Eligibility for Medicare in Virginia


Medicare eligibility in Virginia is determined by standards set by the Centers for Medicare and Medicaid Services (CMS). Eligibility for Medicare is often confused with eligibility for Medicaid because both are government-sponsored health care plans and they share a similar name. However, discovering how to qualify for Medicare reveals an entirely different process than what is required for the Medicaid application process. Medicare benefits eligibility extends to a limited section of the population, while Medicaid eligibility is needs based. Medicare eligibility requirements can be slightly different for each level of health care coverage offered by the program. Each Part of Medicare provides a different type of service. Some people meet Medicare qualifications automatically and will not need to go through the simple application process before coverage begins. Others who do not meet age-related Medicare qualifications must have certain conditions to participate in the program. Potential applicants can continue reading the sections organized below to learn who is eligible for Medicare, eligibility requirements for different parts of Medicare and who is eligible to get help with prescription drug costs.

Basic Medicare Eligibility in Virginia

Medicare eligibility in VA can vary depending on which type of Medicare you need. Most people qualify for Medicare in Virginia when they meet the minimum age requirement for participation. Others obtain Medicare eligibility by receiving disability benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB) for a set amount of time. Medicare benefits eligibility is also extended to people who suffer from end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s Disease). Medicare qualifications include being able to provide proof of United States citizenship or legal residency for a specific amount of time. Learn more about who is eligible for Medicare in VA by downloading our comprehensive guide to Medicare benefits.

Original Medicare (Part A and Part B) Eligibility

Original Medicare eligibility includes receiving Part A, which meets the minimum health care coverage requirement law, and Part B. When qualifying for Medicare in VA, Original Medicare is the type of coverage that most people will receive after reaching the required age of participation. Part A Medicare eligibility provides hospital insurance and covers hospital stays, additional facility-provided services and some home health care services. Part B Medicare eligibility provides medical insurance, which covers doctor’s visits, preventative services and other outpatient-type services. Part B also covers medical supplies. Most people who qualify for Medicare in Virginia will receive Part A for free because they or their spouse, parent or child earned it by paying Medicare taxes for the required period. Although most applicants meet the Medicare qualifications to receive free Part A coverage, the majority of Original Medicare applicants must pay for Part B coverage after completing the Medicare application process and receiving approval. Some eligible for Medicare must pay a premium for Part A, but this is usually only if their income falls within a certain range.

Disabled applicants with eligibility for Medicare begin receiving Medicare coverage once they have received SSA or RRB disability benefits for 24 months. Applicants with ALS or ESRD have specific Medicare benefits eligibility requirements which are determined by their medical condition and the date they begin receiving disability benefits.

Medicare Advantage Plan Eligibility

Virginia Medicare benefits eligibility for Part C coverage allows applicants to receive Medicare from private insurance companies instead of through Original Medicare. These non-government insurers meet all Medicare qualifications, rules and regulations in the way they provide HMO or PPO Medicare Advantage Plans. Applicants wondering how to qualify for Medicare Advantage Plans, or Part C, must meet the same requirements as those applying for Original Medicare. If you qualify for Medicare Part C, note that each company has its own policies, service areas and out-of-pocket costs. To qualify for Medicare participation, these insurers must provide participants with detailed information explaining all provided services and fees. Getting information on requirements for Medicare eligibility can help Virginia residents make educated choices about their health care, so it is important that applicants understand how each coverage plan can best fit their needs.

Medicare Prescription Drug Eligibility

Residents of Virginia eligible for Medicare Part A and Part B will also have the option of receiving prescription drug coverage through Medicare Part D. Therefore, you can qualify for Medicare Part D without having to meet any new requirements. Medicare qualifications for Part D are automatic even if you do not need the coverage because you do not currently take prescription medications. However, CMS recommends that everyone eligible for Medicare Part D should apply for prescription drug coverage during the initial enrollment period to avoid late Part D enrollment fines later. Many Medicare qualifying insurance providers offer Part D prescription coverage as an automatic part of their Medicare Advantage Plans. When exploring health care options, you should get more information about Medicare Part D coverage options to see if this plan is right for you and your family.

Eligibility for a Low-Income Subsidy for Medicare Prescription Drug Coverage

Medicare benefits eligibility in VA includes the option to apply for a low-income subsidy to help pay for your prescription drug costs. If you qualify for Medicare Extra Help, your annual income must fall below the current limits published by the Federal Poverty Guidelines. Medicare qualifications for the Extra Help prescription drug subsidy will vary according to the participant’s household size and total household income.

To learn more about Medicare coverage options, click here for our detailed guide.

Virginia Department of Social Services