The main routes to Medicare coverage

You can get Medicare if you are 65 or older and a U.S. citizen or permanent resident who has lived in the country for at least five years. You do not have to be retired to sign up — you just have to meet the age and residency requirements. Most people become covered this way.

You can also get Medicare before 65 if you have received Social Security Disability Insurance (SSDI) for 24 months, or if you have end-stage renal disease (permanent kidney failure requiring dialysis or transplant) or amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease. These routes do not depend on age.

A third group — people who worked long enough in jobs where they paid Medicare taxes — may have a spouse or ex-spouse who qualifies them. If your spouse is 62 or older and you have been married for at least one year, you may be covered based on their work record, even if you have not worked enough yourself.

Key Takeaways

  • You become covered at 65 if you are a U.S. citizen or permanent resident who has lived here for at least five years, regardless of whether you are still working.
  • You can get Medicare before 65 if you have been on SSDI for 24 months, have end-stage renal disease, or have ALS.
  • If your spouse or ex-spouse worked long enough in Medicare-taxed jobs, you may be covered based on their record even if you did not work enough yourself.
  • You must sign up during your initial enrollment period or face a permanent penalty on your premiums, unless you have employer coverage that delays enrollment.
  • Your work history is measured in credits earned through payroll taxes, and most people need 40 credits (roughly 10 years of work) to may have access to.

Work history and credits: what counts

Medicare is tied to Social Security credits, which you earn by working in jobs where you and your employer pay Medicare and Social Security taxes. You earn up to four credits per year, and most people need 40 credits total to may have access to for Medicare based on their own work record. That usually means about 10 years of work, but the years do not have to be recent or consecutive.

Self-employed people earn credits the same way — by paying self-employment tax on your net business income. The Social Security Administration keeps a record of your credits, and you can check your work history online through your my Social Security account at ssa.gov. If you have worked in the U.S. but are not sure how many credits you have, creating an account and viewing your earnings record takes about 10 minutes.

If you have not worked enough to earn 40 credits yourself, you may still may have access to based on a spouse's or ex-spouse's record. For a current spouse, you need to have been married for at least one year. For an ex-spouse, the marriage must have lasted at least 10 years, and you must be at least 62 years old. Your ex-spouse does not have to be receiving benefits — they just have to be old enough to receive them.

Disability and end-stage renal disease: early Medicare

If you receive SSDI, you become covered by Medicare automatically after you have been on disability for 24 months. You do not have to wait until 65. The 24 months starts from the date your disability benefits began, not from when you applied. Once you reach 65, your Medicare coverage continues under the regular program, and your SSDI becomes Retirement Insurance Benefits (RIB) — the payment amount stays the same, but the program name changes.

People with end-stage renal disease can get Medicare regardless of age or work history. You must have permanent kidney failure that requires dialysis or a transplant, and you must be a U.S. citizen or permanent resident. Coverage usually begins the first day of the month in which your dialysis treatment starts, or the month you receive a kidney transplant.

ALS patients also may have access to for Medicare when ready, without the 24-month wait that applies to other disabilities. If you have been diagnosed with ALS by a neurologist or other may have access to physician, you can contact Social Security to begin the process. Coverage is not automatic — you must report your diagnosis — but the approval is faster than for other conditions.

Permanent residents and citizenship requirements

You must be a U.S. citizen or a lawful permanent resident (green card holder) to get Medicare at 65. If you are a permanent resident, you must also have lived in the United States for at least five consecutive years. Those five years do not have to be when ready before you turn 65 — they can be at any point in your life — but they must be five years total.

If you are a citizen, there is no residency requirement beyond being a U.S. citizen. If you are a permanent resident and have not yet completed five years in the country, you will become covered on the date you reach five years of residency, even if that is after you turn 65.

Refugees and asylees are treated as permanent residents for Medicare purposes after one year, so if you arrived as a refugee or asylee and have been in the country for one year, you may be covered at 65 even if your green card process is still pending.

Enrollment timing and penalties

You should sign up for Medicare during your Initial Enrollment Period (IEP), which is the seven-month window that starts three months before the month you turn 65 and ends three months after. If you miss this window and do not have employer coverage, you will pay a permanent penalty on your Part B and Part D premiums for as long as you have Medicare.

The penalty is 10 percent of the standard Part B premium for each full year you were not enrolled, added to your premium forever. For Part D (prescription drug coverage), the penalty is 1 percent of the national average premium for each month you were not enrolled. These penalties do not go away if you sign up later — they are permanent.

If you are still working and covered by your employer's health plan, you may be able to delay enrollment without penalty. This is called creditable coverage. You must tell Medicare that you have employer coverage when you do sign up, usually by providing a letter from your employer's benefits department. If you do not report it, you may still face a penalty even though you were covered elsewhere.

Spouses and ex-spouses: coverage based on someone else's record

If you have not worked enough to earn 40 credits yourself, you may be covered based on a spouse's or ex-spouse's work record. For a current spouse, you must have been married for at least one year, and your spouse must be at least 62 years old (or any age if they are already receiving Social Security or SSDI). You do not have to be retired — your spouse's age and work history are what matter.

For an ex-spouse, the rules are stricter. The marriage must have lasted at least 10 years, you must be at least 62 years old, and you must be unmarried. Your ex-spouse does not have to be receiving benefits — they just have to be old enough to receive them. If your ex-spouse is not yet 62, you can still may have access to once they reach 62, even if you have not spoken to them in decades.

If you may have access to based on a spouse's or ex-spouse's record, you will still need to sign up during your Initial Enrollment Period to avoid penalties. The fact that you are covered based on someone else's work history does not change the enrollment important date.

Government workers and special rules

Most government employees — federal, state, and local — pay Medicare taxes and earn credits just like private-sector workers. However, some older government workers who were hired before specific dates may have been exempt from Medicare taxes. If you worked for a government agency and did not pay Medicare taxes during part of your career, you may not have enough credits to may have access to on your own.

If you are in this situation, you may still be covered based on a spouse's or ex-spouse's record, or you may be covered under a special government employee rule. The Social Security Administration can review your work history and tell you whether you may have access to. Call 1-800-772-1213 or visit your local Social Security office to ask about your specific situation.

Railroad workers have their own system — the Railroad Retirement Board — which coordinates with Medicare. If you worked for a railroad, contact the Railroad Retirement Board directly to understand how your benefits and Medicare coverage work together.

Frequently Asked Questions

What if I worked outside the United States?

Work done outside the U.S. generally does not count toward Medicare credits, even if you paid taxes in another country. However, some countries have agreements with the U.S. that allow work in those countries to count. Contact the Social Security Administration to ask whether your work in a specific country counts. You can reach them at 1-800-772-1213.

Can I get Medicare if I am not a citizen but have a green card?

Yes, if you are a lawful permanent resident and have lived in the United States for at least five consecutive years. The five years do not have to be recent — they can be from any point in your life. Once you have completed five years of residency, you become covered at 65 if you meet other requirements.

What happens if I do not sign up at 65?

You will face a permanent penalty on your Part B and Part D premiums if you do not sign up during your Initial Enrollment Period and do not have employer coverage. The penalty is 10 percent of the standard Part B premium for each year you were not enrolled, and it stays on your premium for life. It is important to enroll on time to avoid this cost.

Can my ex-spouse affect my Medicare coverage?

No. Once you are covered based on your ex-spouse's record, your coverage does not change if they remarry, move, or stop receiving benefits. Your ex-spouse also cannot see your Medicare information or affect your coverage in any way. The connection is only used to determine whether you may have access to.

Do I need to work to keep my Medicare coverage?

No. Once you are covered by Medicare, you keep your coverage whether you work or retire. Working does not increase your benefits or change your coverage. You can work as long as you want and still have Medicare.