Medicare Disability Coverage For Those Under 65

A Disability and a Long Wait Are Required for Early Medicare Enrollment

Doctor comforting patient in wheelchair
Ariel Skelley/Blend Images/Getty Images

 

Medicare won't be available to most of us until we turn 65, but for some people – those with long-term disabilities or those who have been diagnosed with specific diseases – Medicare is available at any age. It just isn't easy to get.

Medicare Coverage if You Have a Long-Term Disability: First You Need SSDI

If you can establish that you suffer from a long-term disability that prevents you from working, you may qualify for monthly Social Security Disability Insurance (SSDI) payments and for Medicare.

However, it can be a long process and even after you are approved for SSDI, you will have a long waiting period before your Medicare benefits begin.

A request for disability benefits starts with an online application. For your application to be considered, you must have worked enough hours to qualify for Social Security benefits, or be a spouse or dependent of someone who has.

The Social Security Administration has a very strict definition of disability. To be found disabled:

  • You must be unable to do any substantial work because of your medical condition(s); and
  • Your medical condition(s) must have lasted, or be expected to last, at least 1 year, or be expected to result in your death.

Your application for SSDI is likely to move more quickly if you select one doctor as the lead contact for your case. It's best to go with one who has experience with disability cases, responds promptly to requests for information and is familiar with your overall health situation.

It's also a good idea to keep a detailed log of your experiences with everyday activities to document, for example, any difficulties you have with mobility or any side-effects you are experiencing from medications. This will help when you when you have your interview with a representative from Social Security.

The interview may take place on the phone or in person at your local Social Security office.

The Social Security Administration website provides an easy-to-use Disability Starter Kit that includes FAQs, a checklist and a worksheet to help you get ready for your interview.

The Social Security Administration says most applications are processed within three to five months. For most applicants, however, the wait for Medicare benefits is just beginning, even if their application is approved.

Waiting Periods for Medicare Coverage

According to the law, your SSDI payments cannot start until you have been disabled for at least five full months. Your payment will usually start with your sixth month of disability. And, if you have been approved for SSDI, you must wait a full two years after that period passes for your Medicare coverage to start.

When your Medicare starts you will be eligible for both Medicare Part A – hospital and nursing home coverage – and Medicare Part B – doctor visits and outpatient services. You will get a Medicare card in the mail before your 25th month of disability. If you do not want Medicare Part B, you can send back the card. If you keep the card, you will keep Part B and will pay Part B premiums.

Also, you will be eligible for a Medicare Part D Prescription Drug Plan. You can join a Part D plan during the three months before to three months after your 25th month of disability.

Federal law does not require private insurers to sell Medigap insurance—the type of coverage that pays for appropriate services and out-of-pocket expenses not paid for by Medicare—to people under 65, even if they are disabled.

However, 30 states require insurance companies to sell you a Medigap policy, at certain times, even if you are under age 65, although some limit plan availability and there are varying rules for people with end-stage renal disease (kidney failure).

Contact your state insurance agency to find out if your state has a Medigap requirement and to determine the rules that apply to you.

The Problem with the Waiting Period

Commenting in an essay The Long Wait: The Impact of Delaying Medicare Coverage for People with Disabilities, Stuart Guterman of the Commonwealth Fund stated that: 

"At a particularly difficult point in their lives, disabled individuals must wait two years before they are eligible to begin receiving Medicare benefits—a delay that can block access to needed care and relief from financial pressures."

Guterman also noted that:

"As of December 2007, there were 7.6 million SSDI beneficiaries; of those, approximately 1.8 million were in the 24-month waiting period for Medicare coverage. Therefore, nearly one-quarter of Americans who are arguably in greatest need of health care are left to fend for themselves while they wait for Medicare coverage to begin."

Medicare Coverage for Persons with Lou Gehrig's Disease or End-Stage Renal Failure

If you are younger than 65 and have been diagnosed with amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig's disease, you will automatically get Medicare Part A and Part B the month your disability benefits begin (after the end of the five-month waiting period for disability benefits).

If you are undergoing dialysis for end-stage renal disease (ESRD) your Medicare coverage usually starts the first day of the fourth month of dialysis treatments (note that Medicare Advantage plans are generally not available to people under 65 who are enrolling in Medicare as a result of ESRD; these individuals are limited to traditional Medicare instead). Medicare coverage can start as early as the first month of dialysis if you meet all of the following conditions:

  • You take part in a home dialysis training program offered by a Medicare-approved training facility to teach you how to give yourself dialysis treatments at home.
  • Your doctor expects you to finish training and be able to do your own dialysis treatments.
  • You do your own dialysis regularly during the four months you would otherwise have to wait for coverage to start.

If you have employer-sponsored or union-sponsored insurance and you become eligible for Medicare due to end-stage renal disease, Medicare will coordinate with your existing coverage for 30 months. During that time, your private insurance will be your primary coverage, and Medicare will pick up the portion of the remaining costs. At the end of the 30 months, assuming you still have coverage under your group health plan, it will become secondary coverage and Medicare will become primary.

Medicare's booklet Coverage of Kidney Dialysis and Kidney Transplant Services provides an explanation of how to apply for Medicare benefits if you have ESRD.

Sources:

ALS Association. Medicare Information.

Centers for Medicare and Medicaid Services. Coverage of Kidney Dialysis and Kidney Transplant Services.

Medicare.gov. I have a disability.

Medicare.gov. What if I have end-stage renal disease (ESRD)?

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