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Kenneth Guzman-Andrade Medicare Broker

Kenneth Guzman-Andrade

Licensed Health Insurance Broker

Written 4/16/2024

When Do I Have To Take Medicare?

Intro | Should I Take Medicare Now?

|How To Signup For Medicare | Medicare Secondary Options |

I'm Turning 65 But My Spouse Is Not |

Medicare Disability | Medicaid

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  • In certain situations, Medicare must become your primary insurance.

  • These include when you have Marketplace insurance, work for a company with less than 20 employees, and if you’re about to lose Medicaid.

  • Failure to avoid these situations could lead to coverage gaps and Medicare penalties.

When becoming Medicare eligible, you often can take credible work insurance instead of making Medicare your primary insurance. But there are other situations where you have to make Medicare your primary. If you don’t make Medicare your primary in these examples, you may face claim denials, higher taxes, and coverage gaps. Let’s dive into a few common circumstances to ensure you avoid surprises.

You Are On A or State Marketplace Plan

If you are on a marketplace plan, you can no longer be on that plan once you become Medicare-eligible.


This can be due to Turning 65 or going onto Medicare Disability. In some states, that means the federal program Some states have their own health insurance marketplaces. In our home state of New Jersey, it is

The issue is that this tends to be not heavily advertised, and people may never be notified that they’re about to lose coverage. Many new clients have come to us after staying on a Marketplace plan after they became Medicare-eligible. Two things commonly happen.

First, they will start having claim denials. Their insurance company will notify the enrollee that their medical bills cannot be covered because their coverage is no longer valid. This is often after the insurance company doesn’t inform them that they can’t have their Marketplace plan anymore.


Second, clients may have to give back their subsidies at tax time. If you qualify for a tax subsidy on the marketplace, it is only valid while you are eligible for a marketplace plan. Any money given as a subsidy can and usually will be taken back during tax time. Be careful.


We will also tell you of some misleading (and sometimes, unsavory) tactics we have seen some insurance companies use. We have had clients call their marketplace insurance plans to see if they can keep their insurance once they can take Medicare. The customer service representatives at certain companies have told them they don’t have to start Medicare until three months after their 65th birthday. While this is true in other situations, it is not true when you have Marketplace insurance!


Whether this is intentional or ignorant is beside the point. Due to this incorrect information, people will be left with denied claims and high tax bills.


We recommend speaking with one of our brokers a few months before you’re about to be Medicare eligible to help make the transition. Our team will always give you the truth about the best way to proceed with Medicare when you are currently on a marketplace insurace plan. 

You Work For An Employer With Under 20 Employees

Employers who offer health insurance that have over 20 employees have to give their Medicare-eligible employees a comparable health insurance option. If you work for an employer with under 20 employees, they do not.

If you work for a smaller company, your employer can drop you from their health insurance plan upon turning 65. They don’t have to, but in most cases, they do. Be ready a few months before your 65th to transition to Medicare.

Medicare can be more cost-effective than work insurance. In many cases, it’s even better!

Related Article: Medicare vs. Work Insurance and Retiree Coverage 

You’re Losing Medicaid

Once you’re Medicare-eligible, it can be harder to maintain Medicaid status. Most states raise the income and asset requirements required to stay on Medicaid once you can take Medicare. Many people love Medicaid because it has $0 premiums and no out-of-pocket costs. However, many of our clients lose Medicaid once they become Medicare-eligible because the conditions are challenging for almost anyone to stay on.

Be proactive if you’re on Medicaid and approaching Medicare eligibility. Your case can be transferred, and benefits issues can occur while the government decides whether to keep you on Medicaid. You may run into billing and coverage problems for a month or two.

If you lose Medicaid, you are given a Special Enrollment Period to get a Medicare Part D plan or Medicare Advantage plan. Depending on your state, you may need to go through underwriting to enroll in a Medicare Supplement.


Related Article: Medicaid

Do I HAVE to take Medicare?

No one will ever MAKE you take Medicare. It is not mandated by law. All these situations are when you wouldn’t have other health insurance options besides Medicare. If you choose not to take Medicare at this time, you could:

  1. Have long gaps with no health insurance.

  2. Accrue lifetime Medicare penalties.


We don’t recommend not having health insurance. It is a surefire way to accrue bills that you may not be able to pay off, and you may also be unable to get the healthcare you need. Know your situation and make sure you never have a coverage gap.

Don't hesitate to reach out if you need help going onto Medicare due to these situations or others! We have helped thousands of people with Medicare across 24 states and would be happy to help you. Call our Toms River, NJ office at 848-226-6897 or visit to talk to one of our licensed Medicare brokers!

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