You Might Be Eligible for Medicare—But Some People Still Get Denied

Key Takeaways

• Medicare eligibility is not always a guarantee—even if you think you meet the age or disability criteria.

• Being denied Medicare can happen due to documentation issues, enrollment mistakes, or incomplete work history. Knowing how to fix these can help you regain access.

Why You Might Assume You’re Eligible

If you’re turning 65 or have received Social Security Disability Insurance (SSDI) for 24 months, you’re probably under the impression that Medicare enrollment should be automatic. And in many cases, that’s true. But 2025 shows that even as the system becomes more streamlined, not everyone who assumes they qualify ends up enrolled. Mistakes, misunderstandings, and paperwork gaps still leave thousands without coverage each year.

1. Age Alone Doesn’t Always Guarantee Automatic Enrollment

You become eligible for Medicare when you turn 65, but that doesn’t mean you’re automatically enrolled. In 2025, automatic enrollment typically only happens if you’re already receiving Social Security benefits at least four months before your 65th birthday. If you delayed claiming Social Security, you’ll need to actively sign up for Medicare during your Initial Enrollment Period (IEP), which is a 7-month window:

• Starts 3 months before your 65th birthday

• Includes your birthday month

• Ends 3 months after your birthday month

Missing this period could mean you face late penalties or delayed coverage.

2. Disability-Based Eligibility Can Still Be Complicated

People under 65 who qualify for SSDI are generally eligible for Medicare after a 24-month waiting period. In 2025, this rule still applies. However, complications arise when there’s a break in benefits or if the disability isn’t categorized properly. Additionally:

• If you qualify for SSDI but then return to work under a trial period, Medicare can be suspended if benefits are paused.

• The waiting period restarts if you requalify for SSDI after a gap.

These technicalities can result in denial or disruption of Medicare coverage.

3. Citizenship and Residency Requirements Still Apply

Medicare is a federal benefit, and it has specific legal requirements regarding citizenship and residency. In 2025, you must:

• Be a U.S. citizen, or

• Be a permanent legal resident who has lived in the U.S. continuously for at least five years

Even if you meet the age or disability conditions, you can be denied Medicare if your legal status doesn’t align with these requirements.

4. Work History Can Affect Your Part A Premium-Free Eligibility

Medicare Part A is usually premium-free if you or your spouse paid Medicare taxes for at least 40 quarters (10 years). If you haven’t met this threshold, you’ll still be eligible—but you’ll have to pay a monthly premium. In 2025, that amount is $518 if you worked fewer than 30 quarters, and $284 if you worked 30–39 quarters.

However, if your work history isn’t properly documented—like if there are errors in your Social Security earnings record—you could be mistakenly denied premium-free Part A. Fixing this typically involves:

• Requesting an earnings statement from Social Security

• Filing corrections for any missing or inaccurate records

5. Enrollment Mistakes Can Lead to Denial

Medicare enrollment is governed by strict timelines. If you miss your IEP and aren’t eligible for automatic enrollment, you may have to wait for the General Enrollment Period (GEP), which runs from January 1 to March 31. Coverage begins the following July.

Denial or delay may also happen if:

• You enrolled in Part A but forgot to enroll in Part B during the appropriate period

• You declined Part B initially without having other creditable coverage

• You assumed enrollment was automatic but never completed the process

Even in 2025, these administrative missteps still account for a large portion of delayed or denied coverage cases.

6. Medicare Part B Denials from Incomplete Applications

Part B is not automatic if you’re not receiving Social Security. Many applicants fill out only part of the CMS-40B form, or fail to submit required proof of other health coverage when applying during a Special Enrollment Period (SEP).

In 2025, SEPs apply to specific situations, such as losing employer coverage. You have 8 months from the loss of coverage to enroll in Part B without penalty. If you miss the SEP window or apply incorrectly, Medicare can deny your application.

7. Moving Abroad or Extended Travel Can Affect Your Status

U.S. citizens who spend extended time abroad may lose eligibility if their absence impacts their Social Security status. Even if you meet all other criteria, a prolonged absence—especially without maintaining U.S. residency—can complicate your Medicare enrollment.

You won’t be denied based solely on travel, but:

• You must reside in the U.S. to use most Medicare benefits

• Some Medicare Advantage plans may disenroll you if you’re outside the plan’s service area for more than six months

8. Denials Due to Misunderstanding Medicare Advantage Rules

Medicare Advantage (Part C) plans have different enrollment rules compared to Original Medicare. If you miss the Annual Enrollment Period (October 15 to December 7), you may be locked out until the next cycle unless you qualify for an SEP.

Also, if you don’t enroll in both Part A and Part B first, you can’t join a Medicare Advantage plan. Many denials happen when people try to enroll in a plan but haven’t activated their Part B yet.

9. Medicare Denials After Incarceration or Other Coverage Gaps

People released from incarceration or transitioning from Medicaid-only coverage often face issues when re-entering Medicare. In 2025, the Centers for Medicare & Medicaid Services continue to emphasize re-entry assistance—but gaps in records still delay enrollment.

If your Medicare was terminated while you were incarcerated or if Medicaid covered all your services and you never applied for Medicare, you may need to:

• Contact Social Security immediately upon release

• Submit new applications during the appropriate enrollment period

10. Appeals Are an Option—But You Must Act Quickly

If you believe your Medicare denial was an error, you have the right to appeal. In 2025, the process remains time-sensitive:

• You typically have 120 days from the date of the denial notice to file an appeal

• You can request a reconsideration through Social Security or Medicare directly

Appeals are more successful when supported with complete documentation—like proof of residence, work history, or prior enrollment.

What to Do If You Get a Denial Notice

Receiving a denial doesn’t always mean the end of your Medicare eligibility. In 2025, your options may include:

• Enrolling during the next appropriate period (IEP, GEP, or SEP)

• Filing corrections to your Social Security work history

• Appealing with full documentation

• Requesting assistance from a licensed insurance agent listed on this website to walk you through available next steps

When Eligibility Doesn’t Equal Enrollment

It’s easy to assume that turning 65 or receiving disability benefits makes your Medicare coverage automatic—but eligibility alone doesn’t complete the picture. Enrollment timing, documentation, and correct forms are just as critical.

Don’t let preventable errors stand in the way of your healthcare. If you’ve received a denial, reach out to a licensed insurance agent listed on this website for help reviewing your options and completing the necessary steps to get the coverage you’ve earned.