Medicare typically provides coverage for those over aged 65, but those under 65 can also access Medicare benefits if they have disabilities or certain health conditions.
If an individual receives disability benefits from the Social Security Administration, they may qualify for Medicare coverage.
This article explores Medicare coverage for disabled individuals and the rules on eligibility.
It then looks at different Medicare plans for those with disabilities and finishes with an overview of Medicare’s costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers individuals over age 65 and those younger than 65 with specific medical conditions, including those with disabilities who cannot work.
Providing an individual receives Social Security Disability Insurance (SSDI) payments, they qualify for Medicare. Those with end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) also qualify.
At the start of month 25, Medicare automatically enrolls the individual in parts A and B.
During the 2-year waiting period, a person may qualify for health coverage under their employer’s insurance policy.
If they lose their job, they can access health care through the Consolidated Omnibus Budget Reconciliation Act (COBRA).
Once a doctor has diagnosed that a person has a long-term disability, they must wait for 5 months before receiving SSID benefits.
The reason for this waiting period is to prevent those with short-term disabilities from receiving incorrect benefits.
ESRD and ALS
When someone has ESRD or ALS, they do not have to wait for two years before qualifying for Medicare.
If an individual has ALS, Medicare enrolls them in the first month they receive SSDI benefits.
Those with ESRD are eligible for Medicare coverage from the first day of the 4th month of their dialysis treatment.
Once an individual meets the criteria for SSDI, they qualify for auto-enrollment in Medicare Part A and Part B, known as original Medicare.
Original Medicare covers a wide variety of health services based on different parts:
Medicare Part A
Medicare Part A covers inpatient hospital stays, including:
- hospitalization costs such as room and meals
- medical tests
- blood transfusions
- diagnostic testing
- skilled nursing care
Medicare Part B
Medical Part B pays for outpatient medical services, such as:
- doctor’s visits
- some preventive care
- physical therapy
- outpatient care
- ambulance services
- mental health services
- durable medical equipment and prosthetics
- limited prescribed drugs
Medicare Part C
Part C plans, also known as Medicare Advantage, combine the benefits of original Medicare parts A and B.
Private insurance companies offer these plans, which usually include other benefits such as vision, dental, or fitness.
Medical Advantage plans also usually include Part D prescription drug coverage.
One type of Medicare Advantage plan is called a Special Needs plan (SNP). This plan offers tailored coverage to meet the specific needs of those with certain chronic conditions, including ALS and ESRD.
Medicare’s costs for those with disabilities depends on their circumstances.
Different rules apply to each part of Medicare.
Most people do not pay a premium for Medicare Part A, including those receiving Social Security or Railroad Retirement Board benefits.
Providing a person receives SSDI benefits for two years, they will not pay for Part A premiums.
Other costs associated with Part A include a deductible of $1,484 in 2021 for inpatient hospital stays. After someone has met their deductible, Medicare covers the first 60 days of hospital stay.
Once a person has been in the hospital for more than 60 days, additional out-of-pocket costs apply.
Medicare deducts Part B premiums from an individual’s SSDI payment check automatically. The standard Part B premium for 2021 is $148.50.
The Part B deductible is $203 in 2021. After someone meets their deductible, they pay 20% of the Medicare-approved amount for covered services.
If an individual has healthcare coverage from another source, such as their partner’s employment, they can opt-out of Medicare Part B coverage.
However, a late enrolment penalty may apply if a person does not enroll in Part B when they first qualify.
To qualify for Medicare before the age of 65, an individual must have a condition that meets with Social Security’s disability definition.
It is important to note that individuals with a partial or short-term disability do not receive SSD benefits.
The legal definition of disability states that an individual cannot work to support themselves because of a physical or mental impairment, which could cause death or which has or will last for more than one year.
An individual may be eligible to receive extra support based on their income.
Medicare savings plans
The government provides support to those with a low income to pay out-of-pocket costs through four Medicare savings plans:
- Qualified Medicare Beneficiary (QMB) program
- Specified Low-Income Medicare Beneficiary (SLMB) program
- Qualifying Individual (QI) program
- Qualified Disabled and Working Individuals (QDWI) program
If individuals do not qualify for a savings plan, they could consider a Medigap plan.
Private insurance companies provide these plans to cover the out-of-pocket expenses left after Medicare pays its share for covered healthcare services.
Those enrolled in a Medicare Part D prescription drug plan could qualify for the Extra Help program.
Extra Help provides support to those with limited resources to pay for their prescription drugs.
Although Medicare typically covers people aged 65 and over, it provides coverage to younger people with a disability who receive SSDI benefits.
Coverage starts after someone has received SSDI benefits for 2 years, and Medicare enrolls the individual automatically.
If someone has alternative healthcare coverage, they can decline Medicare Part B if they prefer.
Typically, Medicare Part A is premium-free. The individual pays a premium for Part B and out-of-pocket costs such as deductibles and copayments.
The government also provides additional financial support through various programs, including savings plans and Extra Help.
The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.