Understanding Medicare Eligibility for Individuals Under 65 With Disabilities

Since its inception in 1965, Medicare has helped millions of Americans stay healthy and get the medical care they need.

But navigating potential health care 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 better grasp your health care rights, our Medicare guide can be your trusted resource for getting all the answers. We’ll walk you through all the basics.

Medicare and Disability: A Brief Overview

Medicare was designed to cover both adults over age 65 and some people younger than 65 who have 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 health care 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 vs. Medicaid for people with disabilities

Medicare was originally established to provide coverage for older adults who lost employer-based insurance when they retired at age 65. As of the 1970s, it also covers those under 65 who receive Social Security disability benefits. Medicare is funded through federal Social Security taxes and does not have any income limits you must meet to qualify.

Medicaid, on the other hand, is a needs-based program that serves low-income individuals. It’s funded through a mix of federal, state and local taxes. There are no age restrictions to qualify for Medicaid, and the program is administered at the state level.

Because Medicaid is a needs-based program, applicants must meet specific income and asset levels to qualify. Priority is usually given to older adults, those with disabilities, pregnant women, children and families in need. To apply for Medicaid, you’ll need to go through your local state agency that processes those requests.

Keep in mind that, in most states, if you have a disability and you receive Supplemental Security Income, also known as SSI, you’re automatically eligible for Medicaid. More than one-third of Medicaid beneficiaries qualify this way, according to the Medicaid and CHIP (Children’s Health Insurance Program) Payment and Access Commission.

When it comes to considering Medicare versus Medicaid disability benefits, there can be overlap between which program you qualify for, so it’s best to ask a caseworker in your state to clarify your options.

[READ: Medicare Mistakes to Avoid.]

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 provide assistance to 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 non-medical 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 RBR, 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.

[Read: Medicare Enrollment Deadlines You Shouldn’t Miss.]

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, explains Kathleen Holt, a Connecticut-based attorney and associate director for the Center for Medicare Advocacy.

“It’s not a specific condition,” she notes. “You could have multiple sclerosis and continue to work, or you can have MS and be so incapacitated that you reach a point where you meet that criteria and you’re unable to perform regular work activity for a 40-hour workweek.”

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.

Holt notes that about 15% of Medicare beneficiaries are people with disabilities who are younger than 65.

[SEE: Things You Should Know About Medicare.]

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 benefits.

— 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, Holt notes, 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 would be, Holt says. That way, while you’re waiting for Medicare to kick in, you can get coverage through your state’s health insurance exchange.

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.

As you go through the Medicare process, Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services in Washington, D.C., recommends visiting 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.

“Our website makes it very easy for someone to walk through (enrollment) and figure out their eligibility,” Seshamani says.

CMS also staffs a 24/7 call center at 1-800-Medicare (1-800-633-4227) where you can ask questions and get support.

“People can call and say, ‘Hey, I want to check, am I eligible for Medicare? How can I sign up?’ and somebody can help you walk through that,” she explains.

Making sure people are able to enroll quickly and with minimal difficulty is a key focus of her work at CMS.

“It’s really a priority for us to help people figure out what option is best for them,” Seshamani adds.

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.

“The whole point of our SHIP programs is to have individuals locally available to provide in-depth, one-on-one assistance in navigating and enrolling in Medicare,” says Rebecca Kinney, director for the Administration for Community Living Office of Health Care Information and Counseling in Washington, D.C.

You can find your local program and set up an appointment from 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.

“There’s a lot of choices, and things that can be really overwhelming,” she explains. “That’s what SHIP is there (for) — to help them try to sort through and navigate.”

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Understanding Medicare Eligibility for Individuals Under 65 With Disabilities originally appeared on usnews.com

Update 09/20/23: This story was previously published at an earlier date and has been updated with new information.

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