Medicare for Disabled People Under 65: How to Get Coverage

Medicare for Disabled People Under 65: How to Get Coverage

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Although Medicare is well known as a federal program that provides health care to seniors 65 and older, it also covers more than 8 million people with disabilities under the age of 65.

Qualifying for Medicare when you are under the age of 65 is a process that begins by applying for Social Security disability benefits. After several steps are completed, there's usually a two-year waiting period before Medicare's health insurance benefits begin.

Who qualifies for Medicare under 65?

To qualify for Medicare under the age of 65, the Social Security Administration has to first determine that you meet the criteria for disability. Disability is generally defined as having an illness or condition that is expected to last at least one year while depriving you of a certain amount of income each month.

Qualifying disabilities can include but are not limited to the following:

  • Parkinson’s disease
  • Heart disease
  • Multiple sclerosis
  • Mental illness
  • Lupus
  • Cystic fibrosis
  • Permanent kidney failure, also called end-stage renal disease (ESRD)
  • Amyotrophic lateral sclerosis (ALS)

Disabled Medicare beneficiaries under the age of 65 receive the same health insurance benefits as seniors who are enrolled in the program.

It is also important to remember that Medicare provides individual, not group, coverage. Medicare benefits do not extend to family members.

What is the waiting time for Medicare benefits to begin?

With most diseases and conditions, Medicare coverage becomes effective 24 months after you start receiving Social Security Disability Insurance (SSDI) payments.

Steps to qualify for Medicare under the age of 65

  1. The Social Security Administration determines you meet the criteria for disability.
  2. You start receiving Social Security Disability Insurance payments five months after the disability determination.
  3. With most diseases and conditions, Medicare coverage becomes effective 24 months after you start receiving SSDI payments.

Exceptions to the two-year waiting period

The 24-month waiting period does not apply to ESRD and ALS. Medicare coverage with these two conditions starts as soon as you begin receiving SSDI payments.

In addition, if you apply for disability and are turned down but qualify following an appeal, approval of the application is backdated to the first month you would have received SSDI. The 24-month waiting period begins on that date.

If you receive SSDI for a few months and lose eligibility only to regain eligibility months or even years later, all the months and years you should have been collecting SSDI count collectively toward the 24-month waiting period. There is, however, a coverage gap because you will not receive Medicare benefits during the time the appeal is pending.

Medicare costs

The cost of Original Medicare (Parts A and B) is the same for both seniors and the under 65 disabled population. But there are dramatic differences in the cost of Medicare Supplement (Medigap) policies.

Medigap policies are usually much more expensive for disabled Medicare beneficiaries under 65 than for seniors who have Medicare.

Medicare Part A (hospital insurance)

  • Monthly cost: Most Medicare beneficiaries do not pay premiums for Medicare Part A, which covers hospitalization and inpatient care.
  • Deductible: $1,556 for the calendar year
  • Coinsurance: $389 per day for days 61-90 in the hospital

Medicare Part B (medical insurance)

  • Monthly cost: In 2022, the Medicare Part B premium is $170 a month, which is usually deducted from each month's SSDI payment.
  • Deductible: $233 for the calendar year
  • Coinsurance: Enrollees usually pay 20% of medical costs, unless they have additional coverage through a Medigap plan or have a different benefit structure with a Medicare Advantage plan.

Medicare Part C (Medicare Advantage Special Needs Plans)

  • Monthly cost: Rates vary by plan, and in 2022, the average cost is $33 per month. This cost is on top of what you pay for Parts A and B.
  • Deductible and coinsurance: Varies by plan

Medicare Part D (prescription drug plan)

  • Monthly cost: The average cost is about $33 a month, but plans can cost $7 to $130 a month depending on the carrier and extent of coverage. Insurers are not allowed to charge Medicare beneficiaries more based on medical conditions.

Medicare Supplement (Medigap)

  • Monthly cost: Rates are much higher for the under 65 disabled population, with plans often costing more than $600 a month.

Why is Medicare Advantage a good choice for disabled Medicare beneficiaries under 65?

Medicare Advantage plans are the best choice for disabled Medicare beneficiaries under 65 because many combine cost savings with convenience, allowing those who are disabled to bypass certain costs while making it possible for them to enroll in plans tailored to their needs.

Medicare Advantage plans, also known as Medicare Part C plans, function as "all-in-one" alternatives to Original Medicare, encompassing Medicare Part A, Part B and usually Part D prescription drug coverage. The plans eliminate the need to purchase Part D and supplemental plans separately, which is done with Original Medicare.

Unlike Original Medicare, Medicare Advantage plans have out-of-pocket limits, usually around $7,550 a year. This caps the total amount that enrollees pay for covered health care services, an important benefit for those who are managing ongoing health conditions. In contrast, someone who is only enrolled in Original Medicare could face limitless health care costs.

Plans are usually affordable, and most of them charge little or nothing in monthly premiums. Many of the plans also provide extra benefits, covering dental and vision services, for instance.

Special Needs Plans

Unlike Original Medicare, Medicare Advantage offers Special Needs Plans (SNPs) geared for people with specific disabilities.

The two most common SNPs are Chronic Condition Special Needs Plans (C-SNPs) and Dual Eligible Special Needs Plans (D-SNPs).

  • In order to join a C-SNP, your physician has to fill out a chronic condition verification form at the time of enrollment. The availability of the plans varies by county. In some instances, these plans will contract with specialists in certain disease categories such as heart or diabetes care.
  • D-SNPs are available to beneficiaries who qualify for both Medicare and Medicaid, also known as the dual-eligible population. Costs with D-SNPs are very low, requiring little in terms of copays, deductibles and other out-of-pocket costs. Like other managed care plans, some D-SNPs may provide coverage for dental and vision services, and in addition, the plans usually provide transportation to and from physician offices and meal delivery at home.

Drawbacks of Medicare Advantage

Medicare Advantage plans, like Original Medicare, also have disadvantages.

Most of the annual expenses with Medicare Advantage result from copays, coinsurance and other out-of-pocket costs that are driven by the use of health care services. This can make it difficult to budget for health care expenses.

Those who have a disability may use health care services more than their nondisabled counterparts, resulting in more health care spending for copays, coinsurance and other out-of-pocket costs. Before enrolling in a Medicare Advantage plan, it is very important to review the plan’s "Summary of Benefits," which will lay out specific costs of physician visits, hospital stays and other expenses.

Even though Medicare SNPs are geared toward people with disabilities, most plans provide care through HMOs that employ restrictive networks. This can limit flexibility about where you go for health care, curtailing or even prohibiting access to out-of-network care except in cases of emergencies.

This could block access to wanted or even needed providers as well as hospitals and other facilities such as durable medical equipment providers. Before enrolling, it is important to make sure the providers and facilities you need are in a plan’s network.

Despite these drawbacks, Medicare Advantage plans are still the best option for Medicare beneficiaries who have a disability.

Why Medigap policies pose problems for enrollees who are disabled

Many beneficiaries enrolled in Original Medicare buy supplemental or Medigap policies to fill in coverage gaps for Medicare Part A (hospitalization and inpatient care) and Medicare Part B (outpatient care). Parts A and B cover about 80% of costs, creating a need for supplemental policies.

In most states, supplemental or Medigap policies either are not available to Medicare beneficiaries under the age of 65 or are too expensive for this population.

For example, a 65-year-old female nonsmoker who resides in the Tampa, Fla., area will pay $179 a month for a Medigap Plan G policy. But that same plan would cost $479 a month if she was under 65.

There are no federal statutes requiring insurance companies to sell Medigap policies to people under 65, and most states do not have laws regulating how much the plans can charge the under 65 Medicare population. Insurers consider disabled Medicare enrollees high-risk beneficiaries, making insurers reluctant to sell these policies.

As a result, the availability and costs of Medigap plans for the under 65 Medicare population vary, sometimes dramatically, from state to state.

Guaranteed issue and pricing regulations: In these states, insurers must sell Medigap policies to Medicare enrollees who are under 65 and have disabilities. These states also require insurers to hold down costs of the policies.

  • Idaho
  • Illinois
  • Kansas
  • Maine
  • Massachusetts
  • Minnesota
  • Mississippi
  • Missouri
  • New York
  • Oregon
  • Pennsylvania
  • South Dakota

Some availability: In these states, insurers are required to offer at least one Medigap policy to Medicare enrollees under 65.

  • Arkansas
  • California
  • Connecticut
  • Indiana
  • Maryland
  • Michigan
  • New Jersey
  • North Carolina
  • Oklahoma
  • Texas
  • Virginia

All Medigap plans available, but prices may be higher: In these states, insurers are required to make all Medigap policies available to the under 65 population. But the states allow insurers to charge high prices for premiums.

  • Florida
  • Georgia
  • Hawaii
  • Louisiana
  • Montana
  • New Hampshire
  • Tennessee
  • Vermont
  • Wisconsin

Variable availability, but alternatives available: These states do not require insurers to offer supplemental policies to Medicare enrollees who are under 65 and have a disability. But these states have alternative forms of coverage such as high-risk insurance pools.

  • Alabama
  • Alaska
  • District of Columbia
  • Iowa
  • Nebraska
  • New Mexico
  • North Dakota
  • Rhode Island
  • South Carolina
  • South Dakota
  • Washington
  • West Virginia
  • Wyoming

Variable availability: These states do not require supplemental plans for Medicare enrollees under age 65.

  • Arizona
  • Kentucky
  • Nevada
  • Ohio

Keeping Medicare benefits after going back to work

The disabled under 65 population can retain Medicare benefits even after losing SSDI in many instances. Let’s say, for instance, that you lose your SSDI benefits because you went back to work. You’ll still continue to receive Medicare benefits for eight and a half years.

There are some additional requirements involved in keeping your Medicare benefits. If your employer offers health insurance coverage, you have to take that coverage. In this situation, your employer’s coverage becomes primary while Medicare serves as the secondary provider.

Getting financial help for Medicare costs

For some beneficiaries — both the under 65 and senior populations — Medicare costs are exorbitant, stretching and even overwhelming their budgets. Fortunately, financial help is available through Medicare Savings Programs if you meet the financial criteria. The programs are available to all Medicare beneficiaries and generally provide assistance to beneficiaries who are poor but not poor enough to qualify for Medicaid. The programs include the following:

Qualifying for any of these programs also qualifies you for Extra Help, a program that also helps pay for Medicare costs, including prescription drug coverage under Medicare Part D.
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Frequently asked questions

Can you get Medicare early if you are disabled?

Yes. You can get Medicare before the age of 65 if you have a disability. To qualify, you have to apply for disability benefits and the Social Security Administration has to determine that you are disabled.

Is Medicare free for the disabled?

Medicare is not a free program, and it is almost never free for beneficiaries, including enrollees with disabilities. Like private insurance, Medicare carries its own set of costs, including premiums, deductibles and copays that increase annually.

Does SSDI automatically qualify you for Medicare?

Receiving SSDI benefits eventually qualifies you for Medicare benefits. With most diseases and conditions, Medicare coverage begins 24 months after you start receiving SSDI.

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