Paul Sanchez
If you are a senior citizen who does not qualify for Medicare, there are alternative ways to obtain health insurance. Firstly, you can consider purchasing private insurance directly from an insurance company. This option is suitable for those who do not qualify for Medicare or other government-provided insurance plans. Additionally, you may be eligible for Medicaid, which provides health coverage for low-income seniors and individuals with disabilities. If you have a low income, financial assistance is available to help cover medical costs and insurance premiums. Seniors aged 65 and over who do not qualify for Medicaid due to their income may still be eligible through the Medicaid spend-down program, which considers medical costs relative to income. Furthermore, short-term insurance plans can provide temporary coverage until a more permanent solution is available. These plans are often purchased before a traditional insurance policy begins and may be obtained outside of open enrollment periods under certain circumstances.
| Characteristics | Values |
|---|---|
| Medicare eligibility | People aged 65 or older |
| Medicare eligibility | People with a qualifying disability |
| Medicare eligibility | People with End-Stage Renal Disease (ESRD) |
| Medicare eligibility | People with ALS (Lou Gehrig's disease) |
| Medicare Part A | Hospital Insurance |
| Medicare Part B | Medical Insurance |
| Medicare Part C | Medicare Advantage Plan (offered by private companies approved by Medicare) |
| Medicare Part D | Prescription drugs cost assistance |
| Medicaid | Health coverage for low-income seniors also enrolled in Medicare |
| Medicaid | Covers nursing facility care, prescription drugs, eyeglasses, and hearing aids |
| Medicaid spend down program | Allows seniors to subtract medical costs from income to qualify |
| Private insurance | Available for purchase if not eligible for Medicare |
| Insurance through your job | May be available through your employer |
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What You'll Learn
Private health insurance plans
It is important to note that Medicare is a federal health insurance program primarily for individuals aged 65 or older, certain people with disabilities, and those with end-stage renal disease (ESRD). However, not everyone who is 65 or older has the option to enroll in Medicare. For example, immigrants generally become eligible for Medicare after residing in the U.S. for five years.
For seniors who do not qualify for Medicare, private insurance plans can be purchased on the marketplace. These plans may offer cost-sharing reductions and premium subsidies based on income. The ACA also limits premiums for older applicants to three times the rate of younger applicants, providing some financial relief for seniors.
Additionally, Medicaid, a joint federal and state program, provides free or low-cost health coverage to low-income individuals, including seniors. Some states also offer the Children's Health Insurance Program (CHIP), which covers children and, in some states, pregnant women from families with incomes too high to qualify for Medicaid but still in need of assistance.
In summary, while Medicare is the primary health insurance program for seniors in the U.S., private insurance plans are available for those who do not qualify. These plans can be purchased on the health insurance marketplace, and financial assistance options, such as subsidies and reduced premiums, are available to help make coverage more affordable for seniors.
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Insurance through your employer
If you are insured through your employer, you may be able to keep your insurance after turning 65, although you should check with your employer's benefits representative to confirm this. Since Medicare Part A is premium-free for most beneficiaries, you may want to enrol in Part A as soon as you are eligible (i.e. three months before turning 65), even if you plan to continue with your employer-sponsored insurance.
If you decide to keep your employer-sponsored insurance, you may want to delay signing up for Part B until you retire. However, it is a good idea to check with Social Security or Medicare first to confirm that you will not face a late-enrollment penalty.
If you have retiree coverage from a previous job, it may not pay for your health services if you don't have both Medicare Part A and Part B. Ask your benefits administrator how your retiree coverage works with Medicare. Your employer may offer coverage when you have Medicare, such as a supplemental plan, drug coverage, or Medicare Advantage Plan. If they do, ask if you or your family will lose your retiree coverage if you join a plan that your employer doesn't offer.
If you have a Health Savings Account (HSA), you and your employer should stop contributing to your HSA six months before you retire or apply for benefits from Social Security or the Railroad Retirement Board. This will ensure that you avoid a tax penalty.
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Medicaid spend-down program
If your income is too high to qualify for Medicaid, a spend-down program may help you qualify by deducting medical expenses. The spend-down program is also referred to as a medically needy program or Medicaid's Excess Income Program. This program is designed for individuals who do not meet the eligibility requirements for Medicaid due to their income exceeding the specified limit.
The spend-down amount is calculated by subtracting the Medicaid eligibility limit set by your state from your income over a given period, typically ranging from one to six months. For instance, if your monthly income is $2,200 and your state's Medicaid income limit is $2,000, you would be required to spend the difference of $200 on healthcare costs. If you were to spend $250, Medicaid would cover the additional $50. It is important to note that not all states offer a spend-down option, and those that do may have varying income limits and rules.
To determine eligibility for the spend-down program, states may require you to submit receipts or bills to verify your monthly expenses. Alternatively, some states allow you to pay a monthly premium directly to Medicaid for the amount that your income exceeds the Medicaid spend-down level. Additionally, states with spend-down programs may enable you to qualify for Medicaid coverage for nursing facility stays or home and community-based waiver services.
Medically needy programs may have further eligibility restrictions, such as requiring individuals to be aged 65 or older, have a disability, or be blind. These programs establish a medically needy income limit based on an individual's cost of living and household size. For example, if a person's income is $800, but their medically needy income limit is $300, they would need to spend down $500 to become eligible for Medicaid.
Medicaid provides health coverage to approximately 7.2 million low-income seniors who are also enrolled in Medicare. It covers additional services beyond those provided by Medicare, including nursing facility care beyond the 100-day limit, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare, with Medicaid covering the remaining cost up to the state's payment limit.
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Government discounts
While Medicare is health insurance for people aged 65 or older, some people get Medicare automatically, while others have to actively sign up. Those who are eligible for Medicaid but not Medicare can benefit from the following government discounts:
Medicaid
Medicaid provides health coverage to 7.2 million low-income seniors who are also enrolled in Medicare. Medicaid also provides coverage to 4.8 million people with disabilities who are enrolled in Medicare. In total, 12 million people are enrolled in both Medicaid and Medicare, composing more than 15% of all Medicaid enrollees. Individuals who are enrolled in both Medicaid and Medicare can be covered for both optional and mandatory categories. For example, Medicaid can help pay for Medicare premiums and out-of-pocket medical expenses.
State Health Insurance Assistance Program (SHIP)
SHIP offices provide free health insurance benefit counselling for Medicare beneficiaries and their families or caregivers.
Medicare Advantage plans
Medicare Advantage plans offered by private insurers can vary in what they cover and what they cost, but all plans must pay for certain medical services and other expenses. These include annual wellness visits, flu shots, certain other vaccines, and screenings such as a colonoscopy.
SilverSneakers
Some Medicare plans come with a SilverSneakers membership, which gives eligible seniors access to thousands of gym and fitness centre locations across the country.
Prescription assistance programs
Medicare Part D coverage and most Medicare Advantage plans cover some prescription drug costs for seniors. However, if you don’t qualify for Medicare or are looking for more opportunities to cut drug costs, see if you’re eligible for any prescription assistance programs.
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Medicare Part D plan
Medicare is health insurance for individuals aged 65 or older. Those with disabilities, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's disease) may be eligible for Medicare before turning 65.
Medicare Part D is a prescription drug plan that covers most prescription drugs. Original Medicare does not offer drug coverage, so Part D plans can be purchased as standalone plans (PDP) or bundled with Medicare Advantage plans (MAPD). Standalone Part D plans charge a monthly premium and may have an annual deductible, copays, and coinsurance. The monthly premium for standalone plans in 2025 is $590. When filling a prescription for a covered drug, you will usually pay a copayment (a set amount) or coinsurance (a percentage), which may vary depending on the drug tier and the pharmacy used.
Part D plans cover drugs on the plan's drug list, or formulary, as well as vaccines not covered by Medicare Part B and drugs commonly prescribed for Medicare beneficiaries. Insulin prescriptions are also covered, with a 1-month supply costing no more than $35. Part D plans generally do not cover drugs prescribed for anorexia, weight loss or gain, fertility, erectile dysfunction, cosmetic purposes, or hair growth.
To choose a Medicare Part D plan, build a list of the medications you take and estimate your drug costs for a specific plan. You can also consider your preferred pharmacy, as many plans offer cost savings if you use a preferred pharmacy network.
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Frequently asked questions
Seniors who do not qualify for Medicare can consider the following options:
- Purchasing private insurance directly from an insurance company.
- Enrolling in Medicaid, which provides health coverage to low-income seniors and individuals with disabilities.
- Applying for a marketplace health insurance plan through HealthCare.gov or a state health exchange, also known as "Obamacare." These plans offer government discounts for individuals with low to average incomes.
Medicare is specifically designed for individuals aged 65 and older, offering health insurance with comprehensive benefits at a low cost. The program includes Part A (hospital insurance), which is typically premium-free, and Part B (medical insurance), which requires a monthly premium. Additionally, Medicare Advantage Plans (Part C) are offered by private companies, and Part D assists with prescription drug costs.
Yes, an alternative to Medicare Advantage Plans (Part C) is purchasing supplemental coverage through a private health insurance company, often referred to as a Medigap plan. Medigap Plan G, in particular, is recommended as it helps pay for costs associated with Original Medicare (Parts A and B).
