Medicare starts at 65 for most people, but you may be able to start earlier if you have a disability or end-stage renal disease

You become may be able to access for Medicare the month you turn 65, as long as you or your spouse paid Medicare taxes while working. You do not have to wait until your birthday month ends — you can start coverage as early as the first day of the month you turn 65. If you were born on the first of any month, your coverage begins the previous month.

You can start Medicare before 65 if you have been receiving Social Security disability benefits for 24 months, or if you have end-stage renal disease (permanent kidney failure requiring dialysis or transplant) or ALS (amyotrophic lateral sclerosis). These are the only medical conditions that lower the age requirement.

If you are still working at 65 and have health insurance through your employer, you may be able to delay Medicare without penalty, but the rules depend on your employer's size and your spouse's coverage. Delaying past 65 without a valid reason can result in a permanent premium increase.

Key Takeaways

  • You become may be able to access for Medicare at 65 if you or your spouse paid Medicare taxes for at least 10 years of work.
  • You can start Medicare before 65 if you have been on Social Security disability for 24 months, or if you have end-stage renal disease or ALS.
  • You must sign up during your enrollment period or face a permanent penalty on your Part B and Part D premiums.
  • If you are covered by an employer plan at 65, you may delay Medicare, but you need to understand your employer's size and your spouse's situation to avoid penalties.
  • Your birthday month determines when your coverage can start, and the first of the month rule applies even if your birthday is mid-month.

How the 65-year-old rule works

Medicare may be able to access at 65 is automatic if you have already been receiving Social Security retirement benefits. If you have not yet claimed Social Security, you will need to sign up for Medicare separately during your enrollment period. The Social Security Administration does not automatically enroll you just because you turned 65.

You must have worked and paid Medicare taxes (the 1.45% deduction from your paycheck labeled "Medicare") for at least 10 years, spread across your working life. This does not have to be 10 consecutive years. If you are married, your spouse's work history can also make you may be able to access, even if you did not work that long yourself.

If you do not have 10 years of Medicare tax history yourself and your spouse does not either, you may still be able to buy into Medicare Part A by paying a monthly premium. This option exists for people 65 and older who do not meet the work requirement. The premium varies based on how many years of coverage you have.

Starting Medicare before 65: disability and medical conditions

If you have been receiving Social Security Disability Insurance (SSDI) for 24 consecutive months, you become may be able to access for Medicare at any age. The 24-month clock starts from the month your disability benefits began, not from when you applied. Once those 24 months pass, Medicare begins automatically — you do not need to sign up separately.

If you have end-stage renal disease, you become may be able to access for Medicare regardless of age, but you must be aware that your coverage may be limited. Medicare will cover dialysis and related services, but you may need to coordinate with Medicaid or other coverage for non-kidney-related care. You should contact your dialysis center's social worker to understand your specific coverage.

If you have ALS (Lou Gehrig's disease), you become may be able to access for Medicare when ready upon approval of your Social Security disability claim. Unlike other disabilities, ALS does not require the 24-month waiting period. You should receive a Medicare card within a few weeks of your disability approval.

Your enrollment period and what happens if you miss it

Your Initial Enrollment Period is a seven-month window: three months before the month you turn 65, the month you turn 65, and three months after. If you turn 65 in June, your enrollment period runs from March through September. You must sign up during this window to avoid a permanent penalty.

If you miss your Initial Enrollment Period and you do not have a valid reason (called a "may have access to event"), you will pay a penalty on your Part B premium for as long as you have Medicare. The penalty is 10% of the standard Part B premium for each full year you delayed. If you delayed for three years, you pay 30% extra forever. The same penalty applies to Part D (prescription drug coverage) if you go without it.

Valid reasons to delay without penalty include being covered by an active employer health plan (yours or your spouse's), or certain life events like losing your job or losing other coverage. If you have one of these reasons, you must sign up within 63 days of losing that coverage, or the penalty applies.

Working past 65 and employer coverage

If you are still employed at 65 and your employer has 20 or more employees, you can delay Medicare Part B without penalty as long as you are covered by the employer's health plan. Your employer's plan is considered primary, meaning it pays first, and Medicare is secondary. You must still sign up for Part A (hospital insurance) at 65, even if you delay Part B.

If your employer has fewer than 20 employees, Medicare becomes primary at 65, and you should sign up for both Part A and Part B. Delaying Part B in this situation will result in a penalty.

If your spouse is still working and you are covered under their employer plan, the same 20-employee rule applies to you. However, if your spouse's employer has fewer than 20 employees, you must sign up for Medicare at 65 even though you are on their plan.

Special situations: government employees and railroad workers

If you worked for the federal government and are covered under the Federal Employees Health Benefits Program (FEHB), you can delay Medicare Part B without penalty while you are still employed and covered. You must enroll in Part A at 65, but Part B can wait. Once you retire or lose FEHB coverage, you have 63 days to sign up for Part B without penalty.

If you are a retired railroad worker, your coverage through the Railroad Retirement Board (RRB) works differently than standard Medicare. You should contact the RRB directly to understand how your benefits coordinate with Medicare, as the rules are not the same as for other retirees.

If you worked for a state or local government and did not pay Social Security or Medicare taxes, you may not be may be able to access for Medicare at 65 based on your own work history. You would need to rely on your spouse's work history or purchase Part A coverage if you meet other requirements. Contact Social Security to verify your specific situation.

How to sign up for Medicare at 65

You can sign up for Medicare online at Medicare.gov, by phone at 1-800-MEDICARE (1-800-633-4227), or in person at your local Social Security office. If you are already receiving Social Security retirement or disability benefits, you can sign up online through your Social Security account at ssa.gov.

When you sign up, you will choose between Original Medicare (Part A and Part B) or a Medicare Advantage plan (Part C). You will also need to decide about prescription drug coverage (Part D) and supplemental coverage. These choices should be made during your Initial Enrollment Period, though you can change plans during the annual open enrollment period from October 15 to December 7 each year.

You will need your Social Security number and information about any current health coverage. If you are delaying Part B because of employer coverage, tell Medicare that when you sign up — this protects you from penalties later.

Frequently Asked Questions

What if I was born on the first of the month — when does my coverage start?

If you were born on the first of any month, your Medicare coverage begins the month before your 65th birthday. For example, if you were born on July 1, your coverage starts June 1. This is a special rule that applies only to people born on the first of the month.

Can I delay Medicare past 65 if I am still working?

You can delay Part B if your employer has 20 or more employees and you are covered by their health plan. You must still sign up for Part A at 65. If your employer has fewer than 20 employees, you should sign up for both Part A and Part B at 65, or you will face a penalty. Check your employer's size and your plan documents to be sure.

What is the penalty for missing my enrollment period?

The penalty is 10% of the standard Part B premium for each full year you delayed, and it is permanent. If you delayed for two years, you pay 20% extra every month for the rest of your life. The same penalty applies to Part D if you go without prescription drug coverage for more than 63 days in a row.

Do I have to sign up for Medicare if I have VA benefits?

No, you do not have to sign up for Medicare if you receive VA health benefits and do not want it. However, signing up for Medicare Part A at 65 does not cost anything if you have 10 years of work history, and it may cover services the VA does not. Many veterans carry both. If you choose not to sign up, you will not face a penalty.

What happens if I do not have 10 years of work history?

You can still get Medicare Part A at 65 by paying a monthly premium, which varies based on how many years of coverage you have. If you have a spouse with 10 years of work history, you may be able to use their record. Contact Social Security to find out your options and the cost of buying in.