A Closer Look At Medicare Eligibility For Those Under 65 With Disabilities
Since its inception in 1965, Medicare has helped millions of Americans stay healthy and get medical care needed
Navigating potential healthcare plans and understanding Medicare eligibility can be challenging, especially if you're under age 65 and have a disability.
Whether you are recently diagnosed or seeking to grasp your healthcare rights better, our Medicare guide can be your trusted resource for getting all the answers. Here I'll attempt to walk you through all the basics.
Key Takeaways:
- If you’re under the age of 65 and have a disability, you may qualify for Medicare coverage.
- A qualifying disability is almost any health condition that prevents you from being able to work enough to access employer-sponsored health care benefits.
- Before you can enroll in Medicare, you must receive Social Security Disability Insurance for two years. If you have end-stage renal disease or amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig’s disease, that 24-month waiting period is waived.
Medicare and Disability:
Medicare was designed to cover adults over 65 and some people younger than 65 with disabilities that meet certain criteria.
There are several pieces of Medicare, including:
- Part A. This part covers inpatient care in hospitals, Skilled Nursing Facility care, and some home healthcare or Hospice care.
- Part B. Services from doctors and health care providers fall under part B. Coverage includes outpatient care, physical therapy various preventive services, and durable medical equipment, such as wheelchairs and walkers.
- Part C. Also called Medicare Advantage, this part includes plans offered by private companies that are approved by Medicare. These plans bundle Part A, Part B, and usually Part D coverage into a single plan.
- Part D. This part is the prescription medication piece of Medicare.
- Medigap. This supplemental insurance includes "original Medicare" – Part A and Part B – and a plan to pay for coinsurance deductibles.
Medicare Eligibility Criteria for Individuals Under Age 65
In general, if you're under the age of 65 and have a disability, you must be receiving Social Security Disability Insurance, also referred to as SSDI, benefits for two years before you become eligible for Medicare.
Both SSDI and SSI are administered by the Social Security Administration and assist people who meet the federal agency's requirements for disabilities.
- SSDI. You and certain family members – including a spouse, divorced spouse, children under the age of 16, and adult children who were disabled before age 22 – can receive benefits if you are insured. Your eligibility is based on how long and how recently you worked and whether you paid Social Security taxes on those earnings.
- SSI. Adults and children who meet the SSA’s requirements for a qualifying disability and have limited income and resources can receive benefits from this program.
The two programs are different but have the same medical requirements. However, if your situation meets the nonmedical requirements established by the SSA, then you may be eligible for monthly benefits if your medical condition is expected to last at least a year or is terminal. You can apply for benefits via the SSA’s website.
Another federal benefits program, the Railroad Retirement Board, or RRB, was established in the 1930s for railroad workers to support them when financial upheaval from the Great Depression threatened existing retirement and pension programs.
The RRB is an independent federal agency based in Chicago. It’s similar to the SSA in that the agency works directly with recipients via more than 50 field offices across the U.S. Both organizations also use the same definition of total disability and the same formula to calculate payments. To be eligible for RRB benefits, you must have worked for at least 10 years in covered service for the railroad industry or at least five years after 1995.
Disabilities That Qualify for Medicare Under Age 65
The term "disabled" refers to almost any condition that results in a demonstrable disability in which you cannot perform regular, continuous work activity on a full-time basis and that has persisted or is expected to last at least 12 months.
The key to becoming eligible for Medicare benefits is having a medical condition that makes it impossible for you to work enough to access employer-sponsored health care benefits.
Navigating the Application Process
To become eligible for Medicare under the age of 65, there are a few steps you must follow:
- Apply for SSDI benefit
- Wait 24 Months
- Enroll in Medicare
Apply for SSDI benefits
It's important to apply for Social Security because this is the pathway to getting Medicare coverage, You must satisfy the Social Security office that you are disabled and need to draw benefits.
To apply for SSDI, you’ll need the following documents and information:
- Your Social Security number
- Medical records from your doctors, therapists, hospitals, clinics and caseworkers that substantiate your medical issue and disability status
- Laboratory and test results
- Names, addresses, phone and fax numbers of your doctors, clinics and hospitals
- Names of all medications you are taking
- Names of your employers and job duties for the last 15 years
Wait 24 months
There is a 24-month waiting period after you start drawing disability benefits before you become eligible for Medicare coverage. However, if you have either ALS, also known as Lou Gehrig’s disease or end-stage renal (kidney) disease, the waiting period is waived.
For those who do need to wait two years, this period can be a hardship, but during those 24 months, you can access health coverage because of the Affordable Care Act, which was signed into law in 2010.
This program also referred to as Obamacare, provides private insurance options to individuals outside of traditional employer-sponsored health care. A critical piece of these plans is that you can’t be disqualified for a preexisting condition and the disability for which you’re awaiting Medicare.
Enroll in Medicare
Once you’re in the SSDI system and have fulfilled the 24-month waiting period, you’ll be automatically enrolled in Medicare.
Medicare.Gov's "Get Started With Medicare" page, where you’ll be guided through a series of questions about your situation to determine your eligibility and help you get enrolled.
CMS also staffs a 24/7 call center at 1-800-Medicare (1-800-633-4227) where you can ask questions and get support.
Making sure people can enroll quickly and with minimal difficulty is a key focus of her work at CMS.
Comparing Medicare and Social Security
When considering Social Security versus Medicare, it’s important to recognize that these are two separate benefit programs from the federal government. Social Security provides financial support, whereas Medicare is health insurance coverage. These two safety net programs work together to support people with disabilities to remain as healthy as possible.
As mentioned, for someone looking to gain health insurance coverage via Medicare because of a disability, they must first apply for disability benefits from Social Security.
Help Is Available
Regardless of age or disability status, many people can benefit from guidance when first getting enrolled in Medicare or when making changes during an open enrollment period. The great news is that this type of help does exist and is free.
In addition to the services available at CMS, the State Health Insurance Assistance Program – a grant-based program in every state, Washington, D.C., Puerto Rico, Guam, and the U.S. Virgin Islands – can help enrollees.
You can find your local program and set up an appointment on SHIP's website. During your appointment, a SHIP counselor will spend two to three hours with you, either in one sitting or several, to help you understand the aspects of Medicare.
Brian Moore of OhioMedicarePlan is a Medicare Broker Licensed in OH. OhioMedicarePlan is an Ohio-based Insurance Agency specializing in Medicare Benefits, Medicare Planning, Medicare Education, Medicare Evaluation, and Medicare Enrollment for all Ohio beneficiaries. Our experienced team of Medicare Agents is focused on Ohio residents in all 88 Counties who understand Medicare Advantage (Part C), Medicare Supplement -or- Medigap, and Original Medicare, along with navigating (Part D) Medicare Prescription Drug Coverage.OhioMedicarePlan also offers expertise regarding the navigation of the initial engagement process with the Social Security Administration ( SSA ) assisting with your enrollment election periods.OhioMedicarePlan is licensed to sell insurance plans specializing only in the State of Ohio. We do not offer every plan in your area. Currently, we represent all plans offered by Humana, Devoted Health, Mount Carmel Medigold, Anthem ( Elevence Health ), Aetna, and Cigna totaling 74 options. Please contact Medicare.Gov, 1-800-Medicare or your local Health Insurance Program to get information on all your options. Plans sold through or represented by OhioMedicarePlan are processed through the individual licensing of Brian C. Moore. For more information or a No-Cost assessment of your circumstances, Visit www.OhioMedicarePlan.Com or www.OhioMedicarePlan.Info, or by calling 937-241-5544.