Who Is Eligible for Medicare?

🎯 10 Key Takeaways: Medicare Eligibility in 2026

Most Americans qualify for Medicare at age 65 — if they or their spouse paid Medicare payroll taxes for at least 10 years (40 quarters).

You don’t have to be 65 — people of any age with ALS, ESRD, or 24+ months of SSDI qualify.

Women and men have identical eligibility rules — there is no gender-based difference whatsoever.

Green card holders qualify after 5 years of continuous U.S. residency — but new immigrants are not eligible until that threshold is met.

A 2025 federal law eliminated Medicare eligibility for many visa categories — refugees, asylees, and TPS holders are no longer eligible as of July 2025 (with coverage terminating by January 2027).

Not all U.S. citizens automatically get premium-free Part A — you still need 40 quarters of Medicare tax payments, or you’ll pay up to $565/month.

Medicare is not mandatory, but declining Part A means forfeiting Social Security benefits — and repaying every dollar you’ve received.

You cannot get Medicare at age 55 — no legislation enabling a buy-in at 55 has passed.

Medicaid and Medicare are completely different programs — Medicaid is income-based and state-administered; Medicare is age/disability-based and federally administered. Some people qualify for both (“dual eligibles”).

Part A and Part B have different eligibility nuances — Part A is tied to work history; Part B is available to anyone eligible for Part A who pays the $202.90/month premium.

✅ 1. The Four Pathways Into Medicare: Age, Disability, ALS, and Kidney Failure

There are exactly four ways to qualify for Medicare in 2026. Every single enrollee entered through one of these doors.

🚪 Eligibility Pathway	Age Requirement	Key Condition	Waiting Period	Enrollment
Age-based (standard) 🎂	65 or older	40 quarters of Medicare tax payments (you or spouse)	None	Automatic if receiving Social Security; manual otherwise
SSDI disability 🏥	Any age	Must be receiving Social Security Disability Insurance	24 months of SSDI payments	Automatic in month 25
ALS (Lou Gehrig’s disease) ⚡	Any age	Diagnosed with ALS	None — immediate	Automatic when SSDI begins
ESRD (kidney failure) 🩺	Any age	Permanent kidney failure requiring dialysis or transplant	3 months after regular dialysis (1 month for home dialysis)	Must enroll manually

For all four pathways, you must also meet citizenship or residency requirements: You need to be a U.S. citizen or a legal permanent resident living in the U.S. for at least 5 years.

💡 Critical insight: There are no illnesses or underlying conditions that disqualify people for Medicare coverage. Once you’re enrolled, Medicare covers the same benefits regardless of whether you qualified by age or disability. Your pre-existing conditions cannot be used to deny coverage, limit benefits, or charge you more.

🇺🇸 2. Not All U.S. Citizens Automatically Get Free Medicare — Here’s the Work History Requirement

Being a U.S. citizen is necessary but not sufficient for premium-free Medicare Part A. The critical variable is work history — specifically, how many quarters you or your spouse paid Medicare payroll taxes.

💼 Work History (Quarters)	Part A Premium (2026)	Who This Applies To
40+ quarters (10+ years) ✅	$0/month — premium-free	Most working Americans and their spouses
30-39 quarters (7.5–9.9 years) ⚠️	$311/month	People with partial work histories
Fewer than 30 quarters ❌	$565/month	People who worked little or not at all in the U.S.
No quarters at all	$565/month (if eligible to buy in)	Stay-at-home spouses without a qualifying partner, some immigrants

Medicare Part A is premium-free for more than 99 percent of beneficiaries. But that remaining 1% — largely immigrants who arrived later in life and people who worked primarily in jobs not covered by Social Security (certain state/local government employees, for example) — face a hefty bill.

Who qualifies through a spouse’s work record: You don’t have to have worked 40 quarters yourself. If your current spouse, ex-spouse (if the marriage lasted at least 10 years), or deceased spouse earned 40 quarters, you qualify for premium-free Part A at age 65.

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💡 Critical insight: Certain public-sector employees — particularly teachers, firefighters, and police officers in states that opted out of Social Security — may discover at 65 that they don’t have enough quarters for premium-free Part A. If your career was entirely in a state or local government that had its own pension system instead of Social Security, check your quarter count with the SSA well before turning 65.

🛂 3. Which Visa Holders Can Get Medicare — And Who Just Lost Eligibility Under the 2025 Law

This is where Medicare eligibility changed dramatically. Starting in July 2025, Medicare eligibility is restricted to U.S. citizens, permanent residents (green card holders), Cuban-Haitian entrants, and people residing under the Compacts of Free Association.

This new restriction means that several categories of lawfully present immigrants who previously qualified for Medicare are now being phased out:

🛂 Immigration Status	Medicare Eligible in 2026?	Details
U.S. citizen ✅	Yes	Must meet work history or disability requirements
Green card holder (lawful permanent resident) ✅	Yes	Must have 5 years continuous residency + work history or pay premiums
Cuban-Haitian entrant ✅	Yes	Retained eligibility under 2025 law
Compact of Free Association (COFA) residents ✅	Yes	Marshall Islands, Micronesia, Palau
Refugee ❌	No longer eligible	Previously eligible; coverage terminating by January 2027
Asylee ❌	No longer eligible	Previously eligible; coverage terminating by January 2027
Temporary Protected Status (TPS) ❌	No longer eligible	Previously eligible; coverage terminating by January 2027
Undocumented immigrants ❌	Never eligible	No pathway to Medicare
Tourist/visitor visa (B-1/B-2) ❌	Not eligible	Non-immigrant visa; no Medicare access
Student visa (F-1) ❌	Not eligible	Non-immigrant visa; no Medicare access
Work visa (H-1B, L-1, etc.) ❌	Not eligible for benefits	Pays Medicare taxes but cannot access benefits until becoming a permanent resident

By July 2026, the new law directs the head of the Social Security Administration to identify newly ineligible immigrants already enrolled in Medicare and notify them that their coverage will be terminated in January 2027.

💡 Critical insight: H-1B visa holders and other temporary work visa holders face a frustrating paradox — they pay Medicare payroll taxes on every paycheck but cannot access Medicare benefits until they become permanent residents. Those payroll tax contributions do count toward their 40-quarter requirement, so if they eventually get a green card and meet the 5-year residency rule, those earlier tax payments will help qualify them for premium-free Part A later.

🚫 4. Who Is Not Eligible for Medicare at Age 65 — The Exceptions Nobody Talks About

Turning 65 does not guarantee Medicare for everyone. Several groups discover they’re excluded even after reaching the standard eligibility age:

❌ Group	Why They Don’t Qualify	Available Alternative
Non-citizens with fewer than 5 years of U.S. residency	Residency requirement not met	Purchase private insurance or ACA Marketplace plan
People who never worked (and whose spouse didn’t either) in Medicare-taxed employment	No work quarters earned	Can purchase Part A at $565/month if residency requirement is met
Undocumented immigrants	Not eligible regardless of age or work history	May qualify for emergency Medicaid in some states
Citizens or residents living permanently abroad	Medicare generally doesn’t cover care outside the U.S.	Can enroll but benefits only apply within U.S. borders
People who renounced U.S. citizenship	Lost eligibility upon renunciation	No Medicare pathway
Refugees, asylees, and TPS holders (post-July 2025 law)	Eligibility removed by federal legislation	Must seek coverage through Marketplace, Medicaid (if qualifying), or other programs
People who want Part A but refuse to forfeit Social Security	Part A and Social Security are legally linked	Cannot decline Part A while receiving Social Security payments

💡 Critical insight: A surprising number of Americans who worked their entire careers in state or local government positions exempt from Social Security (common in 15 states including Ohio, Massachusetts, Colorado, Texas, and California for certain employees) discover at 65 that they don’t qualify for premium-free Part A. They may need to purchase Part A or rely entirely on their government retiree health plan.

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🏥 5. Part A Eligibility: It’s All About Work History and Payroll Taxes

Medicare Part A — hospital insurance — has the most specific eligibility criteria because it’s funded primarily through the 2.9% Medicare payroll tax (split equally between employer and employee at 1.45% each).

You qualify for premium-free Part A if any one of these applies:

✅ Qualifying Scenario	Details
You worked 40+ quarters paying Medicare taxes	Standard qualification — covers most Americans
Your spouse worked 40+ quarters	Includes current, divorced (marriage lasted 10+ years), or deceased spouse
You’re 65+ and receive Social Security retirement benefits	Automatic enrollment
You’re 65+ and receive Railroad Retirement Board benefits	Automatic enrollment
You’ve received SSDI for 24 months	Automatic enrollment regardless of age
You have ALS	Immediate enrollment when SSDI begins
You have ESRD	Eligible regardless of age after waiting period
You’re a government employee who paid Medicare taxes for 40 quarters	Federal employees hired after 1983 pay Medicare taxes

If you’re under age 65 and you’ve received disability benefits from Social Security or the Railroad Retirement Board for at least 24 months, you’ll automatically get Medicare Part A and Part B.

💡 Critical insight: Part A enrollment is retroactive for up to 6 months if you sign up after age 65. This is important for people with HSAs — since you can’t contribute to an HSA once enrolled in any part of Medicare, those backdated months could create a tax problem if you were still making HSA contributions during that retroactive period.

🩺 6. Part B Eligibility: Available to Everyone Who Has Part A — But You Pay for It

Medicare Part B (medical insurance, covering doctor visits, outpatient services, and preventive care) has simpler eligibility requirements: anyone eligible for Part A is also eligible for Part B. The difference is that Part B always requires a monthly premium.

📋 Part B Eligibility Details	2026 Facts
Who qualifies	Anyone eligible for Part A (age 65+ or qualifying disability/condition)
Monthly premium	$202.90 (standard); up to $689.90 with IRMAA surcharges
Annual deductible	$283
Coinsurance	20% of Medicare-approved amount after deductible
Is it mandatory?	No — but declining it carries permanent late enrollment penalties
Late enrollment penalty	10% added to premium for each full 12-month period you could have had Part B but didn’t
Can you delay without penalty?	Yes — if you have creditable employer coverage through a company with 20+ employees

If you don’t have to pay a premium for Part A, you can choose to sign up when you turn 65 or anytime later. But Part B requires careful timing. If you delay without qualifying coverage, the penalty follows you permanently.

💡 Critical insight: Part B covers some things people don’t realize, including one “Welcome to Medicare” preventive visit within the first 12 months of enrollment, annual wellness visits, flu shots, certain cancer screenings, diabetes testing, and mental health services. Conversely, it does not cover routine dental, vision, or hearing — which is a common shock for new enrollees.

👩 7. Women and Men Qualify for Medicare Under Identical Rules — Period

This question appears repeatedly in searches, and the answer requires zero qualifications: Medicare eligibility is entirely gender-neutral. No provision of federal law creates different age thresholds, waiting periods, premium amounts, or enrollment timelines based on sex or gender.

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The confusion likely stems from how private insurance historically worked before the Affordable Care Act. Before 2014, private insurers could — and routinely did — charge women higher premiums than men for identical coverage (a practice called “gender rating”). Medicare has never operated this way.

👤 Factor	Women	Men
Eligibility age	65	65
Disability pathway	24-month SSDI wait	24-month SSDI wait
Premium amounts	Identical	Identical
Spousal eligibility	Can qualify through husband’s work record	Can qualify through wife’s work record
Coverage benefits	Identical	Identical

🔄 8. Medicare vs. Medicaid: Two Completely Different Programs That Millions Confuse

One of the most persistent confusions in American healthcare is the difference between Medicare and Medicaid. They sound similar but operate on entirely different principles.

⚖️ Feature	Medicare 🏛️	Medicaid 🏥
Administered by	Federal government (CMS)	State governments (with federal funding)
Primary basis for eligibility	Age (65+) or disability	Low income and limited assets
Income test?	No (anyone at 65+ qualifies regardless of income)	Yes — strict income and asset limits
Age requirement	65+, or any age with qualifying disability	Any age — children, pregnant women, adults, seniors
Premium cost	Part B: $202.90/month; Part A: usually $0	Usually $0 or very low
Covers long-term nursing home care?	No (only short-term skilled nursing)	Yes — primary payer for long-term care
Available in all states?	Yes — federal program, same everywhere	Varies — 40 states expanded Medicaid; 10 did not
Can you have both?	Yes — “dual eligibles” get both	Yes — Medicaid can pay Medicare premiums

For most adults in Medicaid expansion states, eligibility is based on income up to 138% of the Federal Poverty Level, which is about $21,597 per year for a single person using early-2026 guidelines.

For seniors needing long-term care Medicaid, the financial criteria are different and stricter: A single senior, 65 years or older, must have income no greater than $2,982 per month for Nursing Home Medicaid and HCBS Waivers in most states in 2026.

💰 Medicaid Income Limits for Seniors (2026)	Single Applicant	Married (Both Applying)
Nursing Home / HCBS Waiver Medicaid	$2,982/month	$5,964/month
Aged, Blind, and Disabled (ABD) Medicaid	~$994–$1,795/month (varies by state)	~$1,491–$2,658/month
Asset limit (most states)	$2,000	$3,000
Home equity exemption	Up to $752,000–$1,130,000 (varies by state)	Same

“Dual eligibles” — people who qualify for both Medicare and Medicaid simultaneously — receive significant financial protection. Medicaid can pay their Medicare premiums, deductibles, and coinsurance, essentially eliminating most out-of-pocket costs.

💡 Critical insight: If you’re a senior with limited income, don’t assume you only qualify for one program. Approximately 12 million Americans are dual-eligible for both Medicare and Medicaid. Your state Medicaid office can evaluate whether you qualify for a Medicare Savings Program that pays your Part B premium and potentially your cost-sharing too.

🔞 9. No, You Still Cannot Get Medicare at 55 — But Here Are Your Options

Though efforts have been made to allow people aged 55 to 64 to get Medicare, there has not been an official bill that has passed yet. The Medicare at 55 Act (S.1742) was introduced in 2017 and went nowhere. Proposals to lower the eligibility age to 60 have also circulated but gained no traction.

If you’re between 55 and 64 without employer coverage, here are your realistic options:

🛡️ Coverage Option for Ages 55–64	Approximate Monthly Cost	Pros	Cons
ACA Marketplace plan	$400–$1,500+ (before subsidies)	Premium tax credits available based on income; comprehensive coverage	Can be expensive without subsidies; narrower networks
COBRA (from former employer)	$600–$2,000+	Keeps same doctors/plan	Limited to 18 months; no employer subsidy; very expensive
Spouse’s employer plan	Varies	Often most affordable option	Depends on spouse’s employer offering coverage
Medicaid (if income-qualifying)	$0 or near-$0	Free or very low cost	Must meet strict income limits; not available in all states for childless adults
Short-term health insurance	$100–$400	Low premiums	Limited benefits; doesn’t cover pre-existing conditions; not ACA-compliant
Health sharing ministries	$200–$500	Community-based; lower premiums	Not insurance; no guaranteed coverage; religious requirements may apply

💡 Critical insight: If you retire at 55 and need to bridge 10 years until Medicare, your total health insurance costs could range from $48,000 to $180,000+ depending on your coverage choices, income, and health status. This “Medicare gap” is one of the biggest financial planning blind spots for early retirees.

⚖️ 10. Why You’re “Forced” to Get Medicare at 65 — The Social Security Connection

Technically, nobody forces you to enroll in Medicare. But the practical reality makes opting out nearly impossible for most Americans.

While Medicare isn’t necessarily mandatory, it is automatically offered in some situations and may require some effort to opt out. Here’s what happens in practice:

If you’re already receiving Social Security benefits when you turn 65, you’re automatically enrolled in both Part A and Part B. You can decline Part B (and stop paying its premium), but you cannot decline Part A without also stopping your Social Security benefits and repaying everything you’ve received.

This creates a de facto mandate for the vast majority of 65-year-olds. The reasons behind this linkage are structural: Part A is funded by the Hospital Insurance Trust Fund, which is built from payroll taxes during your working years. The government considers Part A a “prepaid” benefit you’ve already earned — and the law was written so that Social Security and Part A are inseparable.

❓ “Can I decline…”	Answer	Consequence
Part A while keeping Social Security?	No ❌	Must forfeit and repay all Social Security benefits
Part B while keeping Part A?	Yes ✅	May face 10% penalty per year when you eventually enroll
Part D?	Yes ✅	May face 1% per month penalty when you eventually enroll
Medicare Advantage?	Yes ✅	This is always optional; you keep Original Medicare
All of Medicare while keeping private insurance?	Technically yes	Penalties, and private insurer may reduce payments once you’re Medicare-eligible

One key reason to delay Medicare Part A is because you may want to keep contributing to a health savings account. Once you enroll in any part of Medicare, you can no longer put money into an HSA.

💡 Critical insight: Some private insurers have clauses that reduce or eliminate their payment obligations once you become eligible for Medicare — not just once you enroll. This means declining Medicare doesn’t necessarily protect your private insurance benefits. Always read your policy’s coordination-of-benefits language, and talk to your plan administrator before your 65th birthday.

🗺️ 11. State-by-State Variations: Where Supplemental Coverage Differs Dramatically

While Medicare itself is a federal program with uniform rules across all 50 states, several key aspects of the Medicare experience vary significantly by state:

🗺️ State-Variable Factor	How It Varies
Medigap access under 65	16 states guarantee full access with premium protections; 4 states have zero protections for under-65 beneficiaries
Medicaid expansion	40 states + D.C. expanded Medicaid (covering more dual-eligibles); 10 states did not
Medicare Savings Programs thresholds	Income and asset limits for state programs that pay Medicare premiums vary by state
Medigap pricing method	States allow “attained-age” (premiums rise as you age), “issue-age” (based on age at purchase), or “community-rated” (same price for all)
Medicare Advantage plan availability	Plan options, premiums, and benefits differ by county
State supplement to Medicare	Some states (like Connecticut, Massachusetts) offer additional programs for seniors

Four states have no provisions and no plans geared to the under-65 population for Medigap. Eight states and D.C. have no coverage requirement for insurers but coverage is available. Twelve states require insurers to offer at least one Medigap plan to those under 65. Ten states make all plans guaranteed-issue but under-65 premiums can be much higher. Sixteen states make all plans guaranteed-issue and include restrictions on premiums.

💡 Critical insight: If you qualify for Medicare through disability before age 65, your state essentially determines whether you can get affordable supplemental insurance. In states like New York, all Medigap plans are available to under-65 beneficiaries at regulated rates. In Arizona, Ohio, or North Dakota, you may have zero Medigap options until you turn 65 — leaving you exposed to Original Medicare’s 20% coinsurance with no out-of-pocket cap.

❓ Frequently Asked Questions

Can a non-citizen who has worked in the U.S. for 20 years get Medicare? If they’re a green card holder who has lived in the U.S. for at least 5 continuous years and paid Medicare taxes for 40 quarters, yes — they qualify on the same terms as a citizen. Green card holders are among only three groups of lawfully present noncitizens that retain Medicare eligibility under the new law.

I’m on an H-1B visa and pay Medicare taxes. Can I use Medicare? Not while on a temporary work visa. You must become a lawful permanent resident (green card holder) and meet the 5-year residency requirement. However, the quarters of Medicare tax you’re paying now will count toward your 40-quarter requirement when you eventually qualify.

My elderly parent just immigrated. When can they get Medicare? If immigrants are permanent residents for 5 years, have continuously resided in the U.S. for that duration, and are 65 years of age or above, they can buy Medicare coverage. However, without 40 quarters of U.S. work history, they’ll pay up to $565/month for Part A plus $202.90/month for Part B — over $9,200 per year in premiums alone.

Can I have Medicaid and Medicare at the same time? Yes. Approximately 12 million Americans are “dual eligibles.” If you qualify, Medicaid pays your Medicare premiums and most cost-sharing, giving you comprehensive coverage with minimal out-of-pocket costs.

Does receiving SSI (Supplemental Security Income) qualify me for Medicare? Not directly. SSI can qualify you for Medicaid in most states, but Medicare eligibility requires SSDI (Social Security Disability Insurance), which is a different program. SSDI is based on work history; SSI is based on financial need. They can overlap, but only SSDI triggers Medicare eligibility after 24 months.

If I lose my disability status, do I lose Medicare? If a person’s condition improves to the point that they no longer qualify for SSDI, they will also no longer be eligible for Medicare. Should this happen, they must wait until they reach age 65 before re-enrolling. However, there is an extended period of coverage available for people who return to work while still medically disabled.

This article reflects 2026 Medicare and Medicaid eligibility rules as published by the Centers for Medicare & Medicaid Services (CMS), the Social Security Administration (SSA), Medicare.gov, HealthCare.gov, the Kaiser Family Foundation (KFF), and state Medicaid agencies. Immigration-related eligibility changes reflect the federal law enacted in 2025. Eligibility criteria are subject to federal and state regulation. Contact 1-800-Medicare, your local State Health Insurance Assistance Program (SHIP), or your state Medicaid office for personalized guidance. This content is informational only and does not constitute legal, financial, or immigration advice.

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