Medicare isn’t just for Americans age 65 and older. You can also be eligible for Medicare if you meet certain other criteria. Medicare Part D, which is Medicare’s prescription drug plan, is included in this eligibility.
To be eligible for Medicare, you must qualify in one of the following ways:
- You’re age 65 and you can enroll in Medicare parts A and B.
- You’ve received Social Security disability payments for at least 2 years. The waiting period for Medicare is waived if you receive a diagnosis of amyotrophic lateral sclerosis (ALS). With this condition, you’re eligible the first month you receive a disability payment.
- You receive a diagnosis of end-stage renal disease (ESRD) or kidney failure and you need to have dialysis or a kidney transplant. Railroad employees with ESRD can contact Social Security to find out about eligibility for Medicare at 800-772-1213.
- Children under age 20 with ESRD can qualify if they have at least one parent eligible for Social Security benefits.
Remember: You’re eligible for Part D if you’re eligible for Medicare.
Now let’s look at Medicare Part D eligibility in more detail. The main eligibility requirements for Medicare Part D include:
Age 65 or older
For most people, you first become eligible to enroll in Medicare Part D from 3 months before your 65th birthday to 3 months after your birthday.
When you find a plan to join, you’ll need to provide your unique Medicare number and the date you became eligible. You can enroll online, call the provider of the Part D Plan you want directly, or call 800-MEDICARE for help with a plan.
A qualifying disability
If you’re not 65 but have a disability that qualifies you to receive Social Security or Railroad Retirement Disability benefits, you’re eligible for Part D 3 months before the 25th month of benefit payments until 3 months after your 25th month of receiving benefits.
There are rules for when you can and can’t enroll in a Medicare Part D plan. There are enrollment dates, dates when you may change your plan, and dates for dropping your coverage. Here is a basic overview of important dates for adding or modifying your Medicare prescription drug coverage.
October 15 to December 7
This is the open enrollment period. If you’re eligible, during this time you may:
- enroll in a plan that provides prescription coverage
- change Part D plans
- drop Part D coverage, which may result in penalties if you have no prescription coverage
January 1 to March 31
You can change or drop Medicare Advantage plans with Part D coverage or join original Medicare (parts A and B) during this time.
You can’t join a Part D plan during this time if you have original Medicare.
April 1 to June 30
If you enrolled in coverage for Medicare parts A or B and want to add Part D, you can enroll during this period the first time. After this, to change Part D plans, you must wait for open enrollment (October 15 to December 7).
If you have questions about your Medicare part D coverage or enrollment periods, reach out to the insurance company from whom you purchase your coverage, contact the State Health Insurance Assistance Programs National Network (SHIP) navigator, or call 800-MEDICARE.
It’s a good idea to sign up for a Part D plan when you become eligible, even if you’re not taking any prescription medications. Why? Medicare adds on a 1 percent penalty to your premium permanently if you don’t enroll within 63 days of your initial eligibility period.
The penalty rate is calculated based on the national premium rate for the current year multiplied by the number of months you didn’t enroll when you were eligible. So, if you wait, your extra penalty payment will be based on how long you didn’t have Part D coverage. This can add up.
The base premium changes year to year. If the premium goes up or down, your penalty changes, too.
If you have a Medicare Advantage plan, when you turn 65, you still need to have Part D coverage.
You can avoid the penalty if you have Medicare “creditable coverage” from another plan. This means you have drug coverage that’s at least equal to the basic Medicare Part D coverage from another source, like an employer.
Since the penalty can add to your premium cost, it makes sense to buy a Part D plan at low cost when you become eligible. You can change plans during each open enrollment time if you need different coverage.
All Part D and prescription drug plans are offered through private insurance. Availability varies by state.
The right plan for you depends on your budget, medication costs, and what you want to pay for premiums and deductibles. Medicare has a tool to help you compare plans in your area looking ahead to 2020.
- Part D. These plans cover prescription medications for outpatient services. All plans have to offer some basic level of drug coverage based on Medicare rules. Specific plan coverage is based on the plans’ formulary, or drug list. If your doctor wants a drug covered that’s not part of that plan’s list, they’ll need to write a letter of appeal. Each nonformulary medication coverage decision is individual.
- Part C (Advantage plans). This type of plan can take care of all your medical needs (parts A, B, and D), including dental and vision coverage. Premiums might be higher and you might have to go to network doctors and pharmacies.
- Medicare supplement (Medigap). These plans help pay for some or all out-of-pocket (OOP) costs like deductibles and copays. There are 10 plans available. You can compare the rates and coverage with your original Medicare coverage gap and premiums. Choose the best option to give you maximum benefits at the lowest rates.
New Medigap plans don’t cover prescription drug copays or deductibles. Also, you can’t buy Medigap insurance if you have a Medicare Advantage plan.
If you take specialty or expensive medications or have a chronic condition that requires medications, choose the plan based on what’s covered to give you the most benefit.
Remember, the plan you choose isn’t set in stone. If your needs change year to year, you can switch to another plan in the next open enrollment period. You’ll have to stay in the plan an entire year, so choose carefully.
When using the Medicare plan finder to choose a Part D plan, enter your medications and doses, then select your pharmacy options. Of the available drug plans, you’ll see the lowest monthly premium plan displayed first. Keep in mind, the lowest premium plan may not fit your needs.
There’s a drop-down selection to the right of the screen listing three options: lowest monthly premium, lowest yearly drug deductible, and lowest drug plus premium cost. Click through all the options and look at your choices before making a final decision.
- Choose a plan based on your overall health and medication needs.
- Where you live — such as if you live in multiple states during the year or a rural location — might affect available plans. Ask a navigator for help with the best option.
- Your OOP costs for premiums, deductibles, and copays can vary with plans. Review what isn’t covered. Add the costs of noncovered items and then compare that to lower premiums to see which is the better option.
- Medicare rates plans based on member surveys and other criteria from 1 to 5. Check the plan rating before making your decision. You can switch one time into a five-star plan from a lower-rated plan between December 8 and November 3.
- You can add Medigap coverage for the OOP costs if you have original Medicare with Part D coverage.
- If you have doctors and pharmacies you like, make sure they’re listed in the network of your plan.
IMPORTANT to know when using medicare.gov
The Medicare.gov website has recently been updated. If you’re new to Medicare, there are important differences. The new format will show the lowest cost premium in bold first. However, this may not be the best option for your needs. Look carefully at different combinations and compare the coverages related to the medications you take.
Medicare Part D is an important benefit that helps pay for prescription drugs not covered by original Medicare (parts A and B).
There are private medication plans that you can add to your original Medicare coverage, or you can choose a Medicare Advantage plan (Part C) with drug coverage. These plans may also provide dental and vision benefits. Keep in mind that premiums may be higher and you might have to go with in-network doctors and pharmacies.
If you have prescription drug coverage through your employer or union that’s at least as good as basic Medicare coverage, you can keep that plan. Go with what gives you the best coverage at the best rate.
Remember, there’s a permanent penalty added to your premium if you don’t choose a drug plan or have drug coverage when you’re eligible.
The Medicare.gov website has been updated recently and options and displays have changed. Reach out to a state navigator or call 800-MEDICARE for help with selecting the best plan for you.