)

Medicare has different parts

Medicare Part A (Hospital Insurance)

Part A helps cover your inpatient care in hospitals. Part A also includes coverage in critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also covers hospice care and home health care. You must meet certain conditions to get these benefits.

Can I get Part A?

Generally, you’re eligible for Part A if you:

Are 65 or older and you meet the citizenship and residency requirements.

Get disability benefits from Social Security or the Railroad Retirement Board for at least 25 months.

Get disability benefits because you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease).

Have ESRD and meet certain requirements.

How much does Part A coverage cost?

You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes for at least 10 years while working. If you aren’t eligible for free Part A, you may be able to buy Part A if you’re:

65 or older and you have (or are enrolling in) Part B and meet the citizenship and residency requirements.

Under 65, disabled, and your free Part A coverage ended because you returned to work. (If you’re under 65 and disabled, you can continue to get free Part A for up to 8 ½ years after you return to work.)

In 2016, people who have to buy Part A pay premiums up to $411 each month. In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both.

What’s a Part A late enrollment penalty?

If you get Part A for free, you won’t have to pay a Part A late enrollment penalty if you decide to enroll after you first become eligible. If you aren’t eligible for free Part A, and you don’t buy it when you’re first eligible, your monthly premium may go up because you may have to pay a late enrollment penalty.

The penalty is 10% for every 12 months you didn’t have the coverage. You’ll have to pay the late enrollment penalty for twice the number of years you could have had Part A, but didn’t sign up. For example, if you were eligible for Part A for 2 years but didn’t sign up, you’ll have to pay a 20% higher premium for 4 years. Usually, you don’t have to pay a penalty if you meet certain conditions that allow you to sign up for Part A during a Special Enrollment Period. See here for more information about Special Enrollment Periods.

Medicare Part B (Medical Insurance)

Part B helps cover medically necessary services like doctors’ services, outpatient care, and other medical services that Part A doesn’t cover. Part B also covers many preventive services. Part B coverage is your choice. However, you need to have Part B if you want to buy Part A.

How much does Part B coverage cost?

You pay the Part B premium each month. Most people will pay the standard premium amount, which is $121.80 in 2016 if you sign up for Part B when you’re first eligible. This amount can change every year. You can find up-to-date premium amounts on Medicare.gov.

Important: In most cases, if you don’t sign up for Part B when you’re first eligible, you’ll have to pay a late enrollment penalty for as long as you have Part B. Also, you may have to wait until the General Enrollment Period (from January 1 – March 31) to enroll in Part B and coverage will start July 1 of that year.

Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more.

If your yearly income in 2014 was

You pay (in 2016)

File individual tax return

File joint tax return

File married & separate tax return

$85,000 or less

$170,000 or less

$85,000 or less

$121.80

above $85,000 up to $107,000

above $170,000 up to $214,000

N/A

$170.50

above $107,000 up to $160,000

above $214,000 up to $320,000

N/A

$243.60

above $160,000 up to $214,000

above $320,000 up to $428,000

above $85,000 up to $129,000

$316.70

above $214,000

above $428,000

above $129,000

$389.80

If you have questions about your Part B premium, call Social Security at1-800-772-1213. TTY users should call 1-800-325-0778.

What’s a Part B late enrollment penalty?

In most cases, if you don’t sign up for Part B when you’re first eligible, you’ll have to pay a late enrollment penalty for as long as you have Part B. The late enrollment penalty takes the standard premium amount and increases it by 10% for each full 12-month period that you could have had Part B, but didn’t. For example, if you were first eligible for Part B in July 2013, but didn’t enroll until January 2016, you’d have a 20% late enrollment penalty. The standard premium amount would be increased by 20% for as long as you have Part B.

How can I pay my Part B premium?

If you get Social Security, Railroad Retirement Board (RRB), or Office of Personnel Management (OPM) benefits, your Part B premium will be automatically deducted from your benefit payment. If you don’t get these benefit payments, you’ll get a bill. If you choose to buy Part A, you’ll always get a bill for your premium. There are 4 ways to pay these bills:

Mail your premium payments to:

Medicare Premium Collection Center P.O. Box 790355 St. Louis, MO 63179-0355

If you get a bill from the RRB, mail your premium payments to:

RRB Medicare Premium Payments P.O. Box 979024 St. Louis, MO 63197-9000

Pay by credit card. To do this, complete the bottom portion of the payment coupon on your Medicare bill and mail it to the address above.

Sign up for Medicare Easy Pay, a free service that automatically deducts your premium payments from your savings or checking account each month. Visit Medicare.gov to learn more and to find out how to sign up.

Make an online bill payment. Ask your bank if it allows customers to pay bills online. Not all banks offer this service and some may charge a fee. You’ll need to give the bank this information:

Account number: your Medicare number without dashes (you’ll find this number on your red, white, and blue Medicare card.)

Biller name: CMS Medicare Insurance

Remittance address:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

If you have questions about your premiums or need to change your address on your bill, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. If your bills are from the RRB, call 1-877-772-5772. TTY users should call 1-312-751-4701.

Can I get Part B if I don’t have Part A?

If you aren’t eligible for free Part A, you can buy Part B without having to buy Part A, if you’re:

65 or older

A resident of the U.S., and one of these:

—a U.S. citizen

—an immigrant lawfully admitted for permanent residence who has lived in the U.S. without a break for the 5-year period immediately before the month you file for enrollment in Part B

How do I know if I have Part A or Part B?

If you’re not sure if you have Part A or Part B, look on your red, white, and blue Medicare card. If you have Part A, “Hospital (Part A)” is printed on the lower left corner of your card. If you have Part B, “Medical (Part B)” is printed on the lower left corner of your card.

You can also call or visit your local Social Security office, or call Social Security at 1-800-772-1213 for more information about Part A and Part B eligibility. TTY users should call 1-800-325-0778. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office.

Medicare Part C (also known as Medicare Advantage)

Medicare Advantage Plans (like HMOs or PPOs) provide your Part A and Part B coverage and many times offer additional benefits. Private insurance companies approved by Medicare run these plans. Generally, you must see doctors in the plan. Most Medicare Advantage Plans cover prescription drugs (Medicare Part D). You choose the Medicare Advantage Plan (with or without prescription drug coverage) and pay a monthly premium. Costs vary by plan.

Medicare Part D (prescription drug coverage)

Medicare prescription drug coverage is available to everyone with Medicare. Private companies provide this coverage. You choose the Medicare drug plan and pay a monthly premium. Each plan can vary in cost and specific drugs covered. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty. You may have to pay this penalty for as long as you have Medicare drug coverage.

For more information, look at your “Medicare & You” handbook. You can also view the handbook at Medicare.gov/publications.

For more information

Visit Medicare.gov

Call 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048.

Visit socialsecurity.gov

Call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Section 2—Part A & Part B Enrollment

When can I sign up?

There are 3 times you can sign up for Medicare:

Initial Enrollment Period—If you’re eligible for Medicare when you turn 65, you can sign up during your Initial Enrollment Period. This is a 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

You can sign up for free Medicare Part A (Hospital Insurance) (if you’re eligible) any time after your Initial Enrollment Period starts. Your Part A coverage will start 6 months back from the date you apply for Medicare (or Social Security/RRB benefits), but no earlier than the first month you were eligible for Medicare.

You can only sign up for Part A (if you have to buy it) and/or Medicare Part B (Medical Insurance) during the times listed below.

Important: In most cases, if you don’t sign up for Part B when you’re first eligible, you’ll have to pay a late enrollment penalty for as long as you have Part B and could have a gap in your health coverage.

3 months before

the month you turn 65

2 months before

the month you turn 65

1 month before

the month you turn 65

The month you turn 65

1 month after

you turn 65

2 months after

you turn 65

3 months after

you turn 65

Sign up early to avoid a delay in coverage. To get Part A (if you have to buy it) and/or Part B the month you turn 65, you must sign up during the first 3 months before the month you turn 65.

If you wait until the last 4 months of your Initial Enrollment Period to sign up for Part A (if you have to buy it) and/or Part B, your coverage will be delayed. See the chart here.

If you sign up for Part A (if you have to buy it) and/or Part B during the first 3 months of your Initial Enrollment Period, or sign up for free Part A at any time, your coverage start date will depend on your birthday:

If your birthday isn’t on the first day of the month, your coverage starts the first day of your birthday month. For example, Mr. Green’s 65th birthday is July 20, 2016. If he enrolls in April, May, or June, his coverage will start on July 1, 2016.

If your birthday is on the first day of the month, your coverage will start the first day of the prior month. For example, Mr. Kim’s 65th birthday is July 1, 2016. If he enrolls in March, April, or May, his coverage will start on June 1, 2016. To read the previous chart correctly, use the month before your birthday as “the month you turn 65.”

If you enroll in Part A (if you have to buy it) and/or Part B the month you turn 65 or during the last 3 months of your Initial Enrollment Period, your start date will be delayed:

If you enroll in this month of your initial enrollment period:

Your coverage starts:

The month you turn 65

1 month after enrollment

1 month after you turn 65

2 months after enrollment

2 months after you turn 65

3 months after enrollment

3 months after you turn 65

3 months after enrollment

Special Enrollment Period—Once your Initial Enrollment Period ends, you may have a chance to sign up for Part A (if you have to buy it) and Part B during a Special Enrollment Period, but only if you meet certain requirements. If you’re covered under a group health plan based on current employment, you have a Special Enrollment Period to sign up for Part A and/or Part B at any time as long as you or your spouse (or family member if you’re disabled) is working, and you’re covered by a group health plan through the employer or union based on that work.

If you enroll during a Special Enrollment Period, your Medicare coverage typically begins the month after Social Security gets your completed request. Usually you don’t pay a Part B late enrollment penalty if you sign up during a Special Enrollment Period.

Note: COBRA and retiree health plans aren’t considered coverage based on current employment. You’re not eligible for a Special Enrollment Period when that coverage ends. This Special Enrollment Period also doesn’t apply if you have one of these:

End-Stage Renal Disease (ESRD)

Veterans Affairs and Individual Health Insurance Marketplace coverage

General Enrollment Period—If you don’t sign up for Part A (if you have to buy it) and/or Part B when you’re first eligible, and you don’t qualify for a Special Enrollment Period, you may have to wait until the Medicare General Enrollment Period (from January – March 31) to enroll and coverage will start July 1 of that year. In most cases, you’ll have to pay a late enrollment penalty for as long as you have Part B if you sign up during the General Enrollment Period.

If you sign up during these months:

Your coverage will begin on:

January

July 1

February

March

Getting Part A and Part B automatically

What if I’m already getting benefits from Social Security or the Railroad Retirement Board (RRB)?

If you’re getting these benefits, in most cases, you’ll automatically get Part A and Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A and Part B will start the first day of the prior month. You’ll get the “Welcome to Medicare” package that welcomes you to the program. This package is mailed about 3 months before your 65th birthday. In this package, you’ll get your Medicare card.

Read the “Welcome to Medicare” booklet in this package carefully since you’ll have to decide these:

If you want to keep Part B

If you keep Part B, how you want to get your Medicare coverage

If you want or need Medicare prescription drug coverage

If you want to buy a Medicare Supplement Insurance (Medigap) policy

If you don’t want Part B, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will need to pay the Part B premium. Remember, if you choose not to get Part B when you’re first eligible, you could pay a late enrollment penalty for as long as you have it.

What if I live in Puerto Rico and get benefits from Social Security or the RRB?

You’ll automatically get Part A but not Part B. You must call Social Security at (1-800-772-1213) to sign up for Part B. TTY users should call 1-800-325-0778. If you don’t enroll in Part B when you’re first eligible, you may have to pay a late enrollment penalty for as long as you have Part B.

What if I’m under 65 and disabled?

If you’re eligible for Medicare because of a disability, you’ll automatically get Part A and Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You’ll get the “Welcome to Medicare” package that welcomes you to the program about 3 months before your 25th month of disability benefits. In this package, you’ll get your Medicare card.

Read the Welcome booklet in this package carefully since you’ll have to decide these:

If you want to keep Part B

If you keep Part B, how you want to get your Medicare coverage

If you want or need Medicare prescription drug coverage

If you want to buy Medicare Supplement Insurance (Medigap) policy.

If you don’t want Part B, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will need to pay the Part B premium. Remember, if you choose not to get Part B when you’re first eligible, you could pay a late enrollment penalty for as long as you have it.

What if I have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease)?

If you have ALS, you automatically get Part A and Part B the same month your disability benefits begin from Social Security or the Railroad Retirement Board (RRB).

I’m under 65, get disability benefits, and I’m covered under my spouse’s group health plan. Can I enroll in Part A only?

Yes. You automatically get Part A and Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. If you’re automatically enrolled, you’ll get your Medicare card in the mail 3 months before your 65th birthday or your 25th month of disability. If you don’t want Part B, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will need to pay the Part B premium.

I’m disabled and have Part A only. Can I get Part B when I turn 65?

Yes. If you’re still getting disability benefits when you turn 65, you won’t have to apply for Part B. Medicare will enroll you in Part B automatically. Your Medicare card will be mailed to you about 3 months before your 65th birthday.

If you’re not getting disability benefits and Medicare when you turn 65, you’ll need to call or visit your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

I’m under 65 and disabled. I’d like to go back to work. Can I keep my Medicare coverage?

Yes. You can keep your Medicare coverage for as long as you’re medically disabled. If you return to work, you won’t have to pay your Part A premium for the first 8 ½ years. After that, you’ll have to pay the Part A premium.

For more information about Medicare coverage for working people with disabilities, visit socialsecurity.gov. You can also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

I’m under 65 and have Part A due to a disability. I also have group health insurance through my current employer. When can I enroll in Part B?

If you’re disabled, have Part A, and have current employer or union group health coverage, you can sign up for Part B during a Special Enrollment Period. This period is available if you waited to enroll in Part B because you, your spouse, or a family member are still working and had group health coverage (or large group health plan coverage if you’re covered by a family member) through an employer or union based on this current employment.

If this applies to you, you can sign up for Part B:

Any time you’re still covered by an employer or union group health plan, through your, your spouse, or your family member’s current or active employment

During the 8-month period that begins the month after the employer or union group health plan coverage ends, or when the employment ends (whichever is first)

Note: If you’re still working and plan to keep your employer’s group health coverage, you should talk to your benefits administrator to help you decide when you should enroll in Part B.

When I first became eligible for Medicare because of a disability, I didn’t take Part B because I was covered under my spouse’s group health plan. My spouse is retiring, and I want to enroll in Part B. Will I have to pay more because I delayed my Part B enrollment?

It depends. Generally, if you didn’t sign up for Part B when you were first eligible because your spouse was working and you had group health plan coverage based on her work, you can sign up for Part B, without penalty, during a Special Enrollment Period.

My spouse is disabled and has been getting Supplemental Security Income (SSI). Can my spouse also get Medicare?

Getting SSI doesn’t make you eligible for Medicare. SSI provides a monthly cash benefit and health coverage under Medicaid. Your spouse may qualify for Medicare when he/she turns 65 or has received disability benefits for 24 months.

Should I notify Medicare when my spouse and I stop working?

Yes. It’s important that you call Medicare at 1-800-MEDICARE (1-800-633-4227) when you or your spouse stops working. TTY users should call 1-877-486-2048. If you or your spouse is retired, you should call the Coordination of Benefits Contractor at 1-800-999-1118.

Signing up for Part A and Part B

What if I’m close to 65, but not getting Social Security or Railroad Retirement Board (RRB) benefits?

If you aren’t getting Social Security or RRB benefits (for example, because you’re still working) and you want Part A or Part B, you’ll need to sign up (even if you’re eligible to get free Part A). If you’re not eligible for free Part A, you can buy Part A and Part B.

Be sure to sign up for Part B during your Initial Enrollment Period so you don’t have to pay a lifetime late enrollment penalty if you sign up for it later.

Important: If you’re not getting Social Security benefits, Medicare won’t mail you any enrollment information. You’ll need to call Social Security at 1-800-772-1213 at least 3 months before you turn 65 to avoid any penalties. TTY users should call 1-800-325-0778. If you worked for a railroad, contact the Railroad Retirement Board (RRB) to sign up. After you enroll, you’ll get your Medicare card.

What if I missed my Initial Enrollment Period or am older than 65 and not getting Social Security or RRB benefits?

If you aren’t getting Social Security or RRB benefits (for example, because you’re still working) and you want Part A or Part B, you’ll need to sign up (even if you’re eligible to get free Part A). If you’re eligible to get free Part A, you can sign up at any time. Your Part A coverage will begin as early as 6 months before the month you filed, but no earlier than the month you met all other Part A requirements.

If you’re covered under your or your spouse’s group health plan based on current employment, you can also sign up for Part B when you enroll in Part A. If you weren’t covered under a group health plan based on current employment and you want to enroll in Part B, you’ll need to wait for the next General Enrollment Period (from January 1 – March 31) and coverage will start July 1 of that year.

Important: In most cases, if you don’t sign up for Part B when you’re first eligible, you’ll have to pay a late enrollment penalty for as long as you have Part B.

I only worked a short time. Do I have to enroll in Part A?

No. If you aren’t eligible for free Part A, you don’t have to enroll. However, if you want to buy Medicare coverage and you want Part A, you also have to buy Part B. If you buy Part A and/or Part B (you must pay a premium for both), you must sign up during your Initial Enrollment Period, during a General Enrollment Period, or a Special Enrollment Period (see here). Remember, if you don’t sign up when you’re first eligible, you may have to pay a late enrollment penalty.

Turning 65 and you or your spouse is still working

I’m still working and have health coverage from my employer. My husband is turning 65 this April. If we decline Part B and decide to enroll at a later date, will we have to pay a late enrollment penalty?

No, as long as you’re eligible for and enroll during a Special Enrollment Period. If you wait to enroll in Part B because you or your spouse are working and have group health coverage through an employer or union based on this current employment, you can enroll during a Special Enrollment Period. You can sign up for Part B during one of these times:

Any time you’re still covered by an employer or union group health plan, through your or your spouse’s current or active employment

During the 8-month period that begins the month after the employer or union group health plan coverage ends, or when the employment ends (whichever is first)

Note: If you’re still working and plan to keep your employer’s group health coverage, you should talk to your benefits administrator to help you decide when you should enroll in Part B. When you sign up for Part B, you automatically begin your Medigap Open Enrollment Period. Once your Medigap Open Enrollment Period begins, it can’t be changed or restarted. For more information on Medigap, visit Medicare.gov/publications to view the booklet “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.”

I currently have Part B but I (or my spouse) have returned to work and I now have group health coverage from my employer or union. I don’t think I need both Part B and group health coverage. What can I do?

If you drop Part B, you may be able to sign up for it again during a Special Enrollment Period (see here). Make sure that your group health plan coverage is in effect before you drop Part B. In this case, the cost of Part B won’t go up when you join later. Remember, when you drop Part B, your coverage ends the next month. Also, if you drop Part B after 65, you won’t get another Medigap Open Enrollment Period when you restart Part B. For more information on Medigap, visit Medicare.gov/publications to view the booklet “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.”

My spouse has never worked and will turn 65 before I do. Can my spouse get Medicare at 65?

If you’re at least 62 and have worked at least 10 years in Medicare-covered employment, your spouse can get Part A and Part B at 65.

If you’ve worked at least 10 years in Medicare-covered employment but aren’t yet 62 when your spouse turns 65, he or she won’t be eligible for free Part A until your 62nd birthday. In this case, your spouse should still apply for Part B at 65 to avoid paying a higher Part B premium. However, if you’re still working and your spouse is covered under your group health plan, he or she could delay Part B enrollment without paying higher premiums.

I’ll be 65 next month and I’ve only worked for a few years. Can I enroll in Medicare?

Yes, you can enroll in Medicare. If you’ve worked less than 10 years in Medicare-covered employment you’ll have to pay a monthly premium for Part A, and will have to sign up for Part B. You’ll also have to pay the Part B premium. To enroll in Part A and Part B or find out how much your Part A premium will be, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Medicare and End-Stage Renal Disease (ESRD)

Am I eligible for Medicare if I have ESRD?

Yes, you can get Part A and Part B no matter how old you are if your kidneys no longer work, you need regular dialysis or have had a kidney transplant, and one of these applies to you:

You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.

You’re already getting or are eligible for Social Security or RRB benefits.

You’re the spouse or dependent child of a person who meets either of the requirements listed above.

You must also file an application and meet any waiting periods that apply.

Note: Call Social Security at 1-800-772-1213 for more information about the required amount of time needed under Social Security to be eligible for Medicare. If you get benefits from the RRB, call your local RRB office or 1-800-808-0772.

How do I sign up for Medicare if I have ESRD?

If you’re eligible for Medicare because of ESRD, you can enroll in Part A and Part B by visiting your local Social Security office or by calling Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Note: If you’re already enrolled in Medicare based on age or disability, and you’re already paying a higher Part B premium because you didn’t enroll in Part B when you were first eligible, the penalty will stop when you become eligible for Medicare based on ESRD. Call your local Social Security office to make an appointment to reenroll in Medicare based on ESRD. For more information on ESRD, visit Medicare.gov/publications to view the booklet “Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.”

When does my Medicare coverage begin if I enroll in Medicare because of ESRD?

When you first enroll in Medicare based on ESRD and you’re on dialysis, your Medicare coverage usually begins with the fourth month of dialysis treatments.

If you’re eligible for Medicare and have employer group health plan coverage, you’ll have primary coverage through your employer group health plan for the first 30 months of Medicare eligibility (which begins with the fourth month of dialysis). After the first 30 months, Medicare will pay primary while your employer plan pays secondary. Your employer group health plan may pay for the first 3 months of dialysis treatments.

In some cases, your Medicare coverage can start earlier. For example, if you take a course in self-dialysis training or get a kidney transplant during the 3-month waiting period after the start of dialysis, your Medicare coverage may start earlier.

Will my Medicare coverage end if I have ESRD?

If you have Medicare only because of kidney failure, your Medicare coverage will end:

The end of the 12th month after the month you stop dialysis treatments

The end of the 36th month after the month you had a successful kidney transplant

Your Medicare coverage will resume if one of these applies to you:

You have to start dialysis again or get a kidney transplant within 12 months after the month you stopped getting dialysis

You continue to get dialysis or get another kidney transplant within 36 months after a transplant

Can I sign up for Part B if I’m over 65 (or disabled), only have Part A, and have ESRD?

Yes. If you currently have Part A based on age or disability, and you refused Part B when you were first eligible, you can enroll in Part B without paying a late enrollment penalty if you enroll in Part B based on ESRD. To enroll in Part B, call or visit your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

I’m over 65 (or disabled). I’m paying a late enrollment penalty because I didn’t enroll in Part B when I was first eligible. Now that I have ESRD, do I need to continue to pay the higher Part B premium?

No. When you apply for Medicare and enroll in Part B based on End-Stage Renal Disease (ESRD), your Part B late enrollment penalty will be stopped. Call or visit your local Social Security office, or call Social Security at 1-800-772-1213.

Where can I get more information about ESRD?

For more information about ESRD, visit Medicare.gov/publications to view the booklet “Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.”

You can also call your local End-Stage Renal Disease Network, State Health Insurance Assistance Program (SHIP), or your State Survey Agency for more information about ESRD. To get their phone numbers, visit Medicare.gov or shiptacenter.org. Or, you can call 1-800-MEDICARE (1-800-633-4227) and ask for their phone number. TTY users should call 1-877-486-2048.

For more information about disability benefits, visit socialsecurity.gov. Or, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. If you get benefits from the Railroad Retirement Board, visit rrb.gov or call 1-877-772-5772.

Retiree coverage

What’s my full retirement age?

Full retirement age is the age you’re eligible to get full Social Security retirement benefits. This age depends on the year you were born.

If you were born...

Your full retirement age is...

1937 or earlier

65

1938–1959

65 and 2 months—66 and 10 months. It depends on the year you were born.

1960 or later

67

Note: If you retire between 62 and your full retirement age, and start getting Social Security benefits before your full retirement age, your benefits are reduced.

To find your exact full retirement age and how it affects your Social Security retirement benefits, visit socialsecurity.gov. You can also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Can I still get Medicare at 65?

Yes, you’re still eligible for Medicare starting at 65, no matter what year you were born.

If you or your spouse worked and paid Medicare taxes for at least 10 years, you’re eligible for free Part A at 65. You’re also eligible for Part B if you choose to get it and pay a monthly premium.

When you first become eligible for Part A, you have a seven-month period (your Initial Enrollment Period) to sign up for Part B. Generally, your Initial Enrollment Period begins 3 months before your 65th birthday, includes the month you turn age 65 and ends 3 months after your birthday month.

Important: If you don’t enroll in Part B when you’re first eligible, you may have to pay a late enrollment penalty for as long as you have Part B coverage. In addition, you may have to wait to enroll which can delay this coverage.

Will I be eligible for Medicare if I retire at 62?

No. You can’t get Medicare until you’re 65. If you retire, you may be able to keep your group health plan coverage from your employer or union. Talk with your benefits administrator about your health care coverage before you retire.

Can I have Medicare and retiree coverage?

Yes. When you become eligible for Medicare, you’ll probably need to enroll in both Part A and Part B to get full benefits from your retiree plan. Your retiree plan usually offers benefits that fill in Medicare’s gaps in coverage and sometimes include extra benefits, like prescription drugs. Remember, retiree coverage isn’t a Medicare Supplement Insurance (Medigap) policy. Since retiree coverage isn’t based on current employment, if you delay enrolling in Part B when you’re first eligible, you won’t be eligible for a Special Enrollment Period to enroll in Part B later.

If you aren’t sure how your plan works with Medicare, get a copy of your plan’s benefits booklet. For more information about how your retiree coverage works, call your benefits administrator. If you have questions about Medicare, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

I’m a retired Federal employee with a Federal Employees Health Benefit Plan (FEHBP) and I’m eligible for Medicare. Do I need to enroll in Part B?

Enrolling in Part B is your choice. Federal retirees are offered the same Medicare benefits as all other retirees. You can enroll in Part B during your Initial Enrollment Period, if you don’t enroll in Part B when you’re first eligible, in most cases, you’ll have to pay a late enrollment penalty for as long as you have Part B. For more information about FEHBP, visit opm.gov. For information about enrolling in Part A or Part B, call or visit your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Veterans’ benefits

This is health coverage for veterans and people who have served in the U.S. military. The Department of Veterans Affairs (VA) may provide long term care for service-related disabilities or for certain eligible veterans. The VA also has a Housebound and Aid and Attendance Allowance Program that provides cash grants to eligible disabled veterans and surviving spouses. For more information, visit va.gov, or call the VA at 1-800-827-1000. TTY users should call 1-800-829-4833.

I have Health Insurance Marketplace coverage

The Health Insurance Marketplace is generally for people who need to buy individual or family health insurance or for people who are offered employer coverage (sometimes called “SHOP” coverage) through the Marketplace. Medicare isn’t part of the Marketplace. Once your Medicare coverage starts, health insurance companies generally aren’t allowed to sell you a plan through the Marketplace for individuals and families.

The Affordable Care Act requires most people to have health coverage. Once your Part A coverage starts, you’ll meet this requirement.

If you have a Marketplace plan, consider these things when deciding to keep Part B:

If you don’t keep Part B and choose to enroll in it later, in most cases you’ll have to wait to enroll and pay a late enrollment penalty for as long as you have Medicare.

You’ll no longer be eligible for premium tax credits or other savings for a Marketplace plan based on your income once your Part A coverage starts. You’ll have to pay full price for your Marketplace plan.

If you have SHOP coverage based on active employment, this is treated the same as if you’re working and covered through your employer.

If you enrolled in a Marketplace plan before you were eligible for Medicare, you can end your coverage in your Marketplace plan once your Medicare coverage starts. Visit HealthCare.gov to learn more.

I have coverage through a health savings account (HSA)

What happens to my HSA when I sign up for Medicare?

You can’t contribute to your HSA once you’re enrolled in Medicare. If you contribute to your HSA after your Medicare enrollment date, you may have to pay a tax penalty. If you’d like to continue contributing to your HSA, you shouldn’t apply for Medicare, Social Security, or Railroad Retirement Board (RRB) benefits. Because your enrollment date for Medicare (i.e., when your coverage starts will generally be 6 months before your application date, you must stop contributing to your HSA 6 months before applying for Medicare.

Premium-free Part A coverage begins 6 months back from the date you apply for Medicare (or Social Security/RRB benefits), but no earlier than the first month you were eligible for Medicare.

To avoid a tax penalty, you should stop contributing to your HSA at least 6 months before you apply for Medicare.

You can only enroll in Part B at certain times. If you have an HSA with a High Deductible Health Plan (HDHP) based on your or your spouse’s current employment, you may be eligible for a Special Enrollment Period to enroll in Part B later without a lifetime late enrollment penalty. If you qualify, you can wait to enroll in Medicare until you (or your spouse) stop working or lose your employer group health plan coverage based on that employment.

You can withdraw money from your HSA after you enroll in Medicare to help pay for medical expenses (like deductibles, premiums, coinsurance, or copayments).

Living outside the U. S.

I live outside the U. S., and I don’t have Part B. Can I get Part B and will I pay more?

It depends on your situation:

Situation #1: If you’re over 65, currently getting Social Security benefits and Part A, and you didn’t take Part B when you were first eligible, you may only apply for Part B during the General Enrollment Period. This period runs from January 1 – March 31, and you may have to pay a late enrollment penalty for as long as you have Part B.

Situation #2: If you live outside of the U.S., you’re over 65, and you’re eligible for Social Security benefits, you may file an application for monthly benefits and Part A. You’ll have to file for Part B during the General Enrollment Period. This period runs from January 1 – March 31, and you may have to pay a late enrollment penalty.

Situation #3: If you’re a U. S. citizen, you’re over 65, you’re not eligible for Social Security benefits, and lived in a foreign country when you turned 65, you must live in the U. S. to file for Part B. You’re first eligible to enroll in Part B the month you return to the U. S. to establish your new residence. You won’t have to pay a late enrollment penalty if you enroll in Part B when you first return to the U. S.

Although you may be able to enroll, in most cases, you won’t be able to get Medicare-covered services while living outside the U.S. Medicare generally can’t pay for any of your hospital or medical bills unless you get your medical care in the U.S. (including Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). Under certain limited circumstances, medical services provided in outside of the United States also may be covered by Medicare, but only if you’re living in the U.S.

Section 3—For More Information

Where to get more information

Enrolling in Medicare:

Visit socialsecurity.gov

Call Social Security at 1-800-772-1213.TTY users should call 1-800-325-0778.

Note: You may also be able to apply for retirement, spouses’ disability, and Medicare benefits online if you meet certain rules.

Questions about Medicare:

Visit Medicare.gov

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Medicare publications

To read, print, or download copies of booklets, brochures, or fact sheets on different Medicare topics, visit Medicare.gov/publications. You can search by keyword (like “rights” or “mental health”), or select “View All Publications.” If the publication you want has a check box after “Order Publication,” you can have a printed copy mailed to you. You can also call 1-800-MEDICARE (1-800-633-4227) and say “Publications” to find out if a printed copy can be mailed to you. TTY users should call 1-877-486-2048. Some publications are also available as podcasts that you can download and listen to.

Section 4—Definitions

ALS—Amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease.

Creditable prescription drug coverage—Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Critical access hospital (CAH)—A small facility that provides outpatient services, as well as inpatient services on a limited basis, to people in rural areas.

End-Stage Renal Disease (ESRD)—Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Extra Help—A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

Group health plan—In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.

Home health care—Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.

Hospice—A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver.

Large group health plan—In general, a group health plan that covers employees of either an employer or employee organization that has at least 100 employees.

Medicaid—A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medically necessary—Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

Medicare Advantage Plan (Part C)—A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Part A (Hospital Insurance)—Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)—Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Medicare prescription drug coverage (Part D)—Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.

Medigap Open Enrollment Period—A one-time-only, 6-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.

Medigap policy—Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage.

Premium—The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Preventive services—Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).

Skilled nursing facility (SNF)— A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

State Health Insurance Assistance Program (SHIP)—A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

State Survey Agency—A state agency that oversees health care facilities that participate in the Medicare and/or Medicaid programs. The State Survey Agency inspects health care facilities and investigates complaints to ensure that health and safety standards are met.

Supplemental Security Income (SSI)—A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits aren’t the same as Social Security retirement or disability benefits.

TTY—A TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment. People who don’t have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Blvd. Baltimore, MD 21244-1850

Official Business Penalty for Private Use, $300

CMS Product No. 11036 Revised April 2016

Available in Spanish, Braille, Audio CD, Large Print (English and Spanish). Also available as a podcast and e-book. Visit Medicare.gov/publications for more information.

Suspect fraud? Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Moving? Visit socialsecurity.gov or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

¿Necesita usted una copia de este manual en Español? Llame al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY deberán llamar al 1-877-486-2048.

If you need help in a language other than English or Spanish, call 1-800-MEDICARE and say “Agent.” Then tell the customer service representative the language you need.