Medicare is a health insurance product typically reserved for those who are over the age of 65 and who have contributed to the Social Security Administration throughout their lifetime through payroll deductions. Medicare benefits like this include coverage for many health needs, including preventative care and hospitalization. However, some people may qualify for Medicare coverage before age 65. Typically, this is reserved for those who have a qualifying disability.
The key here is that not all disabilities qualify for Medicare coverage, but that Social Security Disability benefits must be applied for. You must meet the guidelines set by the Social Security Administration for that disability to qualify for coverage. Even if your doctor says you cannot work or that you have a disability, you must meet Medicare rules in this area – and that can be challenging, especially if you don’t know what health insurance coverage is available.
When Do People Under 65 Get Medicare Benefits?
In order to obtain Medicare benefits, you must first qualify for Social Security Disability Insurance. Then, you must have SSDI, as it is often called, for a full 24 months (in most cases). However, to obtain SSDI benefits, a person must wait five months, during which time they must show that they are not able to work. That means that:
- You need to apply for SSDI and prove you cannot work.
- Qualify for SSDI for 5 months.
- Once you qualify for SSDI, then wait 24 more months to obtain Medicare benefits as long as you still cannot work.
There are some conditions that do not have this waiting period. That includes those who are diagnosed with end-stage renal disease (ESRD) as well as amyotrophic lateral sclerosis (ALS). In these situations, you may automatically qualify for Medicare at the time of your diagnosis and not have to wait.
What Disabilities Qualify for SSDI?
Medicare beneficiaries typically have to first work through the Social Security Disability Insurance requirements before they can obtain disabled Medicare benefits. The list of conditions that may help you qualify for SSDI is quite extensive, but every one of them has very specific requirements that must be met. Let’s take a look at some of them.
Heart-related Medical Conditions
There are a number of heart-related conditions that may allow you to meet the needs for SSDI. Most often, the impairment must be severe enough that you cannot work. This may include:
- Chronic heart failure
- Ventricular dysfunction
- Myocardial ischemia with pain with or within necrosis of the muscle
- Syncope due to cerebral perfusion from some type of cardiac cause, such as rhythm or conduction problems
- Vein or artery disorders, including rupture, obstruction, or aneurysm
To qualify, SSDI considers your symptoms, lab tests, testing and diagnosis, treatment response, and functional limitations.
This type of qualification for disability may include disorders related specifically to the skeletal spine or those of the upper or lower extremities. The condition must impact the movement and function of those areas. This could include any bony structures, discs, or ligament related conditions.
Typically this includes conditions that do not heal or improve, including:
- Spinal cord damage and dysfunction
- Inflammatory arthritis
- Curvatures of the skeletal spine that make it hard to breathe, limit heart function, or result in depression
- Non-healing fractures due to cancer
- Leg pain due to peripheral vascular and foot conditions
Diagnostic testing is through here and often involves a grading to determine how limited you may be from the condition.
The Social Security Administration considered respiratory disorders that make it hard for a person to work as well. This includes conditions related to the obstruction, restriction, or diffusion necessary for breathing. There are a wide range of conditions that are evaluated, including:
- Pulmonary fibrosis
- Chronic obstructive pulmonary disease, including chronic emphysema and bronchitis
- Cystic fibrosis
- Chronic pulmonary hypertension
- Lung transplantation
- Respiratory failure
Signs and symptoms are considered, as well as the impact that the condition has on a person’s overall functionality and health.
Digestive System Disorders
There are a number of digestive system disorders that qualify for Medicare benefits through disability qualifications. This includes disorders such as:
- Hepatic (Liver) conditions
- Gastrointestinal hemorrhage
- Short bowel syndrome
- Inflammatory bowel disease
Factors including how well a person responds to treatment, the severity of their condition, and diagnostic information help to determine if a person qualifies for disability.
These conditions are evaluated based on severity and are often based on overall function and lab tests. Some examples include:
- Chronic obstructive uropathy
- Chronic glomerulonephritis
- Hypertensive nephropathy
- Chronic kidney disease
- Hereditary nephropathies
- Kidney transplantation
As noted, those with end-stage renal disease may not have to wait for the full period of qualifying before receiving benefits. Because this is considered an end-of-life matter, individuals qualify right away.
This may include conditions of various types that create impairment in function and pain. Some examples include:
- Hemolytic anemias
- Non-malignant hematological disorders
- Disorders of thrombosis
- Bone marrow failure
- Dysfunction of white or red blood cells, platelets, and clotting factors
- Multiple myeloma
- Human immunodeficiency virus (HIV)
Lab testing, treatment response, and definitive testing are all used to determine if a person qualifies for Medicare benefits.
A number of neurological disorders may qualify for disability coverage based on their overall severity and the limitations they place on a person’s ability to work. Some examples of covered disability conditions include:
- Amyotrophic lateral sclerosis
- Persistent vegetable state
- Early-onset Alzheimer’s disease
- Huntington’s disease
- Parkinsonian syndrome
- Myasthenia gravis
The severity of the symptoms, along with the likelihood that they will be long-term, are key factors here. Co-occurring mental health disorders may also be a consideration.
Special Senses and Speech
There are some conditions that relate to the senses, including blindness and visual disorders. The Social Security Administration advises on these individually based on the level and complexity of the situation. Things like visual acuity and visual fields are often used to better demonstrate a person’s ability to see and function.
Some endocrine disorders may qualify for disability benefits depending on their impact on a person’s ability to work. Most often, these are conditions that create severe hormonal imbalances due to endocrine gland malfunction. Some conditions that may fall into this area include:
- Pituitary gland disorders
- Thyroid gland disorders
- Parathyroid gland disorders
- Adrenal gland disorders
- Diabetes mellitus
- Pancreatic gland disorders
- Diabetic ketoacidosis
- Chronic hyperglycemia
The severity and the person’s ability to respond to treatment may play a role in whether they can receive benefits for these conditions.
Skin disorders that impact a person’s ability to function and meet their needs could fall under disability qualification guidelines. Some examples may include the following:
- Bullous diseases
- Chronic infections
- Genetic photosensitivity disorders
Diagnosis and testing are often requirements for obtaining this type of coverage. The severity of the disorders is often a big factor in determining if a person qualifies for benefits.
Immune System Disorders
Conditions that impact the immune system that makes work impossible or unsafe are considered as well. This includes:
- Dysfunctions of antibody production, including impaired cell-mediated immunity or complement deficiency
- Recurrent or unusual infections and inflammation-causing conditions
- Autoimmune disorders
- Immune deficiency disorders
The details of these conditions are important. If the condition makes it unsafe for a person to work, then coverage may be provided.
The Social Security Administration will evaluate all types of cancer to determine if the condition warrants coverage. Factors that play a role in this decision include the origin of the cancer, how involved it is, how long it has been present, and the effects on a person after therapy is provided.
Mental Health Disorders
Some mental health disorders may qualify for coverage through Medicare. However, this is dependent on the severity and symptoms of the condition. Some people with a diagnosis of the following conditions may qualify:
- Schizophrenia spectrum
- Psychotic disorders
- Bipolar and related disorders
- Neurocognitive disorders
- Depressive disorders
- Anxiety disorders
- Obsessive-compulsive disorders
- Somatic symptoms
- Intellectual disorders
- Neurodevelopmental disorders
- Trauma and stressor-related disorders
- Autism spectrum disorders
- Eating disorders
Diagnosis is often not enough. Treatment information and the response to medication and treatment are also considered.
What Are the Steps to Qualify for Medicare Benefits to Get Started?
If you believe you have a condition that provides you with Medicare eligibility, the next step is to apply for Social Security Disability benefits. Here’s what to expect from this process if you are under the age of 65.
The Social Security Administration considered your condition. People with disabilities must first apply here to obtain any care. The agency then approves your disability as one that is covered.
You start to receive Social Security Disability Insurance payments after five months of having received the determination of your disability qualification.
You will then wait 24 more months until you reach Medicare eligibility under age 65.
What If You Apply and Are Denied Coverage?
There are some situations in which a person may not qualify for disability benefits right away. For example, you may not have proven to the Social Security Administration that you meet the requirement to be considered for this coverage. In that case, you can reapply with more information or documentation.
If you then meet eligibility requirements and are qualified disabled, you can then backdate your application to the first month you would have received SSDI. That would allow you to begin waiting for the 24 months necessary to reach Medicare eligibility. You may also receive compensation for that length of time.
Keep in mind that through this time you must be unable to maintain substantial gainful activity, meaning you cannot work. If you are able to go back to work, some younger Medicare beneficiaries may no longer qualify for health care services.
Does This Mean Health Care Services Are Free?
No. When you qualify for Medicare coverage that means you qualify. It does not mean that your health insurance is free to you. There are a few things to understand when it comes to being under age 65 and having a disability.
First, healthcare services do become available to you as Medicare beneficiaries under age 65. The health insurance program you select, though, may be a bit different.
Here is a look at Medicare costs and what you can expect.
Medicare beneficiaries receive Original Medicare coverage right away. This is the same for those over age 65 as it is for those under the age of 65. If you have a disabling impairment, you may expect to have access to the very best level of care. That is not always the case, even with chronic conditions. Parts A and B are the components of Original Medicare.
Medicare Supplement policies, called Medigap policies, are often necessary. These allow you to get more of the coverage you need to meet your ongoing health needs and goals. Your monthly Part B premium, for example, may not provide you with the full coverage you need, including prescription drug coverage. You can purchase Medicare Advantage Plans to replace Original Medicare, or you can choose to cover more of your medical costs through Medigap plans which extend your coverage further, providing gap coverage.
Medigap policies are expansive for disabled Medicare beneficiaries under 65. They tend to provide more options for those who need a Medigap policy and who qualify for Medicare early.
Also known as hospital insurance, you do not pay any premiums for this type of coverage. It covers the inpatient care you need, such as being admitted to the hospital. Hospital insurance covers the care you receive only in a medical facility like this. You will have a deductible to pay, which renews each year, and you may have to pay coinsurance costs at a specific rate if you are in the hospital for 61 to 90 days per calendar year.
Medicare Part B is a bit different. It covers your preventative care, such as going to your doctor for checkups. You pay a Medicare Part B premium each month. This typically is deducted from the SSDI payment you receive. In addition, there is a deductible to pay, though it is lower than that for hospital stays. You also have coinsurance to pay, which can be 20% of the medical costs you pay. If you have a Medigap plan, this may help to cover some of these added costs.
Also known as Medicare Advantage Plan is designed to be a separate option that replaces the need for Original Medicare. If you are eligible for Medicare and need more coverage, you can choose to use these private insurance companies to cover your costs. Medicare Advantage Plans vary widely in what they cover. You will need to compare several options to determine which is best for you. Medicare Advantage Plans are available to those who are disabled and are called SNPs.
Medicare Part C Medicare Advantage Special Needs Plans
Medicare SNPS will vary based on the plan. These are designed for those who have special medical needs and qualify for early Medicare access prior to age 65. Costs vary significantly but tend to be more affordable than others.
Medicare Supplement Plans
Also known as a Medigap plan, this coverage is higher than what you can expect to pay for Original Medicare as a disabled individual. Both the deductible you pay and the coinsurance responsibility will differ between plans.
Medicare Part D is often a necessary component. It does not pay for medical services but rather prescription drug coverage. As a result, it tends to be very important for many people. There is a monthly premium for these though it tends to be more affordable than other health insurance plans.
Understanding Medicare Special Needs Plans
While Medicare is the same for those under and over the age of 65, the specific type of coverage you have under age 65 is called a Special Needs Plan. These are beneficial because they help to coordinate care for people who have disabilities a bit better than what other coverage options offer.
There are several types of SNPs, including one that is designed for people who have chronic conditions. If you have the qualifying conditions for SSDI, then this is the type of coverage you are likely to need. When comparing policies and coverage options, then, you need to be sure you are looking specifically at this type of qualification and plan.
What about ALS?
Those who have Amyotrophic Lateral Sclerosis (ALS), which is also known as Lou Gehrig’s disease, do not have to wait to obtain Medicare. They are automatically enrolled in Original Medicare, Parts A and B at the time of diagnosis. There is no waiting period for SSDI or Medicare benefits.
What about End-Stage Renal Disease ESRD?
If you have been diagnosed with ESRD or permanent kidney failure, and you need either ongoing dialysis or a kidney transplant, you do not have to wait to obtain the benefits from Medicare. You qualify right away, but there is no automatic enrollment here.
Instead, you will need to sign up for coverage. Your benefits start based on your condition. For example, for those who need a kidney transplant, the coverage starts the month you go in for surgery. If you are receiving dialysis, your coverage will begin on the first day following your fourth full month of dialysis treatments.
Also, note that you do not always continue to qualify for Medicare with ESDR. Rather, if you have a transplant or your condition improves, you may no longer receive coverage. This typically occurs 12 months after you stop receiving dialysis treatment.
Is a Medigap Policy Right for You?
As noted, you have the ability to choose either Medicare Advantage Plans or Original Medicare. If you go with Original Medicare, you could use Medigap for coverage gaps. In some states, Medigap is not even available to those under age 65. In other states, these policies are very expensive and may not be enough to cover their needs. For that reason, it may be best to consider options with Medicare Advantage plans instead.
What Happens When You Go Back to Work?
There are some situations in which a person may go back to work. Their condition improves, or they receive a transplant. In these cases, if you are under 65, Medicare will evaluate your health and symptoms to determine if you can go back to work.
If you lose SSDI because you go back to work, you’ll need to consider a few additional factors. Medicare put in place a new law in October of 2000 that allows a person that has been receiving SSDI benefits to go back to work but continue to maintain their Medicare benefits for as long as 8 ½ years.
A Trial Work Period allows you to go back to work to see if you can handle doing so with your condition. During the first 9 months of that time, in a rolling 5 year period, you can continue to receive your Medicare benefits. During this time, your SSDI continues as well, no matter how much you earn. You will have to let Social Security know that you are doing this.
Once your Trial Work Period ends, that is when your Extended Period of Medicare Coverage begins. This is also called the continuation of Medicare Coverage. It allows most Medicare beneficiaries who have not improved medically to continue to receive coverage for up to 93 additional months, even if you are no longer getting SSDI payments.
Finding Coverage That Fits Your Needs
Medicare coverage for those who are disabled is often very valuable and may be critical to ensuring you get the health care you need. Working with a team to help you to select the best policy for your needs is critical. That can help you to keep your costs down while also helping to ensure you are getting the coverage necessary to maintain your health even if you have a disability. Don’t overlook the value and importance of a well-designed policy that meets all of your needs.