Medicare Part D Drug Benefit Eligibility

checkmark Fact checked Contributing expert: Leron Moore, Medicare consultant - Updated: Jan 12, 2022

 

If you have Original Medicare, you can get a Part D prescription drug plan.

What you should know

  • 1 You must have both Medicare parts A and B to be considered for a prescription drug plan (PDP).
  • 2 A stand-alone PDP can accompany Original Medicare parts A and B to give drug coverage in addition to Original Medicare benefits.
  • 3 Medicare Advantage plans offer an all-inclusive bundle of both medical and prescription coverage in one plan.

Who qualifies for Medicare Part D?

Medicare has many different parts that cater to medical needs. You must have Medicare part A and B to qualify for part D, which is prescription coverage. Medicare Part D isn’t your only option for prescription drug coverage.

  • If you decide to continue coverage with Original Medicare, you can add a stand-alone PDP to it. 
  • If you decide to purchase a Medicare Supplement plan (Medigap), you can also purchase a PDP to accompany it to provide drug coverage. 
  • A Medicare Advantage plan includes prescription drug coverage and you don’t need to seek other prescription drug coverage outside of that. 
 

Age 65 and older

If you’re 65 and older you qualify for Original Medicare based on age. Once you have enrolled in both Medicare parts A and B, you can choose a stand-alone PDP, a Medicare Advantage Plan or a Medicare Supplement plan to give you drug coverage

Qualifying disabilities 

If you have received Social Security Disability Insurance (SSDI) benefits, you are eligible for Medicare after 24 months of receiving benefits. Your eligibility begins three months before your 25th month, during your 25th month, and three months afterward. This only applies to individuals who haven’t reached 65 years of age. For example:

  • End-stage renal disease (ESRD): Once you have had at least three months of regular dialysis treatment or a kidney transplant, Medicare eligibility begins. 
  • Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease): If you’ve been diagnosed with ALS, your eligibility starts immediately after SSDI benefits begin.

If you meet the criteria for Social Security benefits, you’re typically enrolled into Medicare parts A and B automatically. 

Who doesn’t qualify for Medicare Part D?

To qualify for Medicare Part D coverage you must have Original Medicare coverage, both parts A and B. Naturally, if you don’t enroll into both parts, it would make you ineligible for prescription coverage. 

Medicare Advantage Plans

If you have a Medicare Advantage Plan, you may be able to choose your own Part D plan. However, if your Medicare Advantage Plan has prescription coverage, you can’t choose a separate Part D plan.

When should you enroll in Medicare Part D?

There are designated election periods when you can enroll into either a Medicare Advantage Plan or a stand-alone prescription drug plan. Read on to find a description of each election period and when they happen. 

Medicare Part D Enrollment Periods
Initial Enrollment Your IEP gives you the option of enrolling into Original Medicare three months before your birthday month, during your birthday month, and three months afterward. Once you’re an active Medicare beneficiary, it makes you eligible for Medicare Advantage and/or a stand-alone drug plan. If you enroll into Medicare during this election period, your effective date for coverage typically is the first day of the following month of the month you applied.
Open Enrollment Period The Open Enrollment Period/Annual Enrollment Period occurs annually October 15 through December 7. During this period, you can join, switch, and drop your plan. If you enroll into a plan during this time, your effective date is January 1 of the following year.
General Enrollment Period/Medicare Advantage Plan Enrollment Period During the General Enrollment Period, which is from January 1 through March 31 of each year, you can enroll in Medicare for the first time, including Part D. If you’re enrolled in a Medicare Advantage Plan, you can make a change to another Medicare Advantage Plan or switch back to Original Medicare and add a PDP.
Special Enrollment Period If you’re eligible for a Special Enrollment Period (SEP), you have 60 days to enroll into the plan of your choice in your service area. There are several circumstances that qualify you for an SEP. For example, if you have moved outside of the service area of your existing plan, or if you have lost coverage through no fault of your own.

Are seniors required to have Medicare Part D?

Enrolling in a Medicare Part D plan isn’t required, but there may be a penalty enforced if you don’t. If you don’t have prescription coverage or choose not to enroll into a PDP, a late enrollment penalty may be assessed. There are some exceptions, such as a working aged senior who is still working at age 65 or older and has employer coverage.

Once the penalty is assessed, it’ll follow you for the duration of your time with Medicare ― no matter what plan you select in the future. Although not required, it’s beneficial to have or enroll into a Medicare Advantage Plan with prescription coverage or a stand-alone PDP upon becoming Medicare eligible. 

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Contributing Expert:

Leron Moore, Medicare consultant

Leron Moore has guided Medicare beneficiaries and their families as a Medicare professional for nearly 15 years. First as a Medicare provider enrollment specialist, and now a Medicare account executive, Moore works directly with Medicare beneficiaries to ensure they understand Medicare and Medicare Advantage Plans.