Do I Qualify for Medicare with a Disability?

Dani Milton
November 3, 2020

Throughout the world, millions of people live with chronic disabilities. In the United States, almost 61 million American adults have a disability, according to the Centers for Disease Control and Prevention. A study released by the agency found that many of these individuals face barriers to healthcare access. The CDC discovered that many disabilities (ages 18-44 years old) experienced the following healthcare issues:

One in three people with disabilities didn't have a regular healthcare provider.

One in three Americans with disabilities has an unmet healthcare need because of cost in the previous year.

One in four didn't get a routine check-up in the past year.

Some Americans with disabilities may be able to access health care through Medicare. The program doesn't just ensure retirees; it also provides insurance for younger people with disabilities. If you're a person living with a disability, you'll find out how Medicare can help you access health care.

What Is Medicare?

Medicare is health insurance coverage for Americans ages 65 years and older. The government also allows younger people with disabilities to enroll in the program. Individuals with End-Stage Renal Disease (a permanent kidney failure treated with dialysis or a transplant) can also sign up as can some individuals with severe mental health issues. Others who qualify for Medicare disability coverage are individuals with Amyotrophic Lateral Sclerosis (also called Lou Gehrig’s Disease). Most beneficiaries will receive Original Medicare (Parts A and B).

Medicare Part A is hospital insurance, which most people don’t usually have to pay premiums to receive. It helps pay for inpatient care in a hospital or a limited stay at a skilled nursing facility following hospital care. It also pays for some hospice care, home health care, and non-custodial nursing home care.

Medicare Part B, or medical insurance, covers medically necessary services or supplies that help diagnose and treat health conditions. It pays for services that individuals receive from doctors, outpatient facilities and home health care providers. This insurance also covers durable medical equipment and preventive services. Most Medicare recipients must pay shared costs (coinsurance, copayments, or deductibles) to receive this coverage.

Private insurance companies oversee the following parts of Medicare. They must abide by regulations established by the federal government.

Medicare Advantage Plans were previously known as Part C. This coverage includes the services and benefits provided by Part A and Part B. It also pays for prescription drugs. These plans also cover other benefits such as vision, hearing, and dental, which are bundled together.

Medicare Part D is Medicare prescription drug coverage. – This part provides prescription drug coverage.

Supplemental (Medigap) Policies help pay for Medicare out-of-pocket copayments, coinsurance, and deductible expenses.

Which Disabilities Qualify for Medicare Coverage?

Applicants must establish that they suffer from long-term disabilities or chronic health conditions that prevent them from working. According to the Social Security Administration (SSA), an individual must meet the following requirements before their agency qualifies them as disabled.

  • A person must be unable to perform substantial work because of a medical condition.
  • Your medical condition must last (or expected to last) at least one year or more.
  • Doctors believe that your medical condition could end your life.

Those who qualify for Social Security Disability Insurance (SSDI) and Medicare include:

  • Adults and children who have had congenital disabilities
  • People who have disabling conditions they acquired through illness, trauma, or injuries.
  • Long-term physical conditions (quadriplegia, traumatic brain injuries, etc;)
  • Intellectual or developmental disabilities (cerebral palsy, autism, Down syndrome, and other illnesses)
  • Serious behavioral disorders or mental illnesses (schizophrenia or bipolar disorder)
  • Cognitive Disorders (Dementia, Alzheimer’s Disease).

Applicants with Certain Conditions May Be Unfairly Denied SSDI and Medicare

Some Americans with mental illnesses and cognitive conditions have a higher risk of being denied Social Security Disability Insurance and access to Medicare. These individuals ask their physician for an order that verifies their mental or medical status. Those who should seek these orders may include people with:

  • Alzheimer’s Disease
  • Mental Illness (depression, anxiety, etc.)
  • Multiple Sclerosis
  • Parkinson’s Disease

Individuals Must Receive SSDI Payments to Qualify for Medicare

The federal government says people with disabilities must receive monthly Social Security Disability Insurance (SSDI) or Railroad Retirement Board (RRB) benefits before they qualify for Medicare payments. When a person qualifies for SSDI, the federal government automatically enrolls them into Original Medicare (Parts A and B) after a waiting period. Most people have to work enough qualifying hours at a job to receive these payments, or they should be married to a spouse who has.

How to Apply for SSDI Benefits

To be eligible for disability benefits, a person must be unable to engage in substantial gainful activity (SGA). A person who is earning more than a certain monthly amount (net of impairment-related work expenses) is considered to be engaging in this activity.

These SGA monthly earnings depend on the nature of the person’s disability. The Social Security Act specifies a higher amount for statutorily blind individuals ($2110 in 2020) and a lower one for non-blind people ($1260 in 2020). Amounts change depending on the fluctuations in the national average wage index.

Applicants can apply for Social Security Disability Insurance online. To apply for benefits: Print and review the Adult Disability Checklist provided by the Social Security Administration. It will help you get the information you’ll need to complete your application.

Complete your Disability Benefits Application.

Fill out a Medical Release Form.

Waiting Period for Social Security Disability Insurance and Medicare Benefits

Generally, applicants wait for five months before they can collect Social Security Disability Insurance benefits, while the Social Security Administration (SSA) assesses their disability status. Even after the federal agency green lights a person's SSDI application, the waiting period to receive Medicare benefits is a long process. SSDI recipients must complete a 24-months qualifying period. The first two years of disability benefit entitlement serve as the official waiting period for Medicare coverage. The SSA counts one month for each month of disability benefit entitlement.

Can Previous Months of Disability Count toward your Medicare Qualifying Period?

The SSA will sometimes allow months in previous periods of disability to count toward the 24-month Medicare qualifying period if the new one starts:

Within 60 months after the termination month of the workers receiving disability benefits

Within 84 months after the termination of disabled widows or widowers benefits or childhood disability; or

At any time when the current impairment that caused the disability is the same (or related to) the impairment, which was the basis for the previous disability benefit entitlement period.

Individuals who meet the standards, but don’t qualify for Social Security benefits can purchase Medicare by paying a monthly Part A premium, in addition to the monthly Part B premium.

People with ESRD and ALS Have Shorter Medicare Qualifying Periods

Unlike other persons with disabilities who receive Social Security Disability Insurance payments, individuals with End-Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS) don’t have to wait 24 months before they qualify for Medicare. Eligibility requirements for people with ESRD and ALS are:

ESRD: Three months after their regular dialysis course begins or following their kidney transplant.

ALS: Eligibility begins after the person starts receiving Social Security Disability Insurance benefits.

Can People with Disabilities Return to Work and Keep their Medicare Coverage?

Are you a Medicare recipient under 65 years old? You can keep your coverage as long as you have a medical disability. When you return to work, you won’t have to pay your Part A premium for the first 8 ½ years. After this period ends, you’ll need to pay the premium. If you can’t afford this payment, you may apply for the Medicare Savings Program, also known as the Qualified Medicare Beneficiary (QMB) Program. This state program helps pay for Part A premiums and Part B premiums. It also covers other cost-sharing (such as deductibles, coinsurance, and copayments) for individuals who have Part A and have limited income and resources.

The federal government has established a specific schedule for employed Medicare-eligible recipients who have disabilities. There are three coverage timelines:

Trial Work Period – This time lasts nine months for once a person with disabilities enters the workforce.

Ninety-Three Month Period – This period last 93 months after the trial month period. During this time, a person with disabilities can keep their premium-free Medicare coverage.

Indefinite Period – This time begins after the 93-month period. Workers lose their premium-free Medicare coverage and begin paying monthly premiums for this insurance.

For more information, review statute 42 U.S.C. § 422© and read regulation 20 C.F.R. § 404.1593).

Medicare’s Trial Work Period

The federal government has established a trial work period for Medicare beneficiaries. During this time, people who receive SSDI benefits can test their ability to work and still be considered disabled.

The Social Security Administration doesn’t consider jobs performed during the trial work period as proof that a person’s disability has ended. They must stay employed for at least nine months. This session doesn't have to be consecutive: it can extend throughout 60 months. In 2019, when a person’s gross earnings exceed $880 for 30 days, it qualifies as one month of services during the individual's trial work period. In 2020, this amount has increased to $910 during a one-month timeframe.

A person who receives SSDI benefits can continue receiving Medicare and Social Security Income during the maximum nine-month trial work period during any rolling five-year time frame (60 months). They must meet federal requirements to qualify for this period.

The 93-Month Work Period

Under federal law, Medicare beneficiaries can get at least 93 months of hospital and medical insurance once their trial work period ceases as long as they have a disabling impairment. Under this statute, the person’s health insurance may continue once he or she goes to work and engages in substantial gainful activity (SGA).

The SSA doesn’t require Medicare recipients with disabilities to pay premiums for hospital insurance during the 93-Month Work Period. Even if their cash SSDI benefits end, they can continue to receive health insurance once the premium-free Medicare coverage ends due to work.

As long as your disabling condition meets federal guidelines, you can keep your Medicare coverage for at least 8 ½ years after you return to work (this 8 ½ year period includes your nine-month trial work period). You will also get to keep your Medicare hospital insurance (Part A) and medical insurance (Part B) coverage.

If your SSDI cash benefits stop due to your work, you or a third party (if applicable), will be billed every three months for your medical insurance premiums. If you’re still receiving cash benefits, they will deduct your medical insurance from your check.

Indefinite Period Following the 93-Month Work Period

Beneficiaries can purchase Medicare hospital and medical insurance if they continue to have a disability at the end of the period.

People with disabilities are eligible to buy Medicare coverage if they are:

Younger than 65 years old

Have an impairment which causes a disability

Their Medicare coverage ceased due to work

What Type of Medicare Insurance Can Beneficiaries Purchase?

Individuals can purchase Premium Hospital Insurance (Part A) at the same monthly rate, which uninsured eligible retired beneficiaries pay. It is $437.00 per month for 2019 or $240 if the beneficiary has earned 30 quarters of coverage.

Additionally, the person can purchase Premium Supplemental Medical Insurance (Part B) at the same monthly premium, which uninsured eligible retired beneficiaries pay. It is $135.00 per month for 2019. The beneficiary can also buy Hospital Insurance separately without Supplemental Medical insurance. They can also buy Supplemental Medical Insurance only if they purchase Hospital Insurance.

How Can a Beneficiary Enroll?

Beneficiaries who are paying for Medicare premiums have several opportunities to enroll in the Medicare program.

During the initial enrollment period. It is the month that the government notifies the beneficiary about the end of their premium-free health insurance and the following seven months.

During the annual general enrollment period (January 1 through March 31 of each year),

During a special enrollment period if a beneficiary has enrolled in an employer group health plan.

Some individuals with low income and limited resources may qualify for State assistance with their expenses. For details, read Qualified Disability for Working Individuals.

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