Project Kos | Stage 1. Getting Started

Getting started

Turning 65 starts a series of enrollment windows with deadlines that matter for the rest of your life. Missing some of them cannot be undone. This page helps you understand which path applies to your situation and what to do, in what order, before time runs out.

Which path is yours?

Start here I'm preparing Not sure which path is yours. Answer a few questions to find out.

Under 65 Pre-Medicare You need coverage now and Medicare has not started yet.

Still working Working past 65 You have employer coverage and are approaching or past 65.

Turning 65 Medicare You are entering Medicare for the first time.

Lower income Medicaid You may qualify for help paying for care or coverage costs.

Under 65, with disability Disability to Medicare You receive disability benefits and Medicare is coming.

Veteran VA Healthcare You served and want to use your VA healthcare benefit.

Retired military TRICARE for Life You are a military retiree and TRICARE carries into Medicare. More detail coming

Federal retiree Federal Employee Benefits You retired from federal service and have your employer health plan. More detail coming

Native American Indian Health Service You are a tribal member and use Indian Health Service facilities. More detail coming

Start here

I'm preparing

Everyone's path into senior healthcare is a little different. The questions below describe nine common situations. Find the one that sounds like yours and click it to see the full picture, including what to do, in what order, and who can help you for free.

Find your path

You are under 65 and need health coverage right now

You need a plan that covers you until Medicare begins at 65. Options include plans through the Health Insurance Marketplace, staying on a former employer's plan temporarily, or joining a spouse's plan. The goal is to get to 65 without a gap in coverage. → Pre-Medicare

You are turning 65 but still working and covered by your employer

You do not necessarily need to sign up for Medicare right now, but the rules about when you must are strict and the penalties for missing them are permanent. Whether you can delay depends on how large your employer is. → Working past 65

You are turning 65 and do not have other health coverage

This is the most common starting point. Medicare becomes your main coverage and you will choose how to fill in the gaps it leaves. The decisions you make in the first few months affect your costs for the rest of your life. → Medicare

Your income is limited and you need help affording care or coverage

Medicaid is a government program that can cover your healthcare costs if your income and savings fall below certain limits. Some people qualify for both Medicare and Medicaid at the same time, which can reduce their costs significantly. → Medicaid

You are under 65 and receive Social Security disability payments

If you have been receiving disability benefits for 24 months, Medicare begins automatically. Most people on disability do not realize this is coming until the Medicare card arrives in the mail. → Disability to Medicare

You served in the military and have not signed up for VA Healthcare yet

VA Healthcare is a benefit you earned through service, but it is not automatic. You have to apply. Most veterans who apply are accepted, and a 2022 federal law expanded eligibility to many veterans who were previously turned away due to toxic exposure. → VA Healthcare

You retired from the military and have TRICARE coverage

When you turn 65, your TRICARE automatically becomes TRICARE for Life, which works alongside Medicare to cover most of what you would otherwise pay out of pocket. There is one thing that will end this benefit if you miss it, and it involves Medicare Part B. → TRICARE for Life

You retired from a federal government job and kept your health plan

Federal employees who retire can keep their workplace health coverage into retirement. When you turn 65, you will decide whether to add Medicare alongside it. That decision is optional but it usually saves money for people who use healthcare regularly. → Federal Employee Benefits

You are a member of a federally recognized tribe

Indian Health Service provides healthcare to tribal members through federal and tribal facilities. It works alongside Medicare and Medicaid rather than replacing them. At 65, enrolling in Medicare expands the care available to you beyond what IHS facilities alone can provide. → Indian Health Service

Not sure which applies

More than one of these may describe you

Many people hold more than one type of coverage. Veterans can have both VA Healthcare and Medicare. Low-income seniors can have both Medicare and Medicaid. Federal retirees can have both their workplace plan and Medicare. If that sounds like you, start with whichever path answers your most pressing question right now. You can always come back for the others.

If you are turning 65 within the next six months, start with Medicare first

Your 65th birthday triggers several enrollment windows, some of which close permanently if you miss them. These deadlines apply regardless of what other coverage you have. If 65 is close, read the Medicare path before anything else so you understand what is coming and when.

A good place to start

None of these describe your situation?

Senior healthcare has more paths than these nine

Railroad retirees enroll through the Railroad Retirement Board rather than Social Security. Non-citizens who are legal permanent residents may qualify for Medicare after five years of residency. People with early retirement through a former employer may have retiree health coverage that bridges to Medicare differently than a standard workplace plan. If your situation is not captured here, the Healthcare Directory lists every organization involved in senior care and can help you identify where to start. The Glossary explains every term you may encounter. And a State Health Insurance Assistance Program counselor in your state can help you navigate situations that do not fit standard paths, entirely for free.

If under 65

Pre-Medicare planning

You are not yet 65, so Medicare has not started. What you need right now is a plan that covers you until it does, with no gap in between. Your options depend on your situation: whether you recently left a job, whether a spouse is still working, or whether you simply need to find something on your own.

What happens, and when

You

Figure out what coverage you have or can get right now

Before you can plan the bridge, you need to know what you are bridging from. If you are still employed, your employer plan likely continues. If you recently left a job, COBRA lets you stay on that plan temporarily. If neither applies, the Health Insurance Marketplace is where most people under 65 without employer coverage find plans. If your spouse works and their plan covers dependents, that is often the simplest path.

Start 60 days out

Marketplace, HR, or COBRA administrator

Get your coverage in place before the gap opens

Marketplace Open Enrollment runs November 1 through January 15 for most states, with coverage starting the following month. If you lose job-based coverage, that event triggers a 60-day Special Enrollment Period that lets you enroll outside the standard window. COBRA election also has a 60-day window from the qualifying event, though premiums are significantly higher because you pay the full cost plus a small administrative fee.

Up to 60 days to enroll

You

Set a reminder six months before your 65th birthday

Medicare's Initial Enrollment Period opens three months before the month you turn 65 and runs for seven months total. If you miss this window without having other qualifying coverage, Medicare can impose a permanent penalty on your Part B premium for as long as you live. The reminder matters more than the coverage itself, because the window arrives quietly and no one is required to notify you.

6 months before 65

You, with a State Health Insurance Assistance Program (SHIP) counselor if needed

Cancel the bridge plan when Medicare begins

Bridge plans do not cancel automatically when Medicare starts. You are responsible for actively ending your Marketplace or COBRA coverage once Medicare begins, or you will pay two premiums for the same period of time. If you had Marketplace subsidies, you are also required to report the change to avoid having to repay them at tax time.

Month of 65th birthday

Common questions

Can I get a subsidy for a Marketplace plan?

Most households with income under 400 percent of the federal poverty level qualify for premium tax credits that reduce the monthly cost. Some lower-income households also qualify for additional help with deductibles and copays. A Marketplace Navigator can run these numbers for your specific household at no cost to you.

How much does COBRA actually cost?

When you are on an employer plan, your employer typically pays most of the premium on your behalf. COBRA requires you to pay the full premium plus a two percent administrative fee, which means costs often jump significantly. For many people, a subsidized Marketplace plan is less expensive than COBRA, even for comparable coverage.

What if my state expanded Medicaid?

Forty states have expanded Medicaid under the Affordable Care Act, which means adults with income up to 138 percent of the federal poverty level may qualify regardless of age. If your income is modest, it is worth checking Medicaid eligibility before purchasing a Marketplace plan, since Medicaid typically has lower or no premiums.

Can I stay on a spouse's employer plan?

You can generally stay on a spouse's employer plan as long as the spouse remains employed and the plan covers dependents. When the spouse retires or leaves the job, that event typically ends your eligibility. At that point you would enter a Special Enrollment Period for Medicare if you are already 65, or turn to COBRA or the Marketplace if you are not yet 65.

Things to watch out for

COBRA does not protect you from Medicare late penalties

Many people assume that having COBRA means they can safely delay Medicare Part B past 65. This is incorrect. COBRA is not considered qualifying employer coverage for purposes of Medicare's late enrollment rules, which means delaying Part B while on COBRA can result in a permanent penalty added to your monthly premium for the rest of your life. If you are turning 65, enroll in Medicare during your Initial Enrollment Period regardless of whether you also have COBRA.

Marketplace subsidies must be reported when Medicare begins

If you receive premium tax credits through the Marketplace and then become eligible for Medicare, you are required to report that change. Continuing to collect subsidies after Medicare eligibility begins is considered an overpayment, and the Internal Revenue Service can require you to repay those amounts when you file your taxes.

Free help near you

Free personal help

Marketplace Navigator or Certified Application Counselor

Navigators and Certified Application Counselors are federally funded to provide free, unbiased help with Marketplace enrollment. They do not sell insurance and do not receive commissions. You can find a local navigator through healthcare.gov or by calling 1-800-318-2596.

Find help at healthcare.gov

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Still working

Working past 65

You are turning 65 but still working, so you already have health coverage through your job. You do not have to sign up for Medicare immediately, but the rules about when you must are strict, and missing a deadline creates a penalty that adds to your Medicare costs permanently. Whether you can delay, and for how long, depends on how large your employer is.

What happens, and when

You with HR

Confirm your employer's size and plan type

The single most important factor in this decision is how many people your employer has on payroll. If your employer has 20 or more employees, your employer plan pays first on any medical claim and Medicare pays second. In that situation, you can generally delay Medicare Part B without a penalty as long as you stay employed. If your employer has fewer than 20 employees, the order reverses: Medicare is supposed to pay first, and your employer plan pays only what Medicare does not cover. If Medicare is not in place in that situation, neither program pays well and you can end up responsible for costs that should have been covered.

3 months before 65

You

Decide whether to enroll in Medicare Part A now or wait

Medicare Part A covers hospital stays and is free for most people who have paid into Medicare through work for at least 10 years. Most people in this situation enroll in Part A at 65 even while keeping their employer plan, because it adds hospital coverage at no extra cost. The main exception is if you contribute to a Health Savings Account, which is a special tax-advantaged savings account tied to certain high-deductible employer health plans. Enrolling in any part of Medicare ends your ability to contribute to that account going forward. If saving into one matters to you, talk to your HR department before deciding.

Within the 3-month window

You with HR

Ask HR for a letter that protects you from a Medicare penalty later

When you retire or otherwise leave your employer plan, ask your HR department for a letter confirming that your employer coverage was creditable, meaning it met Medicare's standards. This letter is what Medicare uses to waive the late enrollment penalty for Part B when you finally enroll. Without it, you may have difficulty proving your delay was justified.

When leaving employer plan

You

Once your employer coverage ends, you have a Special Enrollment Period of eight months to sign up for Part B without a penalty. This window begins the month your employment or employer coverage ends, whichever comes first. Missing this eight-month window triggers the late enrollment penalty, which adds a permanent ten percent surcharge to your Part B premium for every twelve-month period you were eligible but did not enroll.

8-month Special Enrollment Period

Common questions

Should I delay Medicare if I am still contributing to a Health Savings Account?

A Health Savings Account, commonly called an HSA, is a special tax-advantaged savings account attached to certain high-deductible employer health plans. If you are still putting money into one and want to keep doing so, delaying all parts of Medicare, including Part A, is the right approach. Enrolling in any part of Medicare ends your ability to make new HSA contributions going forward, though you can still spend money already saved in the account. Many people choose to stop contributing a few months before Medicare begins to keep the math simple around partial-year contribution limits.

What happens if my employer has fewer than 20 employees?

When your employer has fewer than 20 employees, Medicare is supposed to pay first on your healthcare claims, and your employer plan is only supposed to pay after Medicare has paid its share. If you have not signed up for Medicare in this situation, your employer plan may pay very little or nothing at all, because it is structured to pay second, not first. You could end up responsible for costs that should have been covered. Confirming your employer's size with HR before deciding is essential.

How exactly does Medicare coordinate with my employer plan?

For employers with 20 or more employees, your employer plan pays first on any claim, and Medicare pays second on what remains. This arrangement is called coordination of benefits, and it generally means your out-of-pocket costs stay low without needing to enroll in Part B right away. For smaller employers, Medicare pays first and the employer plan picks up whatever Medicare does not cover.

Can my spouse stay on my employer plan when I retire?

In most cases, your spouse can remain on your employer plan after you retire through COBRA continuation coverage for up to 36 months. The difference is that COBRA requires your spouse to pay the full premium, including the portion your employer previously subsidized, which can be a substantial increase. If your spouse is under 65, they may also want to compare COBRA costs against Marketplace plans before deciding.

Things to watch out for

Small employers create a coverage trap that most people do not see coming

If your employer has fewer than 20 employees and you have delayed Part B enrollment because you assumed your employer plan was protecting you, you may be accumulating uncovered medical costs without realizing it. Your employer plan may be paying as secondary coverage against a Medicare primary that does not exist, which can mean claims are denied or paid at a very low rate. If you have any uncertainty about your employer's size, ask HR directly and verify before your 65th birthday.

Your retirement date and your Part B start date are not the same thing

Part B coverage begins on the first day of the month after you enroll, not the day you enroll. If you retire on the last day of a month and enroll in Part B on that same day, your coverage will not begin until the first of the following month, leaving a gap. Planning your retirement date with at least 30 days of buffer before you need Part B to be active will prevent an unexpected gap in coverage.

Free help near you

Free personal help

State Health Insurance Assistance Program (SHIP)

Every state has a State Health Insurance Assistance Program (SHIP), staffed by trained counselors who provide free, unbiased Medicare guidance. They do not sell plans and have no financial interest in your decision. SHIP counselors are particularly well-equipped to help with employer coordination questions, enrollment timing, and late penalty situations.

Find your local SHIP counselor

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Turning 65

Medicare enrollment

You are approaching or at 65 and entering Medicare for the first time. Medicare is the federal health insurance program for people 65 and older. It has four parts: Part A covers hospital stays, Part B covers outpatient care and doctor visits, Part C (called Medicare Advantage) bundles A and B through a private insurer, and Part D covers prescription drugs. The main decision every new enrollee faces is whether to go with Original Medicare (Parts A and B, usually paired with a Medicare Supplement Insurance plan, commonly called Medigap, and a Part D drug plan) or Medicare Advantage (Part C). The enrollment window around your 65th birthday is the most important deadline of this stage.

What happens, and when

You

Your enrollment window opens 3 months before your 65th birthday

The Initial Enrollment Period is a 7-month window that is the primary opportunity for new Medicare enrollment. It opens 3 months before the month you turn 65, includes your birthday month, and runs 3 months after. Enrolling in the first 3 months means your coverage starts the month of your birthday. Enrolling in the 4th through 7th months means coverage starts 1 to 3 months later. Outside this window, you generally cannot enroll without a penalty unless you have qualifying employer coverage.

7-month window

Social Security Administration

Enroll in Medicare Part A and Part B

You can enroll online at ssa.gov, by calling Social Security at 1-800-772-1213, or in person at a Social Security office. If you already receive Social Security retirement benefits, you are automatically enrolled in both Part A and Part B at 65 and your Medicare card arrives by mail. Part A is premium-free for most people who have paid Medicare taxes for at least 10 years. Part B carries a monthly premium of $185 for most enrollees in 2025, though people with higher incomes pay more through an income-related surcharge.

Takes up to 30 days to process

You with a State Health Insurance Assistance Program (SHIP) counselor

Decide how you want Medicare to work for you

Original Medicare is the traditional federal program. You keep Parts A and B, add a Medicare Supplement Insurance (Medigap) plan from a private insurer to cover the costs Original Medicare leaves behind, and add a separate Part D prescription drug plan. Medicare Advantage is an all-in-one alternative where a private insurance company administers your Medicare benefits, usually including drug coverage, often at lower monthly cost but with provider network restrictions and rules that can change annually.

During enrollment period

You

Fill in the gaps Medicare leaves, before the window closes

Medicare Supplement Insurance, known as Medigap, is private insurance that pays the costs Original Medicare does not cover. Those leftover costs include deductibles, copayments, and the percentage of each bill that Medicare pays but does not cover in full. Medigap plans are sold by private insurance companies but are federally standardized, meaning the same plan letter covers the same things regardless of which company sells it. The open enrollment window for Medigap is six months and begins the month you are both 65 and enrolled in Part B. During this window, insurers are required by federal law to sell you any Medigap plan without asking about your health history. After this window closes, most states allow insurers to deny you coverage or charge higher premiums based on your health conditions, so this window is one of the most consequential deadlines in all of Medicare enrollment.

6-month open enrollment window

You

Make sure your prescriptions will be covered

Medicare Part D covers prescription medications through private insurance plans that contract with Medicare. You should enroll even if you currently take no prescriptions, because Medicare imposes a permanent late enrollment penalty for every month you were eligible but went without Part D coverage. The Medicare Plan Finder tool at medicare.gov lets you compare Part D plans based on your specific medications and find the lowest-cost option for your situation.

During enrollment period

Common questions

Is Medicare Advantage or Original Medicare the right choice?

Neither is universally better. Medicare Advantage plans typically have lower monthly premiums but require you to use a network of providers and get prior authorizations for many services. Original Medicare combined with a Medigap supplement typically costs more per month but accepts any provider in the country who takes Medicare, with no network or referral requirements. The right choice depends on your health, your finances, your current doctors, and your tolerance for uncertainty if plan rules change year to year.

What is the Part B premium and does it change based on income?

The standard Part B premium is $185 per month in 2025 for most people on Medicare. People with higher incomes pay more. The extra amount is calculated based on your income tax return from two years prior and begins for single filers earning over $106,000 per year, or married couples filing jointly earning over $212,000. If your income has dropped significantly since that tax return, you can ask Social Security to use a more recent year's income instead.

Can I switch between Medicare Advantage and Original Medicare later?

Yes. Medicare's Annual Enrollment Period runs from October 15 through December 7 each year, during which you can switch between Original Medicare and Medicare Advantage or change drug plans. However, switching from Medicare Advantage back to Original Medicare does not automatically restore your Medigap coverage. If your Medigap open enrollment window has passed, insurers in most states can deny your Medigap application or charge higher premiums based on your health at that time.

Do I need to sign up if I am already receiving Social Security?

If you are already receiving Social Security retirement benefits before you turn 65, Medicare Parts A and B enroll automatically and your Medicare card arrives by mail about three months before your 65th birthday. You do not need to do anything for Parts A and B. You do need to actively choose a Part D drug plan and decide whether to add a Medigap plan or switch to Medicare Advantage. No one makes those choices for you automatically.

Things to watch out for

Missing the Medigap six-month window is a decision you cannot take back

When you first enroll in Medicare Part B, you have a six-month window during which insurers are required by federal law to sell you any Medigap plan without asking about your health history. After that window closes, most states allow insurers to deny coverage or charge higher premiums based on your medical conditions. A small number of states provide additional protections, so the rules in your state are worth verifying before you assume you can enroll in Medigap later.

Skipping Part D creates a penalty even if you take no prescriptions today

Medicare imposes a late enrollment penalty for Part D drug coverage equal to one percent of the national base premium for every month you were eligible but did not enroll. That penalty is added to your Part D premium for as long as you have Medicare. Even if you currently take no medications, enrolling in the lowest-cost Part D plan available in your area protects you from this penalty without significant cost.

Medicare Advantage advertising is not the same as Medicare information

In the weeks before and during open enrollment season, television and direct mail advertising for Medicare Advantage plans is pervasive. These are paid advertisements from insurance companies and brokers who earn commissions on enrollment. The information in these ads emphasizes benefits and minimizes trade-offs. Unbiased guidance is available at no cost through your local SHIP counselor, who does not sell plans and has no financial interest in your decision.

Free help near you

Free personal help

State Health Insurance Assistance Program (SHIP)

Every state has a SHIP program staffed by trained counselors who provide free, unbiased Medicare guidance. They do not sell plans, do not receive commissions, and will walk through your specific situation including plan comparisons, cost projections, and enrollment logistics. This is the most valuable resource available to new Medicare enrollees and it costs nothing.

Find your local SHIP counselor

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Lower income or need help with costs

Medicaid enrollment

Medicaid is a government health program for people with limited income and savings. It is run jointly by the federal government and each state, which means the rules and benefits differ depending on where you live. For seniors, Medicaid can cover things Medicare does not, including long-term care and nursing home costs, or it can help pay Medicare premiums and out-of-pocket costs if your income is low enough to qualify.

What happens, and when

You

Figure out which type of Medicaid fits your situation

Medicaid covers different groups of people in different ways, and the rules for seniors are not the same as the rules for families with children. If you are 65 or older with limited income, you may qualify for a version of Medicaid that helps pay for medical care directly. If you have Medicare but struggle with the premiums or copays, a separate set of Medicare Savings Programs can help cover those costs. If you need nursing home care or help at home and cannot afford to pay privately, long-term care Medicaid is the program designed for that situation. If you are under 65 and live in one of the 40 states that expanded Medicaid, you may qualify on income alone.

Before applying

You

Gather the documentation your application will require

Most Medicaid applications require proof of identity, proof of residency, income documentation from the past three months, bank statements, property records, and your Social Security award letter if applicable. Long-term care Medicaid applications additionally require five years of financial records because Medicaid reviews five years of financial history when long-term care is involved. Having complete documentation before you submit significantly reduces processing time, as incomplete packets are the most common reason for delays.

1 to 3 weeks to gather

State Medicaid agency

Submit your application to your state Medicaid office

You can apply online at your state's Medicaid portal, by mail, in person at a county Department of Social Services office, or through healthcare.gov, which will route qualifying applicants to their state Medicaid program. The application itself is free and does not require an attorney, though legal assistance is strongly worth considering for long-term care applications.

Same day submission

State Medicaid agency

The state reviews your application and tells you whether you qualify

Standard Medicaid applications are decided within 45 days. Applications that involve a disability determination take up to 90 days. Long-term care Medicaid applications often take three to six months because of the five-year financial review that long-term care applications require. If approved, coverage is typically retroactive to the date of application or up to three months prior, depending on your state.

45 to 90 days standard

You

Pick a health plan if your state requires it

Most states administer Medicaid through managed care organizations rather than paying providers directly. After approval, you will typically have 30 to 90 days to select a plan from your state's options, or the state will auto-assign you to one. Choosing based on which specialists and pharmacies are in-network for your existing care makes a significant practical difference.

30 to 90 day selection window

You

Renew your coverage every year or it stops

Medicaid eligibility must be confirmed at least once a year. Your state will mail renewal paperwork, and failing to return it by the deadline ends your coverage even if your income and circumstances have not changed. Some states can verify income electronically through tax records and renew coverage without you doing anything, but this is not universal. Do not assume your state does this automatically without confirming directly with your state Medicaid office.

Annually

Common questions

What are the income limits for Medicaid?

Income limits vary by state and by the category of Medicaid you are applying for. For Aged, Blind, and Disabled Medicaid, most states use 100 percent of the federal poverty level as a threshold, which is roughly $15,650 in annual income for a single person in 2025. Medicare Savings Programs extend somewhat higher, up to 135 percent of the federal poverty level depending on the specific program. Your state Medicaid agency can give you the current limits for your state.

What counts as an asset and what is the limit?

For Aged, Blind, and Disabled Medicaid and long-term care Medicaid, most states cap countable assets at $2,000 for an individual. Countable assets include bank accounts, investment accounts, and most property other than your primary home. Assets that are generally not counted include your primary residence if you intend to return to it, one vehicle, prepaid burial arrangements up to a certain value, and some personal property. What counts and what does not varies by state.

Can a person have both Medicare and Medicaid at the same time?

Yes. People who qualify for both programs at the same time are often called dual-eligible, meaning they have both. When that happens, Medicare pays first on most medical claims and Medicaid steps in to cover what Medicare does not, which can include Medicare premiums, copays, deductibles, and services Medicare does not cover at all such as long-term custodial care. For people with limited income who are already on Medicare, checking whether they also qualify for Medicaid is always worth doing.

Is there help paying for prescription drug costs if my income is low?

Yes. The Extra Help program, sometimes called the Low Income Subsidy, is a federal program that helps people with limited income pay Medicare Part D drug plan premiums, deductibles, and copays. It is separate from Medicaid but available to people in a similar income range. People who qualify for full Medicaid automatically qualify for Extra Help as well. Others can apply directly through Social Security. Extra Help can reduce Part D costs to nearly zero for qualifying individuals and is significantly underused because many people do not know it exists.

What is the five-year lookback and why does it matter?

When you apply for long-term care Medicaid, the state reviews the previous five years of your financial history to identify any transfers of assets for less than fair market value. If the state finds such transfers, including gifts to family members or transferring property at below-market prices, it calculates a penalty period during which you are ineligible for Medicaid coverage even if you would otherwise qualify. The penalty period can last months or years depending on the value of the assets transferred. This is why planning well before a long-term care need arises is so important.

Things to watch out for

Gifting assets to family can create years of ineligibility

When families anticipate a future long-term care Medicaid need, a common instinct is to transfer assets to adult children to bring assets below the eligibility threshold. The five-year lookback is specifically designed to identify this, and when such transfers are found, the penalty period can be severe. If a long-term care need is on the horizon, speaking with a certified elder law attorney well before the need arises is the most important step you can take.

Rules vary so significantly between states that general advice can be wrong

Medicaid is administered at the state level within federal guidelines, and states have substantial flexibility in how they structure eligibility, benefits, and income counting. Income limits, asset limits, covered services, home and community-based services waivers, and the application process itself all differ materially from state to state. Information you read online or receive from a friend in another state may not apply to your situation. Always verify with your state Medicaid agency directly.

Medicaid estate recovery can claim the family home after death

Federal law requires states to attempt to recover the cost of certain Medicaid services from the person's estate after they die. In many states, this includes the family home, even if a surviving spouse or dependent was living there. Rules and exemptions vary by state, and planning ahead with an elder law attorney can protect family assets in many situations. This is a dimension of Medicaid that many families discover too late.

Free help near you

Free personal help

Your state Medicaid agency or SHIP

State Medicaid agencies handle applications, eligibility questions, and coverage issues directly. SHIP counselors are equipped to help specifically with Medicare Savings Programs and dual-eligibility questions. For long-term care Medicaid planning, the financial complexity involved makes consulting a certified elder law attorney a worthwhile investment even for people who do not typically use legal services.

Find your state Medicaid agency

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Under 65 with disability

Disability to Medicare

If you receive Social Security disability payments and are under 65, Medicare is coming whether you know it or not. After 24 months of disability benefits, Medicare enrollment happens automatically and your card arrives in the mail. Two conditions skip the wait entirely: permanent kidney failure requiring dialysis or transplant, and ALS (amyotrophic lateral sclerosis). This page walks through what to expect and what to do when it arrives.

What happens, and when

You

Apply for SSDI benefits through Social Security

You can apply online at ssa.gov, by phone at 1-800-772-1213, or in person at a Social Security office. The application requires detailed medical documentation, a complete work history, and evidence that your condition prevents you from engaging in substantial gainful activity and is expected to last at least twelve months or result in death. Initial decisions take three to six months on average, and initial denials are common. Pursuing an appeal with a disability attorney or advocate increases approval rates significantly.

3 to 6 months for decision

You

Find coverage for the waiting period before Medicare arrives

The period between SSDI approval and your Medicare start date can be anywhere from a few months to nearly two years depending on when your disability officially began. During that time you still need health coverage. If you have an employer plan through a working spouse, that can continue. If not, the Health Insurance Marketplace is the most common option, and most people on SSDI qualify for reduced-cost plans based on income. In states that have expanded Medicaid, you may also qualify for Medicaid during the wait, which would cost little or nothing. A Marketplace Navigator can help you find the right option for your income at no cost to you.

Immediately after approval

Social Security Administration

The 24-month Medicare waiting period counts down

After SSDI is approved, there is an additional five-month waiting period before cash benefits begin. Medicare eligibility then begins 24 months from when Social Security determines your disability began, not from the date they approved your claim. If your SSDI approval is retroactive, meaning benefits are owed for months before the approval date, some or all of the 24-month period may already have elapsed and Medicare eligibility may arrive sooner than you expect.

24 months from when disability began

Centers for Medicare and Medicaid Services

Your Medicare card arrives in the mail. You do not need to apply.

The Centers for Medicare and Medicaid Services will mail your Medicare card approximately three months before your Medicare start date. Both Part A and Part B are enrolled automatically. If you have other health coverage through an employer, you may be able to decline Part B for now without penalty, but only if that employer coverage qualifies as equivalent to Medicare. Declining without a valid reason creates a permanent late penalty that adds to your Part B premium every month for the rest of your life.

Card arrives 3 months before

You

Decide how to fill in the gaps Medicare leaves

Once Medicare begins, people on SSDI under 65 can enroll in Medicare Advantage plans and Part D drug plans. Medigap supplement coverage is more complicated. Only about half of states require insurers to offer Medigap plans to people on Medicare under 65, and premiums are often substantially higher than for those enrolling at 65. Checking what your state requires is an important early step.

During enrollment period

You, when you turn 65

A second enrollment window opens when you turn 65

When you reach age 65, you receive a new seven-month Initial Enrollment Period and a new six-month Medigap open enrollment window regardless of how long you have been on Medicare. This is a rare second opportunity to enroll in Medigap without the insurance company reviewing your health history, even in states that did not offer that protection for under-65 enrollees. It is one of the most valuable and least-known rights available to people who came to Medicare through SSDI.

At age 65

Common questions

What if I have end-stage renal disease or ALS?

People with amyotrophic lateral sclerosis receive Medicare beginning the month their SSDI is approved, with no waiting period at all. People with end-stage renal disease who require dialysis receive Medicare beginning the fourth month of dialysis, or earlier if they begin home dialysis training. These are the only two conditions that bypass the standard 24-month waiting period that applies to all other SSDI recipients.

Will I have to pay a monthly premium for Medicare Part A?

Part A is free for most people who have worked and paid Medicare taxes for at least 10 years. That work history can come from you or from a spouse. If you or your spouse meets that threshold, Part A should cost nothing each month. Medicare Part B, which covers doctor visits and outpatient care, carries a standard monthly premium of $185 for most people in 2025 regardless of how you became eligible for Medicare.

What happens to my Medicare if I try going back to work?

Social Security provides a Trial Work Period that lets you test whether you can return to work without losing your disability benefits or Medicare coverage right away. During the Trial Work Period, which can last up to nine months within any five-year window, you can work and earn any amount without affecting your SSDI payments. After the Trial Work Period ends, you have an additional 93 months during which your Medicare coverage stays in place even if your disability payments stop because you are earning too much to qualify.

Can I get a Medigap plan while I am under 65?

Whether Medigap is available to you under 65 depends on your state. Federal law does not require insurers to offer Medigap to people under 65 on Medicare, but roughly half of states have passed their own laws requiring it. Even in states where Medigap is available, premiums for under-65 enrollees are often significantly higher than what people enrolling at 65 pay. When you do turn 65, you will have a new protected enrollment window regardless of prior health history.

Things to watch out for

Your Medicare start date is based on when your disability officially began, not when Social Security approved your claim

The 24-month clock runs from the date Social Security determines your disability began for payment purposes, which is sometimes months before the date they actually approved your claim. If your approval was retroactive, some or all of those 24 months may already have passed, and your Medicare coverage could begin much sooner than you expect. Your Social Security award letter will state the date your disability period officially began. Read it carefully, because that date is what controls your Medicare timeline.

Medigap availability under 65 varies widely by state and cannot be assumed

If you live in a state that does not require under-65 Medigap access, your options for supplemental coverage may be limited to Medicare Advantage or Original Medicare without any supplement. This is a meaningful difference in financial protection, particularly for people with serious conditions that generate high medical costs. Before assuming you can get Medigap, check whether your state has a specific law requiring it for under-65 enrollees.

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Free personal help

SHIP or a state Disability Rights organization

SHIP counselors are equipped to answer Medicare questions for under-65 enrollees, not only those who are 65 and older. For help navigating the SSDI application itself or appealing a denial, your state's Protection and Advocacy network provides free legal assistance focused on disability rights, work incentive programs, and appeals.

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Veteran

VA Healthcare enrollment

You served in the military and have earned a VA Healthcare benefit. It does not start automatically. You have to apply, but most veterans who apply are accepted. Once enrolled, VA can become your primary source of care, and it works alongside Medicare if you have both.

What happens, and when

You

Gather your discharge paperwork and service history

The primary document you need is your DD Form 214, known as the DD-214, which is your Certificate of Release or Discharge from Active Duty. It confirms your service dates, discharge type, and character of service. VA uses this to verify eligibility. If you no longer have your DD-214, you can request a copy through the National Archives online at archives.gov, or a Veterans Service Organization (VSO) representative can assist you in obtaining it.

1-2 weeks to retrieve

You, or with a VSO

Submit your application for VA Healthcare

The application is VA Form 10-10EZ, which you can complete online at va.gov, by phone at 1-877-222-8387, by mail, or in person at any VA medical center. Working with a Veterans Service Organization (VSO) representative to complete this form increases your likelihood of a smooth approval and costs nothing.

1-4 weeks to file

VA reviews your application and assigns a priority group

VA reviews your service history, income, and any disability status to assign a priority group numbered 1 through 8. This number determines the order in which you are enrolled, what you pay in copays, and which services are available to you. Veterans with service-connected disabilities are typically placed in the higher priority groups, meaning lower costs and faster access.

1-4 weeks decision

You

Schedule first primary care appointment

Most veterans are assigned to a Patient Aligned Care Team, which VA refers to as a PACT, at their nearest VA medical center. This is a dedicated team of providers who become your long-term primary care team within the VA system. Your first appointment is typically scheduled within 30 days of enrollment.

Up to 30 days

You, at age 65

Consider enrolling in Medicare when you turn 65, even if VA is your primary care

VA recommends that enrolled veterans also sign up for Medicare at 65. Having both gives you access to any Medicare-accepting doctor outside the VA system, which matters if you travel, move, or need a specialist not available at your local VA facility. Most veterans enroll in Medicare Part A, which covers hospital stays, at no premium cost. Whether to also add Part B, which covers outpatient care, depends on how often you use non-VA providers.

At 65

Common questions

Do I need Medicare if I already have VA Healthcare?

Medicare is not required for enrolled veterans, but the VA strongly recommends enrolling at 65. VA Healthcare only covers care received at VA facilities or authorized through VA Community Care. Medicare gives you unrestricted access to any Medicare-accepting provider in the country, which matters if you travel, move, or need a specialist that is not available through your local VA.

What is a priority group and why does it matter?

Priority groups are a VA classification system running from 1 to 8 that determines the order in which veterans are enrolled, what copays apply, and which services are covered. Veterans with service-connected disabilities rated at 50 percent or higher are typically in priority groups 1 or 2, with no or minimal copays. Veterans with no service-connected disability and higher incomes are in priority groups 7 or 8, and may pay copays for some services. Your priority group is assigned when you enroll and can be reassessed if your situation changes.

Is VA Healthcare free?

For veterans with service-connected conditions, care related to those conditions is generally provided at no cost. For veterans in higher priority groups without service-connected conditions, copays apply for many services. Prescription copays are modest compared to most commercial coverage. The full picture depends on your priority group, the type of care, and whether the care is for a service-connected or non-service-connected condition.

Can I see non-VA providers through my VA coverage?

Yes, through the VA Community Care Network. Community care allows VA to authorize and pay for care with outside providers when the nearest VA facility cannot provide timely or geographically accessible care. You must receive prior authorization for most community care referrals. If you have Medicare as well, you can also see Medicare providers without going through VA at all.

Things to watch out for

VA pharmacy does not protect you from a Medicare drug coverage penalty

VA pharmacy benefits are excellent and free for many veterans, which leads many to skip Medicare Part D drug coverage at 65. The problem is that VA pharmacy is not counted by Medicare as equivalent drug coverage. If you later leave VA, move far from a VA facility, or simply want coverage outside the VA system, you will face a permanent late enrollment penalty added to your Part D premium for every month you went without it. If you plan to rely on VA pharmacy for the rest of your life, that may be a reasonable tradeoff. If there is any chance that changes, enrolling in even a low-cost Part D plan at 65 protects you.

If you were denied VA benefits before 2022, you may now qualify

The PACT Act of 2022 extended VA benefits to veterans exposed to burn pits, Agent Orange, and certain toxic radiation, covering conditions that were previously not recognized as connected to military service. Veterans who applied before this law passed and were turned away may now be eligible. It is worth submitting a new application or asking a Veterans Service Organization representative to review your situation under the updated rules.

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Veterans Service Organization (VSO)

Accredited Veterans Service Organizations including the American Legion, Veterans of Foreign Wars, and Disabled American Veterans provide free benefits counseling and application assistance. VSO representatives are accredited by the VA and have no financial interest in your outcome. Veterans who work with a VSO during the application process have meaningfully higher approval rates than those who apply alone.

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Retired military

TRICARE for Life

You are a military retiree, dependent, or survivor and your TRICARE coverage carries into retirement. When you turn 65, TRICARE automatically upgrades to TRICARE for Life, which works alongside Medicare and covers most of what Medicare does not. There is one thing that will end this benefit if you miss it: you must sign up for Medicare Part B.

We are continuing to expand this section. The overview and key steps below are accurate. More detailed guidance is in progress.

What happens, and when

You

Verify that your DEERS record is current and accurate

The Defense Enrollment Eligibility Reporting System is the database that determines your eligibility for TRICARE benefits. Your name, date of birth, address, and contact information need to be accurate in DEERS for your coverage to process correctly. You can update your DEERS record online at milconnect.dmdc.osd.mil or by calling 1-800-538-9552. Doing this 90 days before your 65th birthday gives enough time to resolve any discrepancies before they affect your coverage.

90 days before 65

Social Security Administration

Enroll in both Medicare Part A and Part B

Both Part A and Part B are required to activate TRICARE for Life. If you skip Part B, your TRICARE for Life coverage will not be available, regardless of your service history or years of enrollment. Enroll during your Initial Enrollment Period around your 65th birthday to avoid any Part B late penalty. You can enroll online at ssa.gov, by phone, or in person at a Social Security office.

During Medicare enrollment period

Automatic

TRICARE for Life activates once both Medicare parts are active

There is no separate enrollment form for TRICARE for Life. Once Medicare Part A and Part B are both active and your DEERS record reflects your current status, TRICARE for Life activates automatically. From that point, Medicare pays first on all eligible claims and TRICARE pays what Medicare leaves behind, typically leaving your out-of-pocket near zero for Medicare-covered services.

Activates automatically

You

Do not add a separate drug plan. Your TRICARE pharmacy coverage already qualifies.

TRICARE's pharmacy benefit meets Medicare's standard for prescription drug coverage, which means you are not required to add a separate Medicare Part D drug plan and will not face a late penalty for going without one. In fact, adding a Part D plan can interfere with your TRICARE pharmacy benefit in ways that may increase what you pay for prescriptions. Before making any change to your prescription coverage, call TRICARE directly to understand how that change would affect your pharmacy access.

Decide before or at 65

Common questions

Do I need Medicare Advantage if I have TRICARE for Life?

Medicare Advantage is not needed and is generally not compatible with TRICARE for Life in any beneficial way. TRICARE for Life already wraps around Original Medicare and pays what it does not cover. Enrolling in a Medicare Advantage plan would change how your claims are processed and could actually reduce what TRICARE pays, since TRICARE for Life is designed specifically to coordinate with Original Medicare Parts A and B.

How much will I pay out of pocket for care?

For Medicare-covered services, TRICARE for Life covers the deductibles, copays, and the percentage of each bill that Medicare does not fully cover, leaving most people with zero out-of-pocket costs on standard Medicare-covered care. For services Medicare does not cover at all, TRICARE may still provide some coverage depending on the service. In practice, people with TRICARE for Life have some of the lowest out-of-pocket healthcare costs of any coverage arrangement in the Medicare system.

Do I need Medigap if I have TRICARE for Life?

TRICARE for Life does the same job as a Medigap supplement - it pays the costs Medicare leaves behind. Purchasing a Medigap plan in addition to TRICARE for Life would mean paying for redundant coverage. Unless you have an unusual reason to need additional protection, Medigap is not necessary when you have TRICARE for Life active.

Can I see any doctor, or am I limited to a network?

You can see any provider who accepts Medicare. Since TRICARE for Life pays the portion of the bill that Medicare does not cover, using a Medicare-accepting provider means TRICARE covers the remainder without requiring additional referrals or authorizations in most cases. You are not limited to military treatment facilities, though you may choose to use them.

Things to watch out for

Skipping Part B ends your TRICARE for Life, and there is no exception

The requirement to enroll in Medicare Part B is absolute for TRICARE for Life eligibility. There is no waiver, no exception for good health, and no way to reinstate TRICARE for Life retroactively if you decline Part B at 65 and later change your mind. Many military retirees assume their service history protects them from this requirement. It does not. If Part B enrollment is delayed or missed, TRICARE for Life cannot be activated until Part B is obtained, and a late penalty will apply to Part B as well.

Outdated DEERS records are one of the most common causes of denied claims

If your DEERS record shows incorrect eligibility information, incorrect dates, or an outdated address, TRICARE for Life claims can be denied even when you are fully entitled to coverage. Verifying and updating DEERS before your 65th birthday is a straightforward step that prevents a frustrating category of problems. Verification takes a few minutes online or by phone and can save weeks of appeals and reprocessing later.

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Official help

TRICARE for Life at tricare.mil

The official TRICARE website provides current costs, benefit details, and guidance specific to TRICARE for Life. The TRICARE for Life contractor also provides direct support by phone for claims and coverage questions.

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Retired federal civilian

Federal Employee Benefits

You worked for the federal government and kept your workplace health insurance into retirement. When you turn 65, you will decide whether to add Medicare alongside it. Unlike military retirees with TRICARE, you are not required to. But for most federal retirees who see doctors regularly, adding Medicare Part B reduces what they pay out of pocket overall, even after accounting for the additional premium.

We are continuing to expand this section. The overview and key steps below are accurate. More detailed guidance is in progress.

What happens, and when

You

Confirm your federal health coverage carries into retirement

Your Federal Employee Health Benefits plan continues into retirement only if you were continuously enrolled for the full five years immediately before you retired. The Office of Personnel Management (OPM) handles billing and enrollment for retirees. If you are uncertain whether you meet this requirement, contact OPM or your HR office before retiring.

Before retirement

You

Medicare Part A covers hospital stays and is free for most people who have worked and paid into Medicare for at least 10 years. Enrolling at 65 adds hospital coverage alongside your federal health plan at no additional cost. Most federal retirees enroll in Part A even if they are not yet sure about Part B, because there is no downside to having the hospital coverage in place.

During enrollment period

You

Decide whether adding Medicare Part B saves you money

Your federal health plan does not require Medicare Part B, so this decision is yours. Adding Part B means paying an additional monthly premium on top of your federal plan, but it also means your federal plan pays far less out of pocket per claim, because many plans waive or significantly reduce deductibles and copays for members who have both. For people who visit doctors regularly, the Part B premium often costs less than the out-of-pocket expenses it eliminates.

During enrollment period, or later via Special Enrollment Period

You

Review your federal health plan options every November

Federal health plan Open Season runs each November and is your annual opportunity to switch plans or coverage levels. Plan costs and benefits change every year, so a plan that was right for you last year may not be the best fit this year. Some carriers now offer Medicare Advantage options designed specifically for federal retirees, which can in some cases reduce or eliminate the federal plan premium for members who are also enrolled in Medicare. Comparing your options each November takes about 30 minutes and can save meaningful money.

November annually

Common questions

Do I need Medicare Part B if I have my federal health plan?

Part B is not required. Your federal health plan covers you on its own. However, most federal retirees who add Part B end up paying less overall because their federal plan reduces or eliminates the deductibles and copays on Medicare-covered visits. The monthly Part B premium is often less than the deductibles and copays it eliminates. A State Health Insurance Assistance Program (SHIP) counselor can help you run the numbers for your specific plan at no charge.

Can I drop my federal health plan and rely on Medicare alone?

You can, but dropping your federal health plan in retirement is generally permanent. Once you leave during Open Season or outside of a qualifying event, re-enrolling is not an option. Most federal retirees keep the plan because it covers dental, vision, and other services that Medicare does not, and because it provides a stable backstop that does not change year to year the way Medicare Advantage plans can.

Are there FEHB Medicare Advantage options?

Several FEHB carriers offer Medicare Advantage plans specifically designed to coordinate with FEHB. In some of these arrangements, enrolling in the carrier's Medicare Advantage plan reduces or eliminates the FEHB premium entirely. Whether this makes financial sense depends on your specific carrier, the Medicare Advantage plan's network, and how you use healthcare. OPM publishes plan comparison data each year during Open Season in November.

What happens to my spouse's coverage if I die?

Whether your spouse can keep the federal health plan after you die depends on a decision you make at retirement called the survivor benefit election. If you elected to provide a survivor benefit when you retired, your spouse can continue under your federal health plan after your death. If you did not elect that benefit at retirement, your spouse's coverage ends 31 days after you pass away. This cannot be changed after the fact, which is why understanding this option before retiring matters.

Things to watch out for

If you switched off your federal health plan in the years before retirement, you may have lost the right to keep it

To carry your federal health plan into retirement, you must have been enrolled continuously for the full five years immediately before the date you retired. A common situation where people lose this right is switching to a spouse's private employer plan for a few years before retirement to save money on premiums. If there was any gap in your federal health plan enrollment during that five-year window, the plan does not carry into retirement and there is no exception or appeal process. If you are not certain whether you qualify, contact the Office of Personnel Management or your HR office before you retire.

Skipping Medicare Part B often costs more than the premium saves

Without Part B, your federal health plan pays first for all doctor visits and outpatient care, and you are responsible for the plan's full deductibles and copays on every claim. For retirees who see doctors regularly, those out-of-pocket expenses often exceed what the Part B monthly premium would have cost. A State Health Insurance Assistance Program counselor can compare your specific federal plan's costs with and without Part B and tell you which is actually cheaper for your usage pattern. The consultation is free.

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Official help

Office of Personnel Management (OPM) or your specific FEHB plan

The Office of Personnel Management administers FEHB for retirees and can answer questions about enrollment, billing, and plan changes. Your specific FEHB plan's customer service team can explain how their plan coordinates with Medicare, what changes when you add Part B, and how to read your explanation of benefits once both coverages are active.

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Native American

Indian Health Service

As a member of a federally recognized tribe, you are eligible to receive healthcare through Indian Health Service. This benefit covers care at IHS-operated facilities, tribally run health programs, and Urban Indian Health Programs for tribal members living in cities. It works alongside Medicare and Medicaid when you hold those as well, rather than replacing them.

We are continuing to expand this section. The overview and key steps below are accurate. More detailed guidance is in progress.

What happens, and when

You

Gather documentation confirming tribal membership

IHS serves members of federally recognized tribes. Most facilities require a Certificate of Indian Blood or a tribal enrollment card as documentation of eligibility. If you do not have these documents, your tribe's enrollment office can issue or verify them. The time this takes varies by tribe, so beginning this process early is worthwhile if your documents are not readily available.

Varies by tribe

You

The three types of IHS-system facilities are federally operated IHS facilities, tribally operated health programs, and Urban Indian Health Programs for tribal members living in cities. Registering at any of these establishes you as a patient and opens access to services. Some tribal health programs operate under compacts with IHS and may have their own registration processes separate from federal IHS procedures.

Same-day registration typically

IHS financial counselor

Let the facility know about any other health coverage you have

IHS is authorized to bill Medicare, Medicaid, VA, and private insurance when patients hold those coverages. When IHS can bill another payer for a service, it stretches the IHS budget further, which means more money is available to cover care for other patients through Purchased and Referred Care, the program that pays for services at outside providers when IHS cannot provide them directly. Sharing your coverage information at registration does not reduce your IHS eligibility. It actually benefits the entire community.

During registration appointment

You, at age 65

Enrolling in Medicare does not end or reduce your IHS eligibility. The two programs work together. Most eligible Native Americans who reach 65 choose to enroll in Medicare because it provides access to care outside of IHS facilities and serves as a secondary payer when IHS provides care. The Medicare Initial Enrollment Period deadlines apply regardless of IHS status, and missing them can create lifetime penalties.

Medicare enrollment period at age 65

Common questions

Do I need Medicare if I already have access to IHS?

IHS provides important healthcare access, but its funding is limited by annual Congressional appropriations. When IHS cannot provide a service directly, it may authorize Purchased and Referred Care to outside providers, but those referrals depend on available funds that can run out during the year. Enrolling in Medicare at 65 gives you access to any Medicare-accepting provider in the country and provides protection when IHS referral funding is exhausted, when you travel, or when you need a specialist not available in your IHS system.

What is Purchased and Referred Care and how does it work?

Purchased and Referred Care is the mechanism by which IHS pays for care at non-IHS providers when IHS facilities cannot provide a needed service. A medical officer at your IHS facility must determine that the care is medically necessary and that IHS cannot provide it. PRC funds are limited and are prioritized based on medical urgency. Elective or non-urgent care referrals may not be authorized when funds are low, which is why having Medicare or Medicaid as a backup matters.

Can I see doctors outside the IHS system?

There are three ways to access non-IHS care. First, through a Purchased and Referred Care authorization from your IHS facility. Second, through Medicare if you have enrolled, which lets you see any Medicare-accepting provider directly without going through IHS. Third, through Medicaid if you qualify by income, which also provides access to enrolled providers in your state. Holding more than one type of coverage gives you more flexibility in where you can receive care.

What if there is no IHS facility near where I live?

Urban Indian Health Programs operate in many cities and provide culturally appropriate primary care, behavioral health services, and care coordination for tribal members who live in urban areas away from reservation or rural IHS facilities. You can search for UIHPs at ihs.gov. Some tribal health programs also offer telehealth services that extend access to members living at a distance. If no nearby option exists, your tribe's health office may be able to identify resources or assist with referrals.

Things to watch out for

Purchased and Referred Care funds run out each year and cannot be assumed

PRC funds are a fixed annual appropriation that is distributed across all authorized patients. As the fiscal year progresses, available funds shrink, and by late in the year many facilities can only authorize PRC for the most urgent medical needs. If you rely on IHS referrals for elective procedures or specialist visits, there is a real possibility that authorization will be deferred or denied. Having Medicare or Medicaid as backup coverage means you are not entirely dependent on PRC availability for non-emergency care outside IHS.

IHS eligibility does not extend Medicare enrollment deadlines

There is no exception to Medicare's enrollment rules for tribal members. If you turn 65 without enrolling in Medicare during your Initial Enrollment Period and do not have qualifying employer coverage, you will face the same late enrollment penalty as anyone else who missed their window. IHS eligibility is not considered qualifying coverage for purposes of delaying Medicare. If you are approaching 65, begin the Medicare enrollment process during the standard window even if you plan to continue using IHS as your primary source of care.

Free help near you

Local help

Your IHS facility, tribal health program, or Urban Indian Health Program

Each IHS facility and tribal health program has patient benefits coordinators and financial counselors who help patients understand the interaction between IHS, Medicare, and Medicaid. They are the best starting point for navigating coverage questions specific to your facility and tribe, since rules can vary meaningfully between tribally operated and federally operated programs.

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