When it comes to Medicare, the common perception is that it is the program set up by the Federal Government to provide affordable health insurance only for those over the age of 65 who have, through payroll deduction, contributed to the Social Security Administration over the course of their working life.
What you may not know is that Medicare can also benefit those who have yet to reach that age threshold — provided they have a qualifying disability.
But how is qualification being determined? For starters, not all disabilities qualify for Medicare coverage – we will go into the details of this later. On top of that, to qualify for under-65 Medicare, an applicant must first apply for Social Security Disability benefits, and he or she must meet the guidelines from the Social Security Administration for that disability to qualify for coverage.
In other words, you need more than your doctor saying that you can’t work because of a disability. There are other steps you need to take in order to receive Medicare health insurance coverage.
Getting Medicare Benefits for Under 65
If you are under 65 and wish to get Medicare coverage, you need to be on Social Security Disability Insurance (SSDI) for a full 24 months. To qualify for SSDI, you must prove that you can’t work because of the disability. This process normally takes about 5 months.
There are exceptions to the above. A couple of conditions — end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS) — may automatically qualify you for Medicare at the time of your diagnosis so that you don’t have to wait.
What Disabilities Qualify for SSDI?
Besides the two mentioned above, there are many other conditions that may help people under 65 to meet the Social Security Disability Insurance requirements and qualify as Medicare beneficiaries. They are generally grouped under these categories:
Heart-related Medical Conditions
Musculoskeletal Disorders
Respiratory Disorders
Digestive System Disorders
Genitourinary Disorders
Hematological Disorders
Neurological Disorders
Special Senses and Speech
Congenital Disorders that Affect Multiple Body Systems
Endocrine Disorders
Skin Disorders
Immune System Disorders
Cancer
Mental Health Disorders
Note that while this list is quite extensive, many of them carry very specific requirements that must be met. For more details about how the Social Security Administration evaluate these impairments for SSDI benefits, check out their website.
How to Get Started Qualifying for Medicare Benefits?
If you are under the age of 65 and think that you have a condition that qualifies you for Medicare eligibility, the first thing to do is to apply for Social Security Disability benefits. And here’re the steps:
Apply to the Social Security Administration, which is the agency that will consider your condition and has the authority to approve your disability as one that is covered.
Five months after receiving the decision of your disability qualification, you will start getting Social Security Disability Insurance payments
From that point, you will need to wait 24 more months before reaching Medicare eligibility under age 65.
What Happens If You Are Denied Coverage?
In the case that your application for disability benefits is rejected, one thing that you can do is reapply with more information or documentation.
The good thing is if your reapplication is deemed to have met the eligibility requirements and you qualify as disabled, you can backdate your application to the first month you would have received SSDI. This means you can begin waiting for the 24 months necessary to reach Medicare eligibility and may also be compensated for that period.
One thing to bear in mind is that to qualify, you must be unable to maintain substantial gainful activity over the time of waiting. Once deemed able to return to work, some younger Medicare beneficiaries may no longer be eligible for health care services.
Will My Health Care Services Be Free Once I Qualify for Medicare?
The simple answer is no. Qualifying for Medicare doesn’t mean that your health insurance is free. This is the same for those who are over 65, though the health insurance program they select maybe different from someone who qualifies for Medicare with disability. Here is a look at Medicare costs and what you can expect.
Original Medicare
All Medicare beneficiaries receive Original Medicare coverage, also known as Medicare Part A & B, right after they qualify for the program. The good news is that if you have a disabling impairment, you will have access to the very best level of care.
But if you require more coverage to meet your ongoing health needs and goals, you may consider getting Medicare Supplement policies, or Medigap policies. An example is if you need prescription drug coverage, which is normally not covered by Original Medicare. Another option is to buy Medicare Advantage Plans to replace Original Medicare.
Medicare Part A
This part of Medicare, also known as hospital insurance, is normally free. It covers the inpatient care you receive when you are being admitted to a hospital. Sometimes you may have to pay a deductible or coinsurance costs at a specific rate if you are in the hospital for 61 to 90 days per calendar year.
Medicare Part B
Medicare Part B covers preventative care, such as medical checkups. This part often requires you to pay a monthly premium, which is typically deducted from the SSDI payment you receive. You will also need to pay a deductible and coinsurance. If you have a Medigap plan, it may cover some of these out-of-pocket expense.
Medicare Part C
As mentioned above, Part C is also known as the Medicare Advantage Plan. It is an option that you can choose to replace Original Medicare if you decide that you need more coverage. They are offered by private insurance companies and can vary widely in coverage. As such you will need to compare several options before deciding which is best for you. Medicare Advantage Plans that are available to those who are disabled are called Medicare Part C Medicare Advantage Special Needs Plans (SNPs)
The cost for different Medicare SNPs can vary significantly but they tend to be more affordable than others.
Medicare Supplement Plans
Another option is a Medigap plan, which normally provides additional coverage for deductibles and copayments of what you can expect to pay for Original Medicare as a disabled individual. Like Medicare Advantage Plans, both the deductible you pay and the coinsurance responsibility for Medigap will differ between plans.
Medicare Part D
Medicare Part D is often a necessary component for disabled participants of the program, as it is responsible for paying for prescription drug coverage. While there is a monthly premium, it is typically more affordable than most other health insurance plans.
Things That You Need to Know About Medicare Special Needs Plans
Medicare SNPs are useful because they tend to do a better job in coordinating care for people who have disabilities than what other coverage options offer.
Participants can choose from different types of SNPs, including some that are designed for people with chronic conditions. As such, when you are comparing policies and coverage options, make sure that you are looking specifically at this type of qualification and plan.
What about ALS and End-Stage Renal Disease (ESRD)?
As mentioned at the beginning of this blog, those suffering from Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease, and End-Stage Renal Disease (ESRD) can potentially qualify for Medicare right away. In fact, ALS patients are automatically enrolled in Original Medicare at the time of diagnosis.
Those suffering from ESRD, or permanent kidney failure, normally require either ongoing dialysis or a kidney transplant. And while they may also qualify for Original Medicare right away, there is no automatic enrollment. These patients will instead have to sign up for coverage and their benefits will start based on their condition. For example, if they require a kidney transplant, the coverage will start the month they go in for surgery. If they are receiving dialysis, their coverage will begin on the first day following their fourth full month of dialysis treatments.
Another important thing to note is that ESDR patients don’t always continue to qualify for Medicare. They may no longer be eligible for coverage if they have a transplant or if their condition improves, though this typically only occurs 12 months after the dialysis treatment is stopped.
Is Medicare Advantage or Medigap Policy the Better Option?
As noted, if you are an under-65 Medicare participant, you have the choice between Medicare Advantage Plans or Original Medicare. If you go with the latter, you could use Medigap for coverage gaps.
But bear in mind that Medigap may not be available to those under age 65 in some states. And even if it does in your state, they can be very expensive and may not be enough to cover all your needs. So make sure you take these factors into consideration when choosing between the two.
What If You Go Back to Work?
So let’s say after a period of treatment, your condition improves and you decide to go back to work. What’s going to happen to your Medicare benefit? The good news is that in October 2000, Medicare put in a new law that allows a person who has been receiving SSDI benefits to return to work while continuing to be eligible for Medicare benefits for as long as 8 1/2 years.
There will be a Trial Work Period, during which you will be allowed to go back to work while being assessed whether you are capable of handling the work with your condition. Over the first 9 months of that time, in a rolling 5 year period, you can continue to receive your Medicare benefits. You will also be able to continue receiving SSDI regardless of how much you earn from work. You do, however, need to let Social Security know that you are doing this.
Once this Trial Work Period ends, your Extended Period of Medicare Coverage begins. The purpose of this is to allow Medicare beneficiaries who have not improved medically to continue to receive coverage for up to 93 additional months, even if they are no longer eligible for SSDI payments.
Speak to an Agent about Medicare Disability Benefits
If you are under 65 and have a disability, Medicare coverage can be critical for you to get the health care you need. To find the best policy, you need to work with a licensed insurance broker or agent with expertise in this area. Not only will that help keep your out-of-pocket spending down, but it will also ensure you are getting the coverage necessary to care for your condition.
