Project Kos | Stage 1. Getting Started

Stage 1

Getting started

Ten paths into the senior healthcare system. Pick the one that fits your situation. Each path covers the timeline, the action steps, the rules, and where things commonly go wrong.

Important: Project Kos provides educational information about Medicare, Medicaid, and other healthcare coverage based on official CMS, SSA, HHS, VA, and DoD sources. This is not medical, legal, or financial advice. Coverage rules change. Individual circumstances vary. For decisions affecting your specific care or coverage, consult your physician, a licensed insurance agent, a SHIP counselor, a VSO, or an attorney as appropriate. Project Kos is not affiliated with any insurance company, government agency, or healthcare provider, and does not sell insurance, healthcare services, or other products.

Start here

Find your path

Answer a few questions and we'll point you to the right path. Each answer either takes you to a path or asks the next question.

Are you 65 or older, or will you turn 65 within the next 12 months?

Still not sure? Free, unbiased help is available from your State Health Insurance Assistance Program (SHIP) at 1-877-839-2675 or shiphelp.org, and from your local Area Agency on Aging at 1-800-677-1116 or eldercare.acl.gov.

Under 65

Pre-Medicare

You need coverage now and Medicare has not started yet.

Pre-Medicare coverage (under 65) is one of the most expensive periods in adult life - you've aged out of cheaper younger-adult options but haven't yet reached Medicare. Three main pathways exist: Affordable Care Act Marketplace coverage with income-based subsidies; Medicaid if income qualifies; and COBRA continuation of employer coverage. Each has tradeoffs around cost, network, and timing. The decision usually depends on income, current network preferences, and how long you need to bridge until 65. The biggest mistake is failing to plan the eventual transition into Medicare - Marketplace plans don't automatically convert and ACA subsidies end at Medicare eligibility.

Pre-Medicare coverage timeline

How to bridge from now until Medicare starts at 65

Now

Identify your gap

How long until you turn 65? What ends your current coverage (job loss, retirement, divorce, aging off parent's plan, COBRA expiring)?

Within 60 days

Apply through ACA Marketplace

healthcare.gov or your state exchange. Loss of coverage triggers a 60-day Special Enrollment Period.

If income qualifies

Apply for Medicaid

Apply at your state agency. 138% FPL ($21,888 single 2026) in expansion states; lower in non-expansion.

If COBRA available

Decide on COBRA

Up to 18 months of employer coverage at 102% of cost. Do the math vs Marketplace before electing.

3 months before 65

Plan transition to Medicare

Your IEP opens. Medicare becomes primary; current coverage decisions affect Medicare timing.

At 65

Medicare begins

Move from Stage 1 prep into Medicare enrollment path. ACA subsidies end at Medicare eligibility.

Your action steps

Identify when your current coverage ends

Job loss date, retirement date, divorce finalization, COBRA expiration, end of parent's plan. The end-date is your trigger for a 60-day Special Enrollment Period through ACA Marketplace.
Estimate your 2026 income

Subsidies depend on it. Up to 138% FPL ($21,888 single, $29,587 couple) qualifies for Medicaid in expansion states. Up to 400% FPL still qualifies for ACA premium tax credits.
Check if you qualify for Medicaid first

Apply at your state Medicaid agency or healthcare.gov. Medicaid is more comprehensive than Marketplace plans for those who qualify. Check the retroactive coverage box if you have recent bills.
Compare ACA Marketplace plans

healthcare.gov or your state exchange. Filter by metal tier (Silver typically has best subsidies), provider network, and prescription formulary.
If COBRA is offered, do the math

COBRA = 102% of full employer cost. ACA with subsidies often costs less. But: COBRA continues your existing network and deductible progress for the year.
Set up calendar reminder for 65

Three months before 65, your Medicare Initial Enrollment Period opens. Set calendar reminders for: 3 months before, birth month, 3 months after.

The rules

ACA Marketplace eligibility

Available to anyone not Medicare-eligible. Loss of qualifying coverage triggers 60-day Special Enrollment Period.

45 CFR 155.420

ACA premium tax credit limits

Available up to 400% FPL ($63,840 single, 2026). Recent expansions made subsidies more generous through 2025; check 2026 status.

26 USC 36B

Medicaid expansion limit

Up to 138% FPL ($21,888 single, $29,587 couple, 2026) in 40 expansion states. Lower limits in 10 non-expansion states.

42 USC 1396a(a)(10)(A)(i)(VIII)

COBRA continuation

Up to 18 months at 102% of full employer cost. Triggered by qualifying events: job loss, divorce, death of covered spouse, aging off coverage.

29 USC 1162

Medicare timing

Initial Enrollment Period: 3 months before 65th birthday month, birth month, 3 months after.

42 CFR 407.14

ACA subsidy termination

Medicare eligibility ends premium tax credit eligibility for the same months. Cannot have both.

26 USC 36B(c)(2)(C)

How it works

The ACA Marketplace works through metal tiers (Bronze, Silver, Gold, Platinum) that determine premium and out-of-pocket cost-sharing. Silver tier is typically the best value for those receiving cost-sharing reduction subsidies (which require enrollment in Silver). Premium tax credits are calculated based on your projected annual income - and reconciled at tax time, so accurate income projection matters.

Medicaid expansion made coverage available up to 138% FPL in 40 states (as of 2026). Non-expansion states cover only narrow categories: typically very low-income parents, pregnant women, disabled individuals, and the elderly. If you live in a non-expansion state and earn below 100% FPL but above your state's specific Medicaid limit, you may fall into the 'coverage gap' - too poor for Marketplace subsidies but ineligible for Medicaid.

COBRA lets you continue your employer plan for up to 18 months after a qualifying event. The cost is up to 102% of the full employer cost - typically far higher than the employee-only contribution you paid while employed. ACA Marketplace coverage with subsidies often costs less than COBRA. But COBRA preserves your existing network, deductible progress, and provider relationships - which can matter if you're mid-treatment.

Going deeper

Identify your coverage trigger event and effective date. Job loss, retirement, divorce, COBRA expiration, end of parent's plan. The end-date opens your 60-day Special Enrollment Period.
Estimate your 2026 income for subsidy purposes. Include all sources: wages, self-employment, investment income, pension, Social Security (if applicable). Conservative estimate is safer than aggressive.
Apply for Medicaid first if income may qualify. medicaid.gov/state-overviews. Medicaid is more comprehensive and cheaper than Marketplace coverage if you qualify. Check the retroactive coverage box if you have recent bills.
If income exceeds Medicaid limit, apply through ACA Marketplace. healthcare.gov or your state exchange. Filter by metal tier, network, and prescription formulary. Silver tier usually best with subsidies.
If COBRA is offered, calculate total cost both ways. ACA with subsidies vs COBRA at 102% of employer cost. COBRA preserves network and deductible; ACA usually cheaper if subsidy-eligible.
Set Medicare-transition reminders 3-6 months before 65. Your IEP opens 3 months before your 65th birthday month. Marketplace coverage doesn't automatically transition; ACA subsidies end at Medicare eligibility.

Where people lose money or access

Underestimating income on Marketplace applicationSubsidies are reconciled at tax time. If you receive more subsidy than you should have based on actual income, you owe the difference back. Conservative income estimates avoid surprise tax bills.

Missing the 60-day SEP after losing employer coverageLoss of coverage triggers a 60-day Marketplace SEP. Miss it and you wait until next Open Enrollment (Nov 1 - Jan 15 typical). Can mean months without coverage.

Falling into the coverage gap in non-expansion states10 states haven't expanded Medicaid. In those states, income below 100% FPL may be too low for Marketplace subsidies AND too high for state Medicaid. The gap leaves you uninsurable through standard channels.

Not planning Medicare transitionACA subsidies end at Medicare eligibility. Marketplace plans don't convert to Medicare. You must actively enroll in Medicare during your IEP. Planning starts 6 months before 65.

Edge cases

Disability before 65

If you receive SSDI, the 24-month Medicare waiting period is bridged by Medicaid (income-eligible) or Marketplace coverage. Document SSDI award letter - useful for both Medicaid eligibility and SEP triggers.

Divorce coverage loss

Loss of spouse's coverage triggers a 60-day SEP. COBRA may also be available from spouse's employer plan. Consider both options carefully.

Aging off parent's plan at 26

Different transition: aging off parent's plan triggers 60-day SEP. ACA Marketplace plans available. Some states allow extension beyond 26 in specific circumstances.

Self-employed with high income

Above 400% FPL, no premium tax credits available - full price. Self-employment health insurance is tax-deductible. Some self-employed retirees consider COBRA as alternative.

Where to go next

Sources

ACA Marketplace: healthcare.gov or your state exchange.
Medicaid eligibility: medicaid.gov/state-overviews.
2026 ACA premium tax credit info: 26 USC 36B; IRS Form 8962.
COBRA rights: 29 USC 1162; dol.gov/agencies/ebsa/laws-and-regulations/laws/cobra.
SHIP Marketplace help: Many SHIPs help with both Medicare prep and Marketplace navigation: 1-877-839-2675.

Still working

Working past 65

You have employer coverage and are approaching or past 65.

Working past 65 with employer health insurance creates the most complex Medicare timing decisions in the entire system. The single biggest factor is your employer's size: 20+ employees means your employer plan pays primary and you can safely delay Part B; fewer than 20 means Medicare must be primary at 65 and skipping it leaves you on the hook for what Medicare would have covered. Beyond the size rule, retirement timing affects multiple windows that don't move together: Part B has an 8-month Special Enrollment Period; Medigap has 63 days; Part D has 63 days. Missing any one creates penalties that follow you for the rest of your Medicare years.

Working past 65 timeline

How employer coverage interacts with Medicare

Now

Verify employer size

Get HR to confirm in writing: 20+ employees = employer plan primary; under 20 = Medicare primary at 65.

3 months before 65

Initial Enrollment Period opens

7-month window. If 20+ employees: enroll in Part A only (free) and delay Part B. Under 20: enroll in BOTH.

At 65

Coverage decision activates

Verify HSA contributions stopped if applicable (Medicare ends HSA eligibility). Get creditable coverage notice from HR.

Each year working

Re-verify creditable status

Drug coverage must be certified creditable annually to avoid Part D late penalty when you eventually enroll.

Within 8 months of retirement

Part B Special Enrollment Period

8 months from end of EMPLOYER coverage (not COBRA). Enroll in Part B without late penalty.

Within 63 days of retirement

Medigap & Part D windows

Medigap guaranteed-issue rights: 63 days. Part D enrollment SEP: 63 days. Tighter windows than Part B.

Your action steps

Get employer size in writing from HR

Federal Medicare Secondary Payer rules depend on this. Get explicit confirmation: '20+ employees' or 'fewer than 20 employees' for Medicare Secondary Payer purposes.
For Medicare Secondary Payer purposes, do we count as 20+ or under 20 employees? I need this in writing.
Get creditable coverage notice annually

Required from employer each year. Confirms drug coverage meets Medicare's standard. Without it, you may face Part D late penalty when you eventually enroll. Save copies.
Enroll in Part A at 65 (it's free)

Even if delaying Part B. Apply via SSA at ssa.gov/medicare or 1-800-772-1213. If receiving Social Security, auto-enrollment. If not, you must apply manually.
Stop HSA contributions before Medicare enrollment

Medicare enrollment ENDS HSA eligibility. Even Part A. Any HSA contribution during Medicare enrollment triggers tax penalty. Coordinate with HR and benefits 6+ months ahead.
Decide Part B timing based on employer size

20+ employees: delay Part B until retirement. Under 20: enroll at 65 (employer plan pays secondary). Confirm in writing with employer plan administrator before deciding.
Plan retirement transition timing

8-month Part B SEP starts at end of employer coverage (NOT COBRA). 63-day Medigap and Part D windows. Coordinate retirement date with these windows.

The rules

20+ employee rule

Employer plan is primary; Medicare can be safely delayed. Part B SEP starts at end of employer coverage.

42 USC 1395y(b)(1)(A)

Under-20 employee rule

Medicare is primary at 65. Employer plan pays as if Medicare were enrolled. Skipping Medicare leaves you owing what Medicare would have paid.

42 USC 1395y(b)(1)(A)

Employee count

Counts ALL full-time and part-time employees in employer plus affiliated entities. Subject to 50% rule for 20+ test.

42 CFR 411.170

Part B Special Enrollment Period

8 months from end of EMPLOYER coverage (NOT COBRA). No late penalty if enrolled within window.

42 CFR 407.20

Medigap guaranteed issue

63 days from loss of qualifying employer-sponsored Medicare-eligible coverage. Federal Plans A, B, C, D, F, G, K, L without underwriting.

42 USC 1395ss(s)(2)

Part D Special Enrollment Period

63 days from loss of creditable employer drug coverage. No late penalty if creditable.

42 CFR 423.38

Creditable coverage requirement

Employer drug coverage must be CERTIFIED creditable annually. Some plans (especially HDHPs) are not creditable.

42 CFR 423.56

HSA contribution termination

Medicare enrollment (even Part A) ENDS HSA eligibility. Contributions during enrollment are subject to tax penalty.

IRC §223(b)(7)

How it works

Medicare Secondary Payer rules determine which insurance pays first when you have multiple coverages. The 20+ employee threshold reflects historical policy that larger employers should bear primary responsibility. The threshold counts the entire employer organization, not just your specific location. A hospital with 5 employees at your specific clinic but 500 system-wide counts as 500 for MSP purposes.

If your employer has 20+ employees and you're 65+ working: your employer plan pays primary for your medical claims. You can enroll in Part A at 65 (it's free) but delay Part B without penalty. When you eventually retire or coverage ends, an 8-month Special Enrollment Period gives you time to enroll in Part B without late penalty. The Medigap 63-day guaranteed-issue window starts at the same trigger.

If your employer has fewer than 20 employees: Medicare must be primary at 65. Even if you have employer coverage, that plan acts as if Medicare were enrolled - meaning it won't pay what Medicare would have covered. You should enroll in BOTH Part A and Part B at 65. Skipping Part B in this scenario creates massive coverage gaps.

HSA contributions present a separate trap. Medicare enrollment of any kind - even Part A - terminates your HSA eligibility. Contributions made during Medicare enrollment trigger tax penalties. If you currently have an HSA, plan transition 6+ months before 65: stop contributions in the months leading up to Medicare enrollment, and verify your last-year contribution doesn't push past your eligibility termination date.

Going deeper

Get your employer size in writing from HR before age 65. Federal Medicare Secondary Payer rules depend on this answer.
For Medicare Secondary Payer purposes, do we count as 20+ or under 20 employees? Please confirm in writing.
Request a creditable coverage notice annually. This protects against Part D late penalty when you eventually enroll in Part D.
Enroll in Part A at 65 (it's free for most). If receiving Social Security, auto-enrolled. If not, apply at ssa.gov/medicare or call 1-800-772-1213.
Stop HSA contributions 6+ months before Medicare enrollment. Coordinate with HR to time the transition. Even Part A enrollment ENDS HSA eligibility.
Decide Part B timing based on employer size. 20+ employees: delay until retirement. Under 20: enroll at 65.
When retirement approaches: calendar all three windows simultaneously. Part B (8 months from end of employer coverage), Medigap (63 days), Part D (63 days).
Get documentation of coverage end-date in writing from employer. Termination letter, COBRA election notice, or formal retirement letter. Required for all three SEPs.

Where people lose money or access

Skipping Part B at small employer (<20)Most expensive mistake in Working Past 65 territory. When Medicare should have been primary but you don't have it, the employer plan denies the Medicare-portion. Result: you owe 80% of medical bills that Medicare would have paid. Can be tens of thousands per year.

Trusting HR's claim that COBRA delays MedicareIt doesn't. COBRA is NOT considered active employer coverage for Part B SEP purposes. Your 8-month window starts when your employer plan ends, not when COBRA ends. Many retirees miss this and face permanent late penalty plus coverage gap.

Continuing HSA contributions after Medicare enrollmentEven Part A enrollment ENDS HSA eligibility. Contributions during enrollment are subject to 6% excise tax annually until corrected. Some employees don't realize they were auto-enrolled in Part A when they applied for Social Security.

Missing Medigap GI 63-day window after retirement63 days passes quickly during the chaos of retirement transition. After that window, Medigap underwriting applies in 47 states. Pre-existing conditions can mean denial or dramatically higher premiums.

Edge cases

Spouse coverage

If covered through spouse's employer plan, the rule applies to spouse's employer (not yours). 20+ employees at spouse's employer = spouse's plan primary. Different employer sizes between you and spouse can create complex coordination.

Multiemployer plans (union)

Union or multiemployer plans may have different rules. Verify with plan administrator and Medicare. Employer size for MSP purposes = sum across all employers in the plan.

Self-employed

Self-employed individuals don't have an employer plan and Medicare timing follows standard IEP rules. ACA Marketplace coverage doesn't extend Part B SEP. Plan transition to Medicare carefully at 65.

End-Stage Renal Disease (ESRD)

Special rules: Medicare is secondary for first 30 months of ESRD entitlement, regardless of employer size. After 30 months, Medicare becomes primary.

Where to go next

Sources

Medicare Secondary Payer rules: 42 USC 1395y(b); 42 CFR 411.
BCRC (Benefits Coordination & Recovery Center): 1-855-798-2627.
HSA + Medicare interaction: IRS Publication 969; IRC §223.
SHIP free counseling: 1-877-839-2675 or shiphelp.org.
1-800-MEDICARE: 24/7 federal line.

Turning 65

Medicare enrollment

You are entering Medicare for the first time.

Medicare enrollment at 65 is a once-in-a-lifetime window with significant consequences for getting it wrong. Your 7-month Initial Enrollment Period (IEP) opens 3 months before your 65th birthday month and closes 3 months after. Inside that window, you decide between Original Medicare and Medicare Advantage; you have a one-time guaranteed-issue right to Medigap; and you must enroll in Part D or face a permanent late penalty. Outside that window, options narrow significantly and costs grow. The single biggest mistake is treating Medicare like a one-button decision - it's actually three separate decisions (A/B, supplement type, Part D) that interact with each other.

Medicare enrollment timeline

Your Initial Enrollment Period and what happens around it

3 months before 65

IEP begins

Your 7-month Initial Enrollment Period opens. Enrolling now means Medicare starts the month you turn 65.

Birth month

Coverage decision

Original Medicare vs Medicare Advantage. If Medigap: 6-month one-time guaranteed-issue window starts now.

Within 63 days

Part D enrollment

Standalone Part D (with Original Medicare) or Part D bundled in MA. 63-day window from Part B effective date.

Within 6 months

Medigap window closes

After 6 months from Part B effective date, 47 states allow medical underwriting for Medigap. Lock in now.

3 months after 65

IEP closes

After this, missing enrollment triggers General Enrollment Period (Jan 1 - Mar 31, coverage starts following month) plus late penalties.

Each Oct 15 - Dec 7

Annual Election Period

Change Part D, change MA plan, switch between OM and MA. Effective January 1 of next year.

Your action steps

Calendar your Initial Enrollment Period

Your IEP runs 3 months before your 65th birthday month, your birth month, and 3 months after. 7 months total. Add to calendar with reminders at each milestone.
Decide: auto-enrollment or manual application

If you're already receiving Social Security or RRB benefits, you'll be auto-enrolled in Parts A and B. Card arrives 3 months before 65. If not, apply yourself at ssa.gov/medicare.
Choose Original Medicare vs Medicare Advantage

OM: nationwide acceptance, no networks, predictable rules, but no OOP cap (need Medigap). MA: typically lower premium, OOP cap built in, but networks and prior auth. Stage 2 explores in depth.
If choosing OM, lock in Medigap within 6 months

Federal Medigap Open Enrollment is one-time, 6 months from Part B effective date. After this window, 47 states allow medical underwriting. Plan G is most popular for new enrollees in 2026.
Enroll in Part D within 63 days

Or have other creditable coverage. Standalone Part D plans for OM; bundled Part D in MA plans. 1% lifetime late penalty for each month delayed beyond 63 days.
Set up MyMedicare.gov account

mymedicare.gov is the official federal portal. Free, no ads. Track claims, EOBs, preventive services. Set up two-factor authentication during signup. Critical for catching billing errors early.

The rules

Initial Enrollment Period

7 months total: 3 months before 65th birthday month + birth month + 3 months after.

42 CFR 407.14

Auto-enrollment trigger

Automatic for those receiving Social Security or RRB benefits. Manual application required otherwise.

42 CFR 406.6

Part A premium

Free for those with 40+ quarters of Medicare-covered work. $311/month with 30-39 quarters; $565/month with fewer than 30 (2026).

CMS 2026 Premiums Fact Sheet

Part B premium 2026

$202.90 standard. IRMAA applies above $109,000 single / $218,000 joint - up to $689.90 at top bracket.

CMS 2026 Premiums Fact Sheet

Part B late penalty

10% premium increase per 12 months delayed beyond IEP. Permanent. Exemption only for those with active employer coverage (20+ employees).

42 CFR 408.22

Medigap one-time window

6 months from Part B effective date for guaranteed-issue Medigap with no medical underwriting. Federal protection.

42 USC 1395ss(s)(2)

Part D late penalty

1% of national base premium ($38.99 in 2026) per month delayed beyond 63 days. Permanent.

42 CFR 423.46

How it works

Medicare has four parts that work together. Part A (hospital insurance) is free for most people because you paid into it through payroll taxes during your working years. Part B (medical insurance) covers physician services, outpatient care, durable medical equipment, and most preventive care - it has a monthly premium ($202.90 standard for 2026). Part C (Medicare Advantage) is an alternative way to receive Parts A and B through a private plan, usually with Part D included. Part D (prescription drugs) is sold by private insurers under contract with CMS.

When you enroll in Medicare, you face three decisions in sequence. First: Original Medicare or Medicare Advantage? Original Medicare lets you see any provider who accepts Medicare nationwide; Medicare Advantage uses provider networks but typically has lower premiums and an out-of-pocket maximum (which Original Medicare lacks). Second: if you choose Original Medicare, do you buy Medigap to cover the 20% coinsurance gap? This must happen within your 6-month one-time guaranteed-issue window. Third: how do you handle prescription drugs? Standalone Part D plan with Original Medicare, or bundled Part D inside a Medicare Advantage plan.

These decisions interact. Original Medicare without Medigap leaves you exposed to unlimited 20% coinsurance - fine if you have low utilization, catastrophic during a serious illness. Medicare Advantage caps your in-network out-of-pocket at $9,250 for 2026 but uses networks that may not include your preferred providers. Medigap eliminates most cost-share but costs $130-280/month depending on plan letter and insurer. The right choice depends on your health status, financial situation, geographic flexibility, and preference for predictability vs lower premium.

Going deeper

Confirm whether you'll be auto-enrolled. If you're already receiving Social Security or RRB benefits when you turn 65, auto-enrollment in Parts A and B is automatic. Card arrives 3 months before 65.
If not auto-enrolled, apply manually at ssa.gov/medicare. Best timing: during the 3 months BEFORE your 65th birthday month. Coverage starts the month you turn 65 if you apply during this window.
Decide Part B timing if you have employer coverage. Verify employer size first.
For Medicare Secondary Payer purposes, do we count as 20+ or under 20 employees? Get this in writing.
Choose between Original Medicare and Medicare Advantage. Use medicare.gov/plan-compare to enter your medications and providers. Compare TOTAL annual cost (premium + estimated copays), not just premium.
If choosing Original Medicare: lock in Medigap during your one-time 6-month guaranteed-issue window. Plan G is most popular for new enrollees in 2026. Compare prices across 3+ insurers - same plan letter has identical benefits by federal law.
Enroll in Part D within 63 days of Part B effective date. Use Plan Finder at medicare.gov/plan-compare with your specific medications. Lowest-premium plan is rarely the lowest-cost plan.
Set up MyMedicare.gov account at mymedicare.gov. Enable two-factor authentication and email notifications for new claims. Critical for catching billing errors early.

Where people lose money or access

Letting auto-enrollment lock you in without thinkingIf you're auto-enrolled in Original Medicare, you may miss the chance to evaluate Medicare Advantage. Or you may want to delay Part B due to employer coverage. Auto-enrollment doesn't mean optimal - review and adjust before your 65th birthday.

Missing the Medigap 6-month windowAfter 6 months from Part B effective date, 47 states allow medical underwriting for Medigap. Pre-existing conditions can mean denial or dramatically higher premiums. The window cannot be reopened. Buy Medigap during the window even if you're healthy - locks in lifetime guaranteed coverage.

Skipping Part D because you're healthyHealthy 65-year-olds become medicated 75-year-olds. The lowest-premium Part D plan costs $0-15/month. The eventual late penalty (1% per month delayed) compounds for decades. Always enroll in something during IEP, even a minimum plan.

Choosing Medicare Advantage on premium alone$0 premium plans often have higher copays, narrower networks, and more prior authorizations. Total annual cost matters: premium + estimated copays + likelihood of needing out-of-network care. Compare carefully.

Edge cases

Working past 65 with employer coverage

If your employer has 20+ employees, you can delay Part B without penalty. Enroll in Part A only (free) at 65. Part B 8-month Special Enrollment Period starts when employer coverage ends. Different rules apply for under-20 employers - see the Working Past 65 path.

Disability before 65

If Medicare-entitled before 65 due to disability, you get a SECOND 6-month Medigap Open Enrollment Period when you turn 65 with full federal protections. State protections during disability vary widely.

Already on COBRA

COBRA does NOT delay Part B SEP. Your 8-month window starts at end of EMPLOYER coverage (not COBRA). Many retirees miss this and face permanent late penalty. Enroll in Medicare while on COBRA if 65+.

End-Stage Renal Disease (ESRD)

ESRD triggers Medicare eligibility regardless of age. Coverage typically starts the 4th month of dialysis. Different rules apply during the first 30 months when group plans pay primary.

Where to go next

Sources

Medicare enrollment timing: medicare.gov/basics/get-started-with-medicare/sign-up.
2026 premiums and IRMAA: CMS 2026 Medicare Parts A & B Premiums Fact Sheet, Nov 14, 2025.
Medigap protection: 42 USC 1395ss; medicare.gov/medigap.
Plan Finder (federal): medicare.gov/plan-compare. Free, ad-free.
SHIP (free counseling): 1-877-839-2675 or shiphelp.org.
1-800-MEDICARE: 24/7 federal line.

Lower income

Medicaid enrollment

You may qualify for help paying for care or coverage costs.

Medicaid is the largest federal-state health insurance program in the United States and the most comprehensive coverage available to those who qualify. For seniors and adults entering Medicaid for the first time, eligibility runs through one of several pathways: ACA expansion (under 65, up to 138% FPL); Aged-Blind-Disabled Medicaid (65+ or disabled); Long-Term Services and Supports (nursing home, HCBS waivers); or Medically Needy programs that allow spend-down. The application is state-specific but federally regulated. Critical detail: Medicaid offers retroactive coverage up to 3 months in most states - meaning if you have recent unpaid medical bills, applying NOW may cover bills from up to 3 months ago.

Medicaid enrollment timeline

Apply, qualify, and maintain coverage

Now

Gather documents

Photo ID, Social Security card, proof of income (Social Security letter, pension statements), bank statements, recent tax return.

Apply

Submit at state agency

medicaid.gov/state-overviews. Online portal in most states; paper application available. Can also apply via healthcare.gov in some states.

Check retroactive box

Cover recent bills

Most states allow 3 months retroactive coverage. Critical if you have unpaid medical bills from before applying.

Within 45 days

Decision arrives

Federal rule: 45 days standard, 90 days for disability-based applications. If approved, coverage may be effective retroactively.

Annual

Recertification

Federal requirement. Some states use ex parte (auto-renewal); others require packet response. Missing the deadline ends coverage.

If denied

Appeal within 60-90 days

About 30-40% of Medicaid denials are reversed on appeal. State fair hearing process is free.

Your action steps

Determine your category

Aged-Blind-Disabled (ABD) Medicaid is typical for 65+. Income limit ~100% FPL. Asset limit varies by state, often $2,000 single / $3,000 couple, but many states have higher or no asset test for ABD.
Gather documentation

Photo ID, Social Security card, proof of income (Social Security letter SSA-1099, pension statements, recent pay stubs), bank statements (last 3-12 months), recent tax return.
Check if your state has retroactive coverage

Federal rule allows up to 3 months retroactive. Some states limit to 1-2 months under demonstration waivers. CRITICAL if you have recent unpaid medical bills.
Apply through state agency or healthcare.gov

medicaid.gov/state-overviews to find your state's portal. Most states accept online application. Some states also accept applications through healthcare.gov.
Check the retroactive coverage box

Easy to miss. If you have any unpaid medical bills from the last 3 months, this can wipe them out. Ask the application reviewer to confirm retroactive coverage was requested.
Set up portal account for ongoing management

Most states have online member portals. Set up early - annual renewal happens through this portal in many states. Federal rule: must apply within 45 days (90 days for disability-based).

The rules

Aged-Blind-Disabled Medicaid

Income limit typically 100% FPL or higher (varies by state). 2026 FPL: $15,960 single, $21,640 couple.

42 USC 1396a

ACA expansion Medicaid

Income up to 138% FPL ($21,888 single, 2026) in 40 expansion states. Different rules than ABD Medicaid.

42 USC 1396a(a)(10)(A)(i)(VIII)

Asset limits (ABD)

Vary by state. Often $2,000 single / $3,000 couple in countable assets, but many states have higher or no asset test for ABD applicants.

State plan amendments

Retroactive coverage

Up to 3 months retroactive in most states. Some states limit to 1-2 months under demonstration waivers.

42 CFR 435.915

Application processing time

States must process within 45 days (90 days for disability-based). Federal requirement.

42 CFR 435.911

Continuous enrollment

12-month continuous enrollment in some states. Standard reapplication annually otherwise.

42 CFR 435.916

Citizenship/immigration

Citizens and qualified non-citizens generally eligible. Some legal immigrant categories have 5-year wait. Emergency Medicaid available for some categories.

42 USC 1396b(v)

How it works

Medicaid is jointly funded by federal and state governments. Each state administers its own Medicaid program within federal rules - meaning eligibility, benefits, and processes vary significantly. Federal law requires certain mandatory coverage groups (low-income pregnant women, children, elderly, disabled) and mandatory benefits (inpatient/outpatient hospital, physician services, lab/x-ray, etc.). States can expand beyond minimums to optional populations and benefits.

Eligibility for seniors typically runs through Aged-Blind-Disabled (ABD) Medicaid. ABD has both an income test and (in most states) an asset test. Income limit is typically 100% FPL ($15,960 single, 2026), though some states are more generous. Asset limits vary widely: typically $2,000 single / $3,000 couple, but some states have eliminated asset tests for ABD applicants entirely.

The application typically goes through your state Medicaid agency website or by paper form. Some states use Healthcare.gov as the initial portal. The application asks for income (Social Security, pensions, wages, all sources), assets (bank accounts, investments, property other than home), household composition, address, citizenship/immigration status. Many states allow online application with electronic verification of income through SSA and IRS data.

Retroactive coverage is critical for those with recent medical bills. Federal rule allows up to 3 months retroactive - meaning if you apply in March and qualify, coverage can be effective back to December. This can wipe out hospital bills, ER visits, or other care during the retroactive period. Some states have demonstration waivers that limit retroactive coverage to 1-2 months; verify your state's policy.

Going deeper

Find your state's Medicaid application portal at medicaid.gov/state-overviews. Or apply through healthcare.gov in some states.
Gather documents before applying: photo ID, Social Security card, proof of income (Social Security letter SSA-1099, pension statements, recent pay stubs), bank statements (last 3-12 months), recent tax return.
Complete application carefully. If you have any recent medical bills (last 3 months), check the box for retroactive coverage on the application.
Verify retroactive coverage was requested. Many state portals let you re-confirm; if not, call to verify after submission.
Can you confirm my application includes a request for 3-month retroactive coverage? I have unpaid medical bills from [date range] that I'd like covered.
Submit and track your application. Federal requirement: 45 days standard, 90 days disability-based. Don't assume processing happened - follow up if you haven't received notice within timeline.
If approved with retroactive coverage: notify all providers from the retroactive period of your effective date. Provide Medicaid ID so they can rebill the retroactive period.
If denied: appeal within deadline (typically 60-90 days). About 30-40% of Medicaid denials are reversed on appeal. State fair hearing process is free and has federal due-process protections.

Where people lose money or access

Missing the retroactive coverage optionForgetting to check the retroactive coverage box means recent bills aren't covered. Always check it if you've had any medical care in the last 3 months. Once application is processed without retroactive coverage, getting it added later is much harder.

Asset transfers in the lookback periodLong-term care Medicaid has a 5-year lookback for asset transfers. Transferring assets shortly before applying creates penalty periods where Medicaid won't pay for nursing home care. Plan with elder law attorney for this category.

Not appealing denialsAbout 30-40% of Medicaid denials are reversed on appeal. Appeals are free and have federal due-process protections. Don't give up at first denial. State fair hearing is your right.

Not reporting income or asset changesFederal rule requires 10-day reporting of income/asset changes. Failure to report can lead to benefit recovery (state demands repayment of Medicaid paid during ineligible period). Staying compliant is much cheaper than facing recovery.

Edge cases

Coverage gap in non-expansion states

10 states haven't expanded Medicaid as of 2026. In those states, income below 100% FPL may be too low for Marketplace subsidies AND too high for state Medicaid. The gap leaves you uninsurable through standard channels until 65.

Spousal impoverishment

Married couples have spousal asset and income protection rules - particularly when one spouse needs nursing home care. Federal rules protect community spouse income and assets. Complex; consult elder law attorney before transferring assets.

Medicaid spend-down

Some states allow income above the standard limit if you spend the excess on medical bills. Track all medical receipts comprehensively. Spend-down rules vary significantly by state.

Presumptive eligibility

Some states have presumptive eligibility - temporary Medicaid coverage while application processes. Available at hospitals, FQHCs, and other sites. Ask if your hospital offers it.

Where to go next

Sources

State Medicaid agencies: medicaid.gov/state-overviews.
Healthcare.gov: healthcare.gov (initial portal in some states).
Federal Medicaid: medicaid.gov.
Area Agency on Aging (free help): 1-800-677-1116.
National Council on Aging benefits checker: benefitscheckup.org.

Disability before 65

Disability to Medicare

You receive disability benefits and Medicare is coming.

Social Security Disability Insurance creates a path to Medicare that runs through a 24-month waiting period - long enough that most beneficiaries need bridge coverage during the wait. Two diagnoses bypass the wait entirely: End-Stage Renal Disease (Medicare starts 4 months after regular dialysis begins) and Amyotrophic Lateral Sclerosis (Medicare starts the same month as SSDI). For everyone else on the standard SSDI-to-Medicare path, the 24 months become a critical planning window: the time to apply for Medicaid or ACA Marketplace coverage, get on Medigap-eligible records, and plan the eventual transition to Medicare without losing coverage continuity.

Disability to Medicare timeline

The 24-month waiting period and the exceptions

SSDI approved

Establish disability date

Date of Entitlement (DOE) is set by SSA. Can be retroactive up to 12 months before application.

Months 1-24

SSDI cash benefits, no Medicare

24-month waiting period for Medicare under most disabilities. Use Medicaid, ACA Marketplace, or COBRA in this gap.

Month 25

Medicare eligibility begins

Auto-enrolled in Part A and Part B. Card arrives 3 months before. You can opt out of Part B if you have other creditable coverage.

ESRD diagnosis

Skip the wait (ESRD path)

End-Stage Renal Disease: Medicare starts the 4th month of regular dialysis (or earlier with home dialysis training).

ALS diagnosis

Skip the wait (ALS path)

Amyotrophic Lateral Sclerosis: Medicare starts the same month SSDI begins. No 24-month wait.

Within 6 months of Part B

Medigap window opens

Federal law gives a Medigap OEP for those under 65 in some states. Re-opens at 65 with full federal protections.

Your action steps

Confirm your Date of Entitlement (DOE)

SSA establishes this when SSDI is approved. Can be retroactive up to 12 months before application. Your 24-month Medicare waiting period starts from DOE, not from approval date.
Calculate when Medicare begins

Standard: DOE + 24 months. Exceptions: ESRD (4 months from regular dialysis or earlier), ALS (same month as SSDI). Verify on your SSA approval letter.
Bridge the gap with Medicaid or ACA

During the 24-month wait, you need other coverage. SSDI doesn't include health insurance. Apply for Medicaid (income-based) or ACA Marketplace (loss of coverage triggers SEP).
Apply for Extra Help / LIS now

Don't wait for Medicare to start. SSDI eligibility plus low income often qualifies for Extra Help on Part D when Medicare begins. Apply via ssa.gov/medicare/part-d-extra-help.
Watch for auto-enrollment 3 months before Medicare

Card arrives 3 months before your Medicare effective date. If you have other creditable coverage, you can opt out of Part B. Default is auto-enrollment in both A and B.
Check Medigap state protections

Federal law doesn't guarantee Medigap for under-65 disability beneficiaries - state law varies. Some states (CA, NY, MA, others) have full protections; others don't. Check before age-65 transition.

The rules

24-month waiting period

Standard rule: 24 months from Date of Entitlement (DOE) to Medicare. DOE can be retroactive up to 12 months before SSDI application.

42 USC 426

ESRD exception

End-Stage Renal Disease: Medicare begins the 4th month of regular dialysis. Earlier with home dialysis training participation.

42 USC 426-1

ALS exception

Amyotrophic Lateral Sclerosis: Medicare begins the same month as SSDI. No 24-month wait.

42 USC 426(h)

Auto-enrollment

Automatic enrollment in Parts A and B 3 months before Medicare effective date. Can opt out of Part B if other creditable coverage.

42 CFR 406.6

Medigap protections (under 65)

Federal law does NOT guarantee Medigap for under-65 disability beneficiaries. State law varies widely - some states (CA, NY, MA, others) have full protections; others have none.

42 USC 1395ss

Medigap protections (at 65)

When disability beneficiary turns 65, full federal Medigap Open Enrollment Period reopens with guaranteed-issue rights for 6 months.

42 USC 1395ss(s)(2)

Trial Work Period

9-month period of unlimited earnings without losing SSDI. Earnings above $1,160/month (2026) count as a trial work month.

42 USC 422(c)

How it works

Your Date of Entitlement (DOE) is set by SSA when SSDI is approved. It can be retroactive up to 12 months before your application date if SSA determines your disability began earlier. This matters because your 24-month Medicare waiting period starts from DOE - meaning if your DOE is retroactive 12 months, your effective Medicare wait may be only 12 more months from application approval.

ESRD and ALS bypass the 24-month wait entirely. ESRD (kidney failure requiring dialysis or transplant) triggers Medicare eligibility regardless of age. Coverage typically starts the 4th month of regular dialysis - earlier with home dialysis training. ALS triggers Medicare the same month as SSDI begins. Both rules eliminate the 24-month gap that would otherwise apply.

During the 24-month wait, you need bridge coverage. Options: Medicaid (if income qualifies, often easier with disability category); ACA Marketplace (loss of coverage triggers SEP, premium tax credits available); COBRA (if recently lost employer coverage). Premium tax credits often make Marketplace coverage more affordable than COBRA. State-specific high-risk pools may also exist.

When Medicare begins (after the 24-month wait or earlier for ESRD/ALS), auto-enrollment occurs in both Parts A and B. Card arrives 3 months before effective date. You can opt out of Part B if you have other creditable coverage, but most disability beneficiaries should keep Part B given the difficulty of getting Medigap later.

Going deeper

Confirm your Date of Entitlement (DOE) via SSA award letter. Note: DOE may be retroactive up to 12 months before your application date.
Calculate your Medicare effective date: DOE + 24 months for standard rule. Exceptions: ESRD (4 months from regular dialysis) or ALS (same month as SSDI).
Bridge the 24-month gap with Medicaid or ACA Marketplace. Apply immediately for whichever fits your income. Don't wait - you need coverage during the gap.
Apply for Extra Help / LIS proactively at ssa.gov/medicare/part-d-extra-help. SSDI eligibility plus low income often qualifies for Extra Help on Part D when Medicare begins.
Watch for Medicare auto-enrollment 3 months before your effective date. Card arrives in mail. If you have other creditable coverage and want to opt out of Part B, return the card with the opt-out form.
Check your state's under-65 Medigap protections. Most states allow some Medigap option for under-65 disability beneficiaries, but rules vary widely. Use shiphelp.org or state insurance department for specific rules.
When approaching 65, prepare for the second Medigap window. Federal protections re-open with guaranteed-issue rights for 6 months from your 65th birthday month.

Where people lose money or access

Going without coverage during the 24-month waitCannot rely on emergency room access for chronic care. Without Medicaid, ACA Marketplace, or other coverage, the 24-month wait creates massive coverage gaps. Bills from this period can be catastrophic.

Skipping Part B after auto-enrollmentEasy to skip if you have other coverage during the wait. But most under-65 disability beneficiaries struggle to qualify for Medigap or alternative coverage later. Keeping Part B preserves more options at 65 transition.

Not understanding state Medigap variationFederal protections don't apply to under-65 disability. State protection varies enormously: California, New York, Massachusetts, Connecticut, Maine, Oregon have strong protections. Many other states have none. Plan accordingly.

Trial Work Period mistakesEarnings above $1,160/month (2026) count as a trial work month. After 9 trial work months, extended period of eligibility starts. Mismanaging the TWP can lead to SSDI termination. Review with SSA before earning.

Edge cases

Working with disability (Ticket to Work)

Federal program supports return to work for SSDI beneficiaries. Continued Medicare for at least 93 months after Trial Work Period ends. Medicare buy-in available even longer for those who lose SSDI cash benefits but want to keep Medicare.

Childhood disability beneficiary

Adults disabled before age 22 can receive Disabled Adult Child (DAC) benefits based on parent's Social Security record. Medicare 24-month rule still applies, but family circumstances vary.

Survivor disability

Disabled widow(er)s aged 50+ can qualify for SSDI based on deceased spouse's record. Same 24-month Medicare wait applies.

Where to go next

Sources

SSDI eligibility: ssa.gov/disability.
Medicare for disabled: medicare.gov/basics/get-started-with-medicare/people-with-disabilities.
SSA general line: 1-800-772-1213.
State Medigap variation: shiphelp.org or your state insurance department.
Center for Medicare Advocacy (free help): medicareadvocacy.org.

Veteran

VA Healthcare

You served and want to use your VA healthcare benefit.

VA Healthcare is a separate federal benefit from Medicare and works alongside it for veterans 65+. Eligibility requires active duty service plus a discharge other than dishonorable, with specific length-of-service rules that vary by enlistment date. After applying via Form 10-10EZ, the VA assigns you to a Priority Group from 1 (highest, $0 for everything) to 8 (lower priority, copays for non-service-connected care). Priority Group reflects service-connected disability rating, income, and special eligibility (POW, Medal of Honor, combat veteran). Working with a free Veterans Service Officer dramatically simplifies the application process and can identify benefits you may not realize you qualify for.

VA Healthcare enrollment timeline

From eligibility check to first appointment

Confirm eligibility

Service requirements

Active duty service + discharge other than dishonorable. Length-of-service rules vary by enlistment date and circumstances.

Apply

VA Form 10-10EZ

Online at va.gov, by phone 1-877-222-VETS, by mail, or in person at any VA medical center. Free and accredited Veterans Service Officers can help.

Within 1 week

Priority Group assigned

Groups 1-8 based on service-connected disability rating, income, and special eligibility. Determines copays and access.

Enrollment letter arrives

Confirms PG and benefits

Save this letter. Your Priority Group can be reassessed if income changes or disability rating updates.

Schedule first appointment

Primary care assignment

VA assigns you to a primary care team at your enrolled facility. Cannot self-select; team-based assignment.

Set up MyHealtheVet

Patient portal

myhealth.va.gov. Premium account unlocks full features: secure messaging, complete medical record, OpenNotes.

Your action steps

Confirm VA eligibility

Active duty service + discharge other than dishonorable. Length-of-service requirements vary. Combat veterans get expanded eligibility under PACT Act of 2022. Find local VSO for free help: va.gov/ogc/recognition.asp.
Apply via VA Form 10-10EZ

Online at va.gov/health-care/apply-for-health-care-form-10-10ez, by phone 1-877-222-VETS (8387), by mail, or in person at any VA medical center. Free Veterans Service Officer help is the fastest path.
Submit DD-214 and supporting documents

DD-214 (separation document) is the key document. If you don't have it, request from National Archives at archives.gov/veterans. Income documentation may be required for income-based Priority Group placement.
Receive Priority Group assignment

Groups 1-8. Group 1 = highest priority, $0 for everything. Group 8 = lower priority, copays for non-service-connected care. Group changes if disability rating updates or income drops.
Set up MyHealtheVet (Premium account)

myhealth.va.gov. Premium account requires identity verification (Login.gov or ID.me, takes 15 minutes). Unlocks secure messaging, full medical record (OpenNotes), prescription refills, lab results.
Schedule Welcome to VA visit

First appointment with assigned primary care team. Bring DD-214, medical records from previous providers, current medication list. VA may also coordinate Medicare for those 65+.

The rules

Service requirements

Active duty + discharge other than dishonorable. Length-of-service rules: pre-1980 enlistment = 90 days. Post-Sept-7-1980 = 24 months continuous OR full period called for. Combat exemptions apply.

38 USC 1710

Priority Group 1

Service-connected disability 50%+, individual unemployability, Medal of Honor recipient. $0 for ALL care.

38 USC 1705

Priority Groups 2-3

Service-connected 10-40%, POW, Purple Heart. $0 for SC care; reduced copays for non-SC.

38 USC 1705

Priority Group 4

Housebound, Aid & Attendance, catastrophically disabled. $0 for SC; reduced non-SC copays.

38 USC 1705

Priority Group 5

Non-SC veterans below income threshold (Geographic Means Test). $0-$15 copays typical.

38 USC 1705

Priority Groups 7-8

Non-SC veterans above income threshold. $15-$50 PCP/specialist copays after first 3 visits/year free.

38 USC 1705

Combat veteran benefit

5 years of free VA care after separation regardless of income, under Priority Group 6. Window starts at discharge.

38 USC 1710(e)

PACT Act expansion

Veterans exposed to toxic substances during service (burn pits, Agent Orange, radiation) have expanded eligibility. New presumptions of service connection.

PACT Act of 2022

How it works

VA Healthcare is administered by the Department of Veterans Affairs through a network of medical centers, community-based outpatient clinics, and contracted community providers. Eligibility flows from service: active duty time, discharge type, and any service-connected conditions. The application (VA Form 10-10EZ) collects service information, income (for income-based Priority Group placement), and any service-connected disability documentation.

Priority Groups exist to allocate VA resources when demand exceeds capacity. Higher priority groups get faster access, fewer or no copays, and broader benefits. Lower priority groups still receive care but with copays and sometimes longer waits. Priority Group can change throughout your VA enrollment - service-connected disability rating increases automatically update; income drops require submitting Form 10-10EZR.

The 2026 Geographic Means Test threshold (single veteran, no dependents) is approximately $39,849 nationally, with higher thresholds in higher-cost areas. Income includes Social Security, pensions, wages, and most other sources. Becoming Medicaid-eligible automatically triggers Priority Group 5 placement. Aid & Attendance approval triggers Priority Group 4.

VA Healthcare runs alongside Medicare for veterans 65+. They are separate programs that don't typically coordinate billing automatically. Most veterans use VA for primary care and Medicare for community providers, hospitals not in the VA system, and specialty care outside the VA network. The VA MISSION Act of 2018 standardized when veterans can use community providers at VA expense.

Going deeper

Find a Veterans Service Officer (VSO). Free, accredited by VA, expert at applications. Locate at va.gov/ogc/recognition.asp. They dramatically simplify the process and identify benefits you might miss.
Gather documentation: DD-214 (separation document), service records, Social Security card, income documentation (Social Security letter, pension statements, recent tax return).
If you don't have DD-214, request from National Archives at archives.gov/veterans. Expedited service for active VA care needs.
Apply via VA Form 10-10EZ: online at va.gov/health-care/apply-for-health-care-form-10-10ez, by phone 1-877-222-VETS, by mail, or in person at any VA medical center.
Note your assigned Priority Group when approval letter arrives. Save the letter - you may need it later for benefit verification.
Set up MyHealtheVet (Premium account). myhealth.va.gov. Premium requires identity verification (15 minutes via Login.gov or ID.me). Unlocks secure messaging, full medical record, OpenNotes, prescription refills.
Schedule Welcome to VA visit. First appointment with assigned primary care team. Bring DD-214, medical records, current medication list.
If 65+, also enroll in Medicare. VA Healthcare doesn't replace Medicare - both are needed for full coverage. Apply at ssa.gov/medicare or 1-800-772-1213.

Where people lose money or access

Applying without a VSOVSOs are free and significantly improve application outcomes. They know the documentation requirements, presumption rules, and benefit interactions. Going alone often results in denials that VSOs would have prevented.

Not updating after disability rating increaseDisability rating increases should automatically update Priority Group, but verify after rating changes. A 50%+ rating moves you to Priority Group 1 with $0 for all care. Easy savings if it's missed.

Not applying for Aid & AttendanceIf you need help with daily activities, A&A approval moves you to Priority Group 4 AND adds substantial cash benefit ($2,424-$2,874/month for veterans, depending on dependents). Most eligible veterans never apply because the benefit isn't well-publicized.

Treating VA as replacement for MedicareVA Healthcare is an additional benefit, not a Medicare replacement. Veterans 65+ should enroll in both. Without Medicare, you're limited to the VA's geographic service area and provider network. Medicare expands access dramatically.

Edge cases

Combat veterans 5-year window

Combat veterans get 5 years of free VA care after separation regardless of income, under Priority Group 6. Window starts at discharge. After 5 years, normal income-based assessment applies.

PACT Act toxic exposure

PACT Act of 2022 expanded benefits for veterans exposed to toxic substances during service. New presumptions of service connection that may shift Priority Group. Verify with VSO if recent diagnosis may relate to service exposures.

Catastrophically disabled

Veterans with permanent total disability (any cause) qualify for Priority Group 4 with reduced copays. Different from Priority Group 1 service-connected catastrophically disabled but similar benefits.

VA + Tribal eligibility

Native American veterans may qualify for both VA Healthcare AND Indian Health Service benefits. Coordination handled at facility level. VA-IHS Memorandum of Agreement reduces double billing.

Where to go next

Sources

VA Healthcare: va.gov/health-care.
VA Health Benefits Hotline: 1-877-222-VETS (8387).
VSO finder (free help): va.gov/ogc/recognition.asp.
VA Pension and A&A: 1-800-827-1000.
Veterans Crisis Line: 988, then press 1; or text 838255.

Retired military

TRICARE for Life

You are a military retiree and TRICARE carries into Medicare.

TRICARE for Life is the secondary health coverage for retired military and their dependents 65+, working alongside Medicare. The system is automatic IF Defense Enrollment Eligibility Reporting System (DEERS) accurately reflects your Medicare enrollment. Get DEERS right, enroll in Medicare Part A and Part B, and TFL activates without separate application - there's no TFL premium and no enrollment form. The complications start when DEERS lags behind Medicare enrollment (30-60 days typical), when providers bill incorrectly, or when you don't have Part B. Verifying DEERS, enrolling in BOTH Parts A and B, and understanding the two-payer flow prevents the common billing nightmares.

TRICARE For Life enrollment timeline

From DEERS verification to first prescription

Before 65

Verify DEERS eligibility

milConnect at milconnect.dmdc.osd.mil. Confirm you're listed as Medicare-eligible retiree, dependent, or surviving spouse.

3 months before 65

Enroll in Medicare A and B

TFL requires both. Without Part B, no TFL benefits. Enroll through SSA at ssa.gov, by phone 1-800-772-1213, or in-person.

DEERS update lag

30-60 days typical

After Medicare enrollment, SSA notifies DEERS. Lag of 30-60 days is normal. Verify DEERS shows Part B effective date.

TFL auto-activates

When DEERS catches up

No application needed. Once DEERS shows Part B, TFL is your secondary coverage. ID cards: Medicare card + military ID.

Set up Express Scripts

Pharmacy mail-order

877-363-1303 or militaryrx.express-scripts.com. Mail-order saves significantly on maintenance medications.

First medical visit

Medicare bills first

Medicare always primary. TFL crosses over automatically. You owe $0 for most Medicare-covered services.

Your action steps

Verify DEERS shows you correctly

milConnect at milconnect.dmdc.osd.mil. Login with DS Logon. Verify name, address, Medicare-eligibility status, and any dependents are accurate. DEERS errors break TFL coverage.
Enroll in Medicare Part A and Part B

TFL requires BOTH. Apply at ssa.gov/medicare. If receiving Social Security, auto-enrolled. If not, apply manually 3 months before 65. Part B has a premium ($202.90 standard 2026); Part A is free for most.
Wait 30-60 days for DEERS update

SSA notifies DEERS when Medicare enrollment finalizes. Lag is typical. Verify DEERS shows your Part B effective date before relying on TFL coverage. milConnect or 1-800-538-9552.
Get your TFL ID setup right

Your Medicare card AND your military ID are both needed at appointments. There is no separate TFL card. Save both digital and physical copies of each.
Set up Express Scripts mail-order

877-363-1303 or militaryrx.express-scripts.com. Mail-order saves significantly on maintenance medications. 90-day supply: $14 generic / $44 brand vs $16/$48 retail. Active duty: $0 everywhere.
Verify Wisconsin Physicians Service contact

WPS-GHA processes TFL claims. 1-866-773-0404. If providers bill you for the 20% Medicare didn't pay, this is the line to call to verify crossover and resolve.

The rules

Eligibility

Military retirees, spouses, and surviving spouses 65+ who are entitled to Medicare Part A based on age.

10 USC 1086(d)

Part B requirement

TRICARE For Life requires both Part A AND Part B. Without Part B, TFL benefits are not active.

10 USC 1086(d)

No TRICARE premium

TFL has no premium. Cost is your Medicare Part B premium ($202.90 standard, 2026, plus IRMAA if applicable).

10 USC 1086(b)

Catastrophic cap 2026

$3,000 family max OOP per fiscal year for cost-shares (excludes Medicare Part B premium).

TRICARE Operations Manual 2026

DEERS as authoritative source

DEERS data drives TRICARE eligibility. Updates flow from SSA but lag 30-60 days typical.

DoD Directive 1341.02

Pharmacy 2026 mail-order

$14 generic, $44 brand-name formulary, $85 non-formulary (90-day supply).

TRICARE Pharmacy Cost-Shares 2026

Pharmacy 2026 retail

$16 generic, $48 brand-name formulary, $85 non-formulary (30-day supply).

TRICARE Pharmacy Cost-Shares 2026

How it works

DEERS is the Defense Department's enrollment database. It tracks military service members, retirees, and their dependents and family members. TRICARE eligibility flows from DEERS - if you're not in DEERS correctly, you're not eligible for TRICARE benefits regardless of your actual status. SSA notifies DEERS when Medicare enrollment finalizes, but the data flow has typical lag of 30-60 days.

When DEERS is current with your Medicare enrollment, TRICARE for Life claims process automatically. Medicare processes the claim first, pays 80% of Part B services. The claim then crosses over electronically to TRICARE via Wisconsin Physicians Service Government Health Administrators (WPS-GHA). TRICARE adjudicates the secondary claim, pays the remaining cost-share. You owe $0 for most Medicare-covered services.

When DEERS lags, the crossover doesn't happen automatically. The provider bills you for the 20% Medicare didn't pay; you have to manually submit to TRICARE for reimbursement using DD Form 2642. TRICARE eventually pays, but during the lag you may receive bills, calls from collections, or credit reporting if it goes long enough.

TRICARE pharmacy is managed separately by Express Scripts. Active duty service members pay $0 everywhere. Retirees and dependents pay copays at retail or mail-order. Mail-order through Express Scripts is dramatically cheaper for maintenance medications: $14 generic 90-day vs $16 generic 30-day at retail. Brand: $44 vs $48. Non-formulary: $85 either way.

Going deeper

Verify DEERS is current via milConnect at milconnect.dmdc.osd.mil. Login with DS Logon. Verify name, address, Medicare-eligibility status, and dependents are accurate.
Or call DMDC Support: 1-800-538-9552. Verify your Part A and Part B effective dates are showing correctly.
If DEERS shows wrong dates: bring Medicare card to nearest ID card facility (RAPIDS site). Have DEERS updated in person. Or upload Medicare card via milConnect for online update - typically processes in 10-14 days.
Enroll in Medicare Part A and Part B. Apply at ssa.gov/medicare. If receiving Social Security, auto-enrolled. If not, apply manually 3 months before 65.
Set up Express Scripts mail-order. 877-363-1303 or militaryrx.express-scripts.com. Have your provider send maintenance prescriptions directly.
Save Wisconsin Physicians Service contact: 1-866-773-0404. This is the line to call if providers bill you incorrectly for Medicare cost-share.
When receiving care, show BOTH your Medicare card AND your military ID. Some providers don't know TFL works as Medicare secondary; document this at first visit.
I have Medicare primary and TRICARE for Life secondary. Please bill Medicare first, then the claim will cross over to TRICARE via WPS-GHA.

Where people lose money or access

Assuming DEERS auto-updatedSSA-DEERS data flow has 30-60 day lag. If you delay verifying, bills accumulate during the lag and crossover doesn't catch up automatically - you have to claim retroactively using DD Form 2642.

Not enrolling in Part BTFL absolutely requires Part B. Without it, TFL benefits are not active. Saving $202.90/month on Part B premium results in losing all TFL coverage - bad math by a factor of 100x.

Provider bills TRICARE primarySome providers (particularly those new to TRICARE) bill TRICARE primary. This is wrong - Medicare must be primary. The claim will be denied; coordinate the rebill. Insist on Medicare primary at the front desk.

Paying the 20% Medicare didn't coverIf Medicare paid 80% and provider bills you the 20%, do NOT pay until you've verified TRICARE crossover. The 20% should be paid by TRICARE. Paying it yourself just creates a refund chase later.

Edge cases

Out-of-area / overseas

TRICARE Overseas Program covers care abroad in some cases (Medicare generally doesn't). 1-877-678-1208. TFL Overseas adds complexity but expands access for retirees living abroad.

Active duty family members

If still active duty (or recently separated), TRICARE Prime/Select rules differ from TFL. TFL is specifically for retirees and dependents 65+ on Medicare.

Surviving spouses

Surviving spouses of military retirees retain TFL eligibility. DEERS must be updated with surviving spouse status. Some benefits transition automatically; others require active update.

Continuing federal employment

Federal employees with military service may have both FEHB and TRICARE-eligible status. Coordination affects costs significantly. See FEHB path for more on this overlap.

Where to go next

Sources

milConnect: milconnect.dmdc.osd.mil. DEERS verification.
DMDC Support: 1-800-538-9552 for DEERS issues.
TRICARE For Life: 1-866-773-0404 (Wisconsin Physicians Service - GHA).
TRICARE Pharmacy (Express Scripts): 1-877-363-1303.
TRICARE Overseas: 1-877-678-1208.

Federal retiree

Federal Employee Benefits

You retired from federal service and have your employer health plan.

Federal Employees Health Benefits is a unique program that lets retirees keep employer-sponsored health insurance into Medicare years. The 5-year rule (must have FEHB for the 5 years immediately before retirement, or full period of eligibility if shorter) is the key threshold. Once carried into retirement, FEHB continues at the same premium structure as active employees, with the government continuing to pay its share. The complications come at 65 when Medicare eligibility creates the Part B decision: enroll alongside FEHB for cost-share waivers and possible Medicare Reimbursement Account (MRA) benefits, or skip Part B and rely on FEHB alone. Most FEHB retirees benefit from Part B, but the math depends on plan choice, MRA availability, and IRMAA exposure.

FEHB into retirement timeline

Carrying federal health insurance through Medicare eligibility

Before retirement

Verify 5-year rule

Must have FEHB for 5 years before retirement (or full period of eligibility if shorter) to carry into retirement. OPM verifies.

At retirement

FEHB continues automatically

Same coverage, same plans. Government still pays its share. Premiums deducted from annuity.

At 65 (or retirement if later)

Part A and Part B decision

Part A is free. Part B is optional. Most FEHB retirees benefit from Part B for cost-share waivers and MRA reimbursements.

Annual Open Season

Nov 10 - Dec 8 each year

Switch FEHB plans, change FEDVIP dental/vision. 2026 average enrollee increase: 12.3%. Compare during this window.

If MRA-eligible plan

Submit receipts annually

Some FEHB plans (BCBS Standard, etc.) reimburse Part B premium and other costs. Use it or lose it.

If TRICARE eligible

Coordinate with DEERS

Federal employees with military service may have both FEHB and TRICARE. Coordination affects costs significantly.

Your action steps

Confirm 5-year FEHB requirement

Must have FEHB for 5 years before retirement (or full period of eligibility if shorter) to carry into retirement. Verify with OPM Retirement Services: 1-888-767-6738. Critical before retirement decision.
Read your plan's annual brochure carefully

opm.gov/healthcare-insurance/healthcare/plan-information. Find the 'Coordination with Medicare' section. Identify whether plan waives cost-share when Part B is primary, and if it has an MRA.
Calculate Part B decision both ways

With Part B: pay $202.90/month + reduced FEHB cost-share. Without: pay full FEHB cost-share but no Part B premium. For most retirees with average usage, Part B nets favorable. Use OPM/SHIP to model.
Estimate IRMAA impact

Income above $109,000 single / $218,000 joint adds to Part B premium ($284-$690/month range). Many federal retirees fall into IRMAA brackets. Factor into Part B math.
Plan retirement timing around Open Season

Federal Open Season runs Nov 10 - Dec 8 (for 2026 plan year). Retiring during or after this window lets you optimize plan choice during transition. Effective Jan 1.
Notify FEHB plan of Medicare enrollment

Once Part B is active, contact your FEHB plan to coordinate primary/secondary status. Some plans require this notification to activate Medicare-coordination benefits like cost-share waivers.

The rules

5-year rule

Must have FEHB for 5 years before retirement (or full period of eligibility if shorter) to carry into retirement.

5 USC 8905(b)

No requirement to enroll in Part B

FEHB retirees are NOT required to enroll in Part B. Unlike most other coverage, FEHB has no creditable coverage rule that triggers Part B late penalty.

5 USC 8905, OPM FEHB Program Handbook

Part B premium 2026

$202.90/month standard. IRMAA above $109,000 single / $218,000 joint - up to $689.90 at top bracket.

CMS 2026 Premiums Fact Sheet

IRMAA brackets 2026

$109K-$137K: +$81.20/mo. $137K-$171K: +$202.90/mo. $171K-$205K: +$324.60/mo. $205K-$500K: +$446.30/mo. $500K+: +$487.00/mo.

CMS 2026 IRMAA Schedule

FEHB premium increases 2026

Average enrollee share rose 12.3% for 2026. Total FEHB increase 10.2% (combined govt and enrollee share).

OPM 2026 Open Season Highlights

Medicare Reimbursement Account (some plans)

BCBS Standard 2026 offers up to $800/individual or $1,600/family in MRA reimbursement. Other plans differ. Plan-specific.

OPM FEHB Plan Brochures (annual)

Federal Open Season

Second Monday of November through second Monday of December annually. For 2026: Nov 10 - Dec 8, 2025.

5 CFR 890.301

How it works

FEHB is administered by the Office of Personnel Management. As a retiree with FEHB, you keep coverage at the same premium structure as active employees (federal contribution continues). FEHB plans vary widely - HMO, PPO, fee-for-service, consumer-driven. Each handles Medicare coordination differently. Some waive cost-share entirely when Part B is primary; others don't.

When you enroll in Part B alongside FEHB, Part B becomes primary for outpatient services. FEHB pays as secondary. Many FEHB plans waive cost-share entirely when Part B is primary, effectively giving you $0 OOP for most services. Some FEHB plans also offer reduced premiums for Medicare-eligible enrollees, partially offsetting the Part B premium.

Without Part B, FEHB pays as primary for everything. Cost-share applies fully. Some FEHB plans charge significantly more in OOP costs without Part B coordination. The math: Part B premium $2,435/year (plus IRMAA if applicable); FEHB OOP without Part B can be $1,500-3,000+ depending on plan. For most retirees with average healthcare needs, Part B nets out near break-even or slightly favorable.

Some FEHB plans offer Medicare Reimbursement Accounts (MRAs) that reimburse Part B premium and other costs. BCBS Federal Employee Program Standard Option offers up to $800/individual or $1,600/family in MRA reimbursement annually. Activation requires enrolling in Medicare alongside FEHB; reimbursement requires submitting receipts. Many retirees miss MRAs because they don't know the benefit exists.

Going deeper

Confirm 5-year FEHB requirement before retirement. Verify with OPM Retirement Services: 1-888-767-6738. Critical before retirement decision.
Read your plan's annual brochure during Open Season. Find the 'Coordination with Medicare' section. Identify whether plan waives cost-share when Part B is primary, and whether it has an MRA.
Calculate Part B decision both ways: with Part B (Part B premium + reduced FEHB cost-share) vs without (full FEHB OOP). Use OPM/SHIP to model with your specific situation.
Estimate IRMAA bracket. Income above $109,000 single / $218,000 joint adds $81-$487/month to Part B premium depending on bracket. Many federal retirees fall into IRMAA territory.
If choosing Part B: enroll within 8 months of retirement to avoid late enrollment penalty.
I'm retired federal with FEHB and want to enroll in Part B during my Special Enrollment Period under 42 CFR 407.20. My FEHB-extension SEP applies.
If your plan offers MRA, activate it through plan member services. Submit receipts according to plan schedule (typically annually). Most plans require online portal submission.
During each annual Open Season (Nov 10 - Dec 8), compare plans. 12.3% average premium increase for 2026 means current plan may no longer be best fit. Compare TOTAL annual cost, not premium alone.

Where people lose money or access

Skipping Part B without doing the mathMany retirees default to skipping Part B because FEHB 'covers everything.' But the math often favors Part B - particularly with cost-share waivers. Don't decide based on assumption; do the actual math both ways.

Not knowing MRA existsPlans don't aggressively promote MRAs. Many retirees pay Part B premium for years before discovering MRA reimbursement. Read your plan brochure annually.

Defaulting to current plan during Open SeasonAverage 12.3% premium increase for 2026 means current plan may be 10-15% more expensive. A small comparison investment annually saves $300-1,000+ in cumulative excess premium.

Confusing Federal Open Season with Medicare AEPFederal Open Season (mid-Nov through early Dec) is for FEHB. Medicare AEP (Oct 15 - Dec 7) is for Part D and MA. If you have both, you may need to make changes during both windows.

Edge cases

FEHB Medicare Advantage plans

Some FEHB carriers (BCBS, Aetna, others) offer Medicare Advantage plans that integrate with FEHB. These can have $0 premium and benefits beyond standard Medicare. Available only if you have Part B. Check during Open Season.

Postal Service (PSHB)

USPS retirees moved to Postal Service Health Benefits Program in 2025 - separate from FEHB. Different plan options and premiums but same general structure and Open Season timing.

TRICARE coordination

Some federal retirees with military service have both FEHB and TRICARE. Open Season decisions affect coordination. Generally TFL retirees rely on TRICARE; some keep minimal FEHB for catastrophic backstop.

HSA contributions

If currently using an HDHP-HSA FEHB plan, Medicare enrollment ENDS HSA contributions. Plan transition before Medicare to maximize HSA last-year contributions.

Where to go next

Sources

OPM FEHB: opm.gov/healthcare-insurance.
OPM Retirement Services: 1-888-767-6738.
FEHB Plan Brochures: opm.gov/healthcare-insurance/healthcare/plan-information.
Medicare Open Season for federal employees: 1-877-872-5627.
SHIP (free counseling, including federal retirees): 1-877-839-2675.

Native American

Indian Health Service

You are a tribal member and use Indian Health Service facilities.

Indian Health Service is the federal health program for American Indians and Alaska Natives, operating through IHS facilities, tribal facilities, and urban Indian health programs (collectively called I/T/U). For tribal members 65+, IHS works WITH Medicare, not instead of it. Medicare reimburses IHS for services provided to Medicare-eligible patients, which expands the IHS budget for everyone in the community. This means enrolling in Medicare at 65 actively helps your tribe's health resources. Most tribal members benefit from Original Medicare paired with IHS care, though some tribes operate their own Medicare Advantage plans designed for tribal members. Tribal sponsorship of Medicare premiums for elders is increasingly common and worth investigating with your tribal benefits office.

Indian Health Service + Medicare timeline

IHS as primary care, Medicare as wraparound

Verify tribal enrollment

Federally recognized status

Must be member of federally recognized tribe (or descendant within criteria). 574 federally recognized tribes.

At any IHS facility

Establish patient status

Bring tribal enrollment documentation, photo ID, and any insurance cards. IHS facility, tribal facility, or urban Indian health program (I/T/U).

At 65

Enroll in Medicare

IHS does NOT replace Medicare. Both work together. Medicare reimburses IHS for services, expanding IHS budget for all patients.

Decide on Medicare type

Original Medicare or MA

Most tribal members benefit from Original Medicare (pairs cleanly with IHS). Some MA plans designed for tribal members exist.

Apply for Special Diabetes Program

Tribal-specific resources

Special Diabetes Program for Indians (SDPI) provides additional support. Contact your IHS facility's diabetes coordinator.

If working in tribal employment

Tribal sponsorship

Some tribes sponsor Medicare premiums for elders. Ask your tribal benefits office about Section 105 medical reimbursement plans.

Your action steps

Verify tribal enrollment

Must be member of federally recognized tribe or descendant within criteria. 574 federally recognized tribes. Your tribal enrollment office can provide documentation.
Establish patient status at I/T/U facility

IHS facility, tribal facility, or urban Indian health program. Bring tribal enrollment documentation, photo ID. Patient registration is one-time but should be updated annually.
Apply for Medicare at 65

IHS does NOT replace Medicare. Both work together. Medicare reimbursing IHS expands the IHS budget for everyone - your Medicare enrollment helps your community.
Choose Medicare type carefully

Original Medicare typically pairs cleanly with IHS - no networks issues. Some MA plans designed for tribal members exist (Tribal Sponsorship plans). Avoid MA plans without tribal-specific design.
Apply for SDPI if relevant

Special Diabetes Program for Indians provides additional support. Contact your IHS facility's diabetes coordinator. Free for tribal members; expanded eligibility for elders.
Ask about tribal sponsorship

Some tribes sponsor Medicare premiums for elders through Section 105 medical reimbursement plans or general welfare exemption funding. Ask your tribal benefits office or council.

The rules

IHS eligibility

Members of federally recognized tribes (574 tribes) and descendants meeting tribal criteria. Each tribe sets its own enrollment rules.

25 CFR 81; Indian Health Care Improvement Act

IHS facilities (I/T/U)

IHS direct facility, tribally-operated facility, or urban Indian health program. All accept Medicare reimbursement.

Indian Health Care Improvement Act, 25 USC 1601

No replacement for Medicare

IHS is supplemental coverage, not primary insurance. Medicare enrollment recommended at 65 for full coverage outside I/T/U facilities.

25 USC 1623

Medicare-IHS coordination

Medicare reimburses IHS at standard rates. This expands IHS budget for the community. Your enrollment helps everyone.

Section 401, Indian Health Care Improvement Act

Special Diabetes Program for Indians

SDPI provides additional diabetes-specific resources at IHS facilities. Free for tribal members; no income restriction.

Section 330C of PHSA

Tribal sponsorship

Some tribes sponsor Medicare premiums for elders through Section 105 medical reimbursement plans or general welfare exemption funding.

IRC §105(b); Tribal General Welfare Exclusion Act

Contract Health Services

When IHS facilities can't provide needed care, Contract Health Services (CHS) authorizes care from non-IHS providers. Limited budget; medical priority used.

Indian Health Care Improvement Act

How it works

IHS operates approximately 170 facilities across the United States, with additional services delivered through tribally-operated facilities under self-determination agreements and urban Indian health programs. Coverage is geographic - patients receive care at facilities in their region. Travel to other IHS regions for care is generally not covered without prior authorization.

For Medicare-eligible tribal members, the relationship between IHS and Medicare is collaborative, not competitive. Federal law since 1976 has authorized IHS to bill Medicare for services provided to Medicare-eligible patients. The reimbursement returns to the IHS facility as additional budget - meaning your Medicare enrollment generates resources for the entire community served by that facility.

Original Medicare typically pairs cleanly with IHS care. You can use any Medicare-accepting provider AND any IHS/T/U facility. Coordination is at the patient level, not the system level. Some tribes operate their own Medicare Advantage plans (Tribal Sponsorship plans) designed specifically for tribal members. These plans typically have $0 premium, comprehensive networks, and integration with IHS care.

Some tribes sponsor Medicare premiums for elders through tribal benefit programs. This may be funded through Section 105 medical reimbursement plans, tribal general welfare programs (which received specific federal tax recognition under the Tribal General Welfare Exclusion Act of 2014), or direct elder care programs. Coverage and amounts vary by tribe - your tribal benefits office or council can provide specific information.

Going deeper

Verify your tribal enrollment with your tribe's enrollment office. Each federally recognized tribe sets its own enrollment criteria. You'll need documentation of enrollment for IHS patient registration.
Establish patient status at your nearest IHS, tribal, or urban Indian health facility. Bring tribal enrollment documentation, photo ID, and any insurance cards. Patient registration is one-time but should be reviewed annually.
At 65, enroll in Medicare. IHS does NOT replace Medicare; both work together. Apply at ssa.gov/medicare or 1-800-772-1213. Your Medicare enrollment helps fund IHS for your community.
Choose Medicare type carefully. Original Medicare typically pairs cleanly with IHS - no network issues. Some MA plans designed for tribal members exist (Tribal Sponsorship plans). Avoid generic MA plans without tribal-specific design.
Apply for Special Diabetes Program for Indians (SDPI) if relevant. Contact your IHS facility's diabetes coordinator. Free for tribal members; expanded resources for elders.
Ask your tribal benefits office about Medicare premium sponsorship.
Does our tribe have a Medicare premium sponsorship program for elders? Section 105 medical reimbursement plan? General welfare program for healthcare costs?
If Contract Health Services becomes relevant: work with your IHS facility's CHS department. Medical priority and budget availability determine authorization. Get authorization in writing before non-IHS care.

Where people lose money or access

Treating IHS as a Medicare substituteIHS doesn't replace Medicare. Tribal members 65+ should enroll in both. Without Medicare, you're limited to I/T/U facilities, which may not be geographically convenient or have all services. Medicare expands access dramatically.

Not enrolling in Medicare to avoid 'losing' IHSCommon misconception. Medicare doesn't terminate IHS eligibility. IHS bills Medicare and uses the reimbursement to expand services. Your Medicare enrollment HELPS your community's IHS budget.

Choosing generic MA plansStandard Medicare Advantage plans may have networks that don't include IHS facilities. Tribal Sponsorship MA plans designed for tribal members handle IHS coordination correctly. Verify before enrolling.

Not exploring tribal sponsorshipMany tribes sponsor Medicare premiums for elders. Many elders never ask, paying $202.90+/month they could have avoided. Tribal benefits offices typically know all available programs but may not advertise them.

Edge cases

Urban Indian health programs

Urban Indian health programs serve tribal members living away from reservation. Same I/T/U status as IHS facilities. Often the practical option for tribal members in major cities.

Native veterans (VA + IHS)

Native American veterans may qualify for both VA Healthcare AND IHS benefits. VA-IHS Memorandum of Agreement reduces double billing. Coordination handled at facility level.

ALaska Native programs

Alaska Native health system (Alaska Native Tribal Health Consortium and regional corporations) operates differently from continental US IHS. Same federal authority but different administrative structure.

Off-reservation care

When IHS can't provide needed care, Contract Health Services authorizes care from non-IHS providers. Limited budget means medical priority is used. Authorization required before care to ensure coverage.

Where to go next

Sources

Indian Health Service: ihs.gov.
IHS facility locator: ihs.gov/locations.
Tribal enrollment offices: Contact your tribe directly through the National Congress of American Indians (ncai.org) for tribal contact information.
Indian Health Care Improvement Act: 25 USC 1601 et seq.
Special Diabetes Program for Indians (SDPI): ihs.gov/sdpi.