Medicare Coverage for People with Disabilities
Although everyone becomes eligible for Medicare coverage at the age of 65, there are ways you can obtain coverage earlier if you are disabled.
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Choosing a health insurance policy can be confusing for anyone, but it's especially important if you have a disability. Finding coverage means learning about the available options, figuring out which programs you qualify for, and then understanding how to actually get your benefits once you’ve chosen a plan. Although everyone becomes eligible for Medicare coverage at the age of 65, there are ways you can obtain coverage earlier. Here's a quick guide to Medicare coverage for those who are disabled.
Qualifying for SSDI or SSI
If a physical or mental disability prevents you from maintaining gainful employment up until your retirement age, you may qualify for Social Security Disability Insurance (SSDI). Eligibility for SSDI depends on:
Age at which the injury occurred
Length of your working career
Recent work history
You need to accrue a certain amount of work credits in order to qualify for SSDI. You earn work credits by paying FICA taxes out of your paycheck, with four credits being the maximum you can earn in a year. If you don’t have enough work credits by the time you become disabled, Supplemental Security Income (SSI) may be a more viable option.
To be eligible for SSI, you must also:
Have low income or assets
Be a U.S. citizen or national (or an alien who meets requirements)
Live in one of the 50 states, District of Columbia, or Northern Mariana Islands (exceptions include children of military parents and students temporarily abroad)
Your marital status and monthly income may also affect your eligibility for SSI.
Those who are approved for SSDI will go through a five-month waiting period before receiving benefits. Beneficiaries will become eligible for Medicare in two years following their SSDI approval.
If you qualify for SSI but not for SSDI, you won't have to go through a waiting period before you become eligible to receive Medicaid benefits.
NOTE: Whether you qualify for Medicare based on age or disability status, you will have access to the same coverage options. You will not be restricted to services that are specifically related to your disability.
Qualifying for Medicare Before 65
If you have a disability, there are two ways you can qualify for Medicare before the age of 65:
You’ve collected Social Security Disability benefits for two years
You have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS)
People with ESRD or ALS do not have to wait through two years of SSDI benefits before qualifying for Medicare. Those with ESRD will typically become eligible for Medicare coverage after a kidney transplant or three months into dialysis treatment. Individuals with ALS will become eligible for Medicare when they collect SSDI benefits.
It’s not impossible for SSI recipients to qualify for Medicare, but coverage is limited to Medicaid in most cases. A disabled person who receives SSI benefits probably won’t be eligible for Medicare until the age of 65.
Some people with disabilities are approved for both SSDI and SSI. Those who are approved for concurrent benefits should visit their Social Security office to determine how to maximize coverage.
Original Medicare vs. Medicare Advantage
Although you can make changes to your Medicare plan at certain times, you want to get the most out of your insurance for the whole duration of coverage. Once you qualify for Medicare—through SSDI benefits or otherwise—it’s time to look at your plan options.
Original Medicare consists of Part A and Part B, or hospital coverage and medical coverage, respectively. This is the “default” Medicare program. This type of Medicare limits the amount you can be charged for medical services, and it’s accepted by most doctors in the United States. Medicare Part B requires monthly premiums, and sometimes Part A does as well.
Medicare Advantage is also known as Medicare Part C. This is a private plan that offers the same benefits as Parts A and B but with different rules, and it may provide benefits that Original Medicare does not. Medicare Advantage typically offers more comprehensive coverage.
Medicare Part D covers prescription drugs. Part D provides plans through private, Medicare-approved companies, and plans require monthly premiums.
How to Choose the Right Plan
Deciding which of these plans is best for you can be tricky, but you can start by considering what you’ll need most. If you’ve been disabled for a long time, you already have a good idea of what health services are necessary. You already know whether or not you need medication, and you know (roughly) how much you can afford to spend on medical expenses.
If you’re newly disabled or just starting to seek treatment, your plan may be a bit more up in the air. If Original Medicare doesn’t seem comprehensive enough for your needs, Medicare Advantage may be the better choice.
Alternatively, you might choose Original Medicare with supplemental coverage for medication, nursing care, or other additional expenses. The higher premium may be worthwhile if it means you can skip some out-of-pocket costs, but your financial situation might make lower premiums more enticing. Try to find a balance that you're comfortable with from both health and financial perspectives.
Coverage Timeline
If you find and maintain gainful employment while disabled, your Medicare eligibility will follow a specific timeline. However, if an individual ceases to meet the required medical criteria and is no longer considered disabled during any of these three periods, Medicare eligibility may be affected.
Trial Work Period: A nine-month period during which workers can receive Medicare and Social Security income at the same time. You must work over 80 hours of self-employment per month or earn a certain amount of money monthly to qualify.
Extended Period of Eligibility: This consists of the 93 months following the Trial Work Period. Disabled workers will not be responsible for Medicare Part A premiums, but they will pay premiums on Part B services. SSDI benefits may also end during this period.
Indefinite Access to Medicare: Disabled workers who are under the age of 65 will continue to receive Medicare benefits as long as they pay the required premiums for both Part A and Part B. State-run programs may help low-income individuals and couples pay these premiums.
There are several ways to get Medicare coverage if you're disabled. If you're not sure which plan best applies to your situation, call your Social Security office