Medicare usually requires that people are 65 years of age or older to qualify for a plan. However, some individuals can qualify for Medicare earlier if they have a disability or certain medical conditions.
These medical conditions include end stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS).
In this article, we detail the eligibility criteria for people who need Medicare earlier than their 65th birthday. We also explain how a person can find out whether they qualify.
A person can qualify for Medicare insurance when they are under 65 years of age if they have one of the following conditions:
- a disability that a doctor can confirm in writing
In these instances, a person may be able to receive Medicare Part A without paying a premium. Part A covers in-hospital treatment and long-term skilled nursing care.
They may also be able to receive Medicare Part B, which covers medical treatment and consultations, such as doctor’s visits and physical therapy sessions.
However, they will have to pay a monthly premium unless they receive assistance from their state’s insurance assistance program.
A person may have a disability that restricts their ability to work. People with these disabilities may often qualify for Social Security (SSA) or Railroad Retirement Board (RRB) benefits.
Once a person has received these benefits for 24 months, they can start a Medicare plan, even though they are under 65 years of age.
A person with a disability may otherwise have difficulty getting health insurance, as a private insurer may charge them higher premiums due to pre-existing medical conditions.
As a result, Medicare provides a more cost-effective coverage option for people who have disabilities.
Examples of disabilities that may qualify a person for Social Security or RRB benefits include:
- back injuries and other musculoskeletal issues
- bleeding disorders
- heart conditions, including congestive heart failure
- mental health disorders, such as depression
- sensory issues, such as vision loss
- speech disorders
- severe respiratory illnesses, such as COPD
Medicare has specific criteria for children under the age of 18 years who wish to claim disability benefits or enroll in Medicare.
The SSA does not pay disability benefits to a young person until they reach 18 years of age. Therefore, a person with a disability does not qualify for Medicare until they are 20 years of age.
An exception to this rule applies to people who are 18 years of age and have ALS. They qualify for Medicare benefits once they reach this age.
End-stage renal disease (ESRD) is the final stage of chronic kidney disease and indicates that a person’s kidneys are not functioning.
As a result, the kidneys cannot filter fluids and electrolytes while removing waste. A person with ESRD produces very little urine, if any. The waste that the body usually removes from the body in urine can build up.
This can become fatal without treatment. However, a person can receive dialysis treatments to act as an artificial kidney system and remove waste from the body. Some people with ESRD may require a kidney transplant.
Those with ESRD can qualify for Medicare if they meet the following criteria:
- They have ESRD, and their kidneys are no longer functioning.
- They require dialysis or have had a kidney transplant.
They must also meet the following requirements:
- They have worked at least 40 quarters, in which they paid Medicare taxes.
- They are eligible for or currently receive Social Security or RRB benefits.
- They are the spouse or dependent child of a person who meets the Medicare eligibility criteria.
Medicare benefits do not often begin immediately, even if a person has ESRD and receives dialysis. For most people with ESRD, Medicare coverage starts in the fourth month of dialysis.
Some exceptions apply. A person can begin receiving Medicare benefits alongside ESRD treatment if they participate in a home dialysis training program to conduct their own dialysis with assistance from a healthcare professional.
However, not all people with ESRD can qualify for at-home dialysis.
People with ALS, or Lou Gehrig’s disease, can qualify for Medicare when they are under 65 years of age.
ALS is a progressive, neurodegenerative disorder that disrupts a person’s ability to speak, move, eat, and ultimately breathe. The condition has no cure and is eventually fatal.
According to the ALS Association, an estimated 16,000 people in the United States have the disorder. A doctor usually diagnoses ALS between the ages of 40–70 years.
Unlike ESRD, those with ALS can receive Medicare Part A benefits in their first month of receiving Social Security or RRB benefits.
The SSA automatically enrolls a person with ALS in a Medicare plan when they start paying Social Security benefits.
According to a 2017 review in Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, a person’s monthly costs with ALS under Medicare can total $10,398 during the month of their diagnosis.
ALS often progresses rapidly and leads to high healthcare costs. This is why a person’s Medicare benefits will usually begin as soon as possible.
A person should contact the SSA with any questions about their work history and eligibility for Medicare by visiting the “Contact Us” section of their site or calling 1-800-772-1213 (TTY: 1-800-325-0778).
If a person receives benefits from the RRB, they can call 1-877-772-5772 to find out more about qualifying for Medicare.
Extra Help is a Social Security program that provides additional financial assistance for people of limited means who need prescription drug coverage through Medicare.
To qualify for Extra Help, an individual must have less than $14,610 in resources. Married couples who live together must have less than $29,160 in combined resources.
The SSA defines resources to include the following:
- bank accounts
- mutual funds
- real estate
A person’s annual income must also be $19,140 or less for an individual or $25,860 or lower for a married couple who live together. Even if an individual is slightly over the income threshold, they may still qualify for Extra Help.
To apply for Extra Help, a person can go to www.SocialSecurity.gov/extrahelp, call the SSA at 1-800-772-1213, or apply in-person at a local SSA office.
People with ESRD, ALS, and certain disabilities may qualify early for Medicare.
Those with ESRD qualify after 2 months of dialysis or after taking a home dialysis training course. People who live with disabilities can apply after 2 years of receiving Social Security benefits.
Individuals with ALS, however, become eligible for Medicare at the same time they can start receiving Medicare coverage.
It is best for individuals to contact Medicare directly to discuss eligibility for their circumstances.