Medicare coverage for people with disabilities

Medicare is a federal health insurance program designed to provide affordable health coverage to those over 65. And for those with certain conditions under the age of 65.

What Disabilities Qualify for Medicare?

If a person is under the age of 65, they qualify for Medicare under the below conditions.

• They’re disabled and have received Social Security Disability benefits for a minimum of 24 months.
• They’ve received disability benefits from the Railroad Retirement Board for at least 24 months.
• They have End-Stage Renal Disease (ESRD).
• They have Lou Gehrig’s disease or Amyotrophic Lateral Sclerosis (ALS).

Does a person automatically get Medicare with a disability?

No, a person does not automatically get Medicare coverage if they have a disability. To qualify for Medicare disability insurance if under the age of 65, they need to be receiving Social Security Disability benefits for at least 24 months.

If they’re eligible for Social Security Disability Insurance (SSDI), they automatically qualify for Medicare insurance after 24 months. The enrollment is effective automatically on the 25th month. They do not need to contact Medicare or apply to be enrolled. Their Medicare card will be mailed to them 90 days before the start of your Medicare coverage.

The 24-month waiting period was put in place to ensure Medicare disability insurance is only extended to people with severe and long-term disabilities. If a person meets the criteria for Social Security Disability Insurance, they’re enrolled in Medicare Parts A and B.

For people with ALS, there is no 24-month waiting period. Medicare enrolls them as soon as their Social Security Disability Insurance (SSDI) benefits start.

Is Medicare mandatory if on disability?

If disabled and receiving Social Security Disability Insurance benefits, an individual is required to enroll in Medicare Part A even if they have another insurance plan. They’re automatically enrolled in Medicare Part A and Part B after 24 months of receiving Social Security disability benefits.

Medicare Part A is premium-free while on disability. But if a person fails to enroll in Part A, they’re required to pay back the Social Security disability benefits. This means that as long as an individual receives disability benefits for 24 months or more, they have to sign up for Medicare Part A.

They will also be automatically enrolled in Medicare Part B. Part B has a monthly premium and is be deducted from their Social Security disability benefits. However, unlike Medicare Part A, a person can opt out of Medicare Part B if they have another insurance plan. It’s important to note that if a person decides to enroll in Medicare Part B after declining it initially, they may have to pay higher monthly premium for it.

What Medicare benefits are available for people with disabilities?

Medicare disability benefits are similar to the coverage benefits Medicare members who qualify based on age receive.

• Medicare Part A coverage – helps covers hospital care, skilled nursing facility, hospice care, and home health.
• Medicare Part B coverage – helps cover doctor visits, certain medical equipment, outpatient services, home health services, and other specified medical services.

Medicare recipients who qualify on disability also have the option to enroll in Medicare plans offered by private insurance companies. This includes Medicare Advantage plans (Part C) and Medicare prescription drug plans (Part D), which offers prescription coverage.

Medicare Supplement Insurance (Medigap) policies

Medigap policies help pay the remaining out-of-pocket costs with Original Medicare. If under age 65 and qualify for Medicare benefits because of a disability, a person may not be able to buy the Medigap policy they want, or any policy until you turn 65.

If disabled and on Medicare, and have another health insurance plan, Medicare pays for covered services after the primary insurance pays. This means it acts as secondary coverage.

Medicare coverage for working people with disabilities

If an individual has a disability and working, their Medicare coverage can fall into one of three plans.

1. Trial Work Period (TWP): A person is entitled to continue receiving Medicare and Social Security disability benefits for a maximum 9-month trial work period during any rolling 5-year period. The nine months of trial work do not have to be consecutive. But the person must meet the set guidelines for gross income or work more than 80 hours per month.
2. Extended Period of Eligibility (EPE): In some cases, a person’s gross income may meet the substantial gainful activity level, but they’re still disabled. In this case, they may continue to receive Medicare coverage after completing the trial work period. They may remain eligible for Medicare coverage for up to eight and a half years under EPE. Even if the SSDI cash benefits cease during this period, they’re still eligible for Medicare coverage.
3. Indefinite Access to Medicare: Working Medicare recipients under 65 years with disabilities may continue to receive Medicare coverage as long as they remain disabled. However, the individual may need to pay premiums for both Medicare Part A and Part B based on their income. If you fall in this category, you may get assistance with premiums from a state-run buy-in program that caters to qualified working persons who are disabled.

Medicare disability requirements list

Individuals can qualify for Medicare disability benefits only if they meet either of the below set criteria for disability.

• They received Social Security Disability Insurance (SSDI) benefits for at least 24 months. These benefits are only paid to those who work in jobs covered by Social Security and have a qualifying medical condition that meets criteria for a disability.
• They have End-Stage Renal Disease (ESRD). Their Medicare coverage begins 90 days after their dialysis treatment begins. If they get a kidney transplant and it’s successful, their Medicare coverage lasts for up to three years after the transplant surgery.
• They have Amyotrophic Lateral Sclerosis (ALS) also called Lou Gehrig’s disease. They immediately qualify for Medicare disability coverage. There is no waiting period. They can apply for Medicare coverage immediately after their diagnosis.

Social Security disability and Medicare

To receive SSDI, a person must have worked and paid Social Security taxes for some time.

Social security has strict guidelines on the conditions classified as a disability that makes a person eligible to receive SSDI benefits. These conditions include:

• Musculoskeletal disorders including amputation, chronic joint pain, and spinal disorders
• Impaired hearing, sight, or speech
• Respiratory disorders including asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis
• Neurological disorders, including ALS, Parkinson’s, epilepsy, multiple sclerosis, and traumatic brain injuries
• Mental health disorders including dementia and schizophrenia.
• Cancer
• Cardiovascular illnesses including heart disease and heart failure
• Digestive disorders including liver and bowel disorders
• Chronic kidney disease
• Disorders of the blood including anemia, sickle cell disease, and bone marrow disorders
• Congenital disorders such as Down syndrome
• Auto-Immune diseases, including lupus, HIV, and inflammatory arthritis

If a person qualifies for SSDI benefits under any of these conditions, they’re automatically enrolled in Original Medicare coverage after 24 months.

Medicare vs. Medicaid disability

As a disabled person, an individual can qualify for medical coverage under Medicare or Medicaid.

Medicare is a federal program that offers affordable Medicare coverage to individuals over 65. And it provides health care for disabled people under the age 65 who qualify. To qualify for Medicare as a disabled person, there are no income limits. However, a person needs to have a qualifying illness or receiving Social Security Disability Insurance benefits for at least 24 months.

Medicaid is a needs-based program designed to cater to people with limited income with no age restrictions for eligibility. Unlike Medicare, Medicaid disability has certain income and asset limits since eligibility is assessed on a person needs basis. If disabled, apply for Medicaid through the state agency for your local area. You’re required to provide proof of your income and assets. These are the main rating factors used to determine eligibility. Medicaid coverage typically covers hospitalization, doctor services, family planning, nursing services, dental services, clinic treatment, pediatric services, and screening services.

What happens to my Medicare disability when I turn 65?

If enrolled on Medicare based on a disability, once a person turns 65, they lose the disability qualification and become eligible based on age. This means they must be enrolled in Medicare Part A and Part B. Once they qualify for Medicare based on age, they have the option to apply for Medicare Supplement Insurance (also called Medigap).

Medigap is not available to individuals under 65 years enrolled on Medicare based on a disability. But once they reach the age of 65, they become eligible to apply for it. This is important since Medigap helps to cover the out-of-pocket costs not covered by Original Medicare, including deductibles and copayments.

Bottom line

Medicare is not just available for those who are age 65. Some disabilities that meet the strict criteria set by Social Security Disability Insurance makes a person eligible for Medicare coverage before the age of 65. Medicare coverage benefits for disabled persons are similar to those who are 65. However, options like Medigap may not be available until a person turns 65. Disabled people may also qualify for Medicaid coverage at any age. Eligibility for it is tied to income levels and financial needs.