Medicare for People With Disabilities
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Medicare isn’t just for people age 65 and older. According to the Centers for Medicare & Medicaid Services, nearly 8 million people with disabilities also have Medicare benefits as of April 2022 — that’s just shy of 1 in every 8 Medicare beneficiaries.
Most people with disabilities need to qualify for Social Security Disability Insurance, or SSDI, to become eligible for Medicare before age 65. People with SSDI typically have a two-year waiting period before they can get Medicare coverage.
Here’s what you should know about how people with disabilities can qualify for Medicare, and how Medicare coverage works for people under age 65.
Do you automatically get Medicare with Social Security disability?
No. SSDI can qualify you for Medicare, but there are conditions. Once you have SSDI, there’s a two-year waiting period before you can get Medicare (unless you qualify for certain exceptions).
You’ll need to meet requirements for both your condition and your work history to qualify for SSDI.
The Social Security Administration administers two income assistance programs for people with disabilities: Social Security Disability Insurance, or SSDI, and Supplemental Security Income, or SSI.
While they have similar names and purposes, the two programs don’t work the same when it comes to Medicare. SSDI can qualify you for Medicare under age 65, while SSI can qualify you for Medicaid, instead.
What disabilities qualify for Medicare under 65?
Not all disabilities or conditions qualify for SSDI benefits. The Social Security Administration, or SSA, refers to its own definition of disability for SSDI as “strict.”
To qualify for SSDI benefits, all of these must be true according to the SSA:
You can’t work or do other “substantial gainful activity” because of a medical condition.
You can’t do work you’ve done in the past or adjust to other work because of the condition.
Your medical condition has lasted at least one year, is expected to last at least one year or is expected to result in death.
Social Security work credits
You need a certain amount of work history to qualify for SSDI. You qualify through Social Security work credits — the same system used for Social Security retirement benefits.
You can earn up to four credits per year of work. In 2022, you earn one credit for every $1,510 in earned wages or income from self-employment, so you earn all four for the year with $6,040.
Most SSDI applicants need 40 Social Security work credits to qualify. If you earn all four each year, that would require 10 years of work history. At least some work needs to be recent, however: You need to have earned 20 work credits in the 10-year period that ended the year your disability started.
If you’re under age 31, you can qualify for SSDI with fewer work credits.
There’s often a two-year waiting period for Medicare
If you’re under age 65 and receive SSDI, there’s generally a 24-month waiting period before you become eligible for Medicare.
During that 24-month period, you might be able to qualify for other health care assistance, including:
Medicaid: In many states, you can qualify for Medicaid if you receive either SSDI or Supplemental Security Income, or SSI. Each state administers its own Medicaid program, so you’ll need to check your state’s rules to see how to qualify.
Marketplace coverage: You can look for coverage from a private insurance company in the health insurance marketplace. Depending on your income, you might qualify for reduced-cost coverage — but note that your SSDI income counts toward those limits.
People with certain conditions don’t have to wait 24 months
If you have certain conditions, the 24-month waiting period for Medicare doesn’t apply.
End-stage renal disease
If you have end-stage renal disease, or ESRD, you can generally get Medicare starting on the first day of your fourth month of dialysis treatments — if you meet certain conditions related to Social Security benefits and your health. You may also be able to qualify for Medicare coverage sooner if you undergo training for home dialysis.
If you’re getting a kidney transplant, your Medicare coverage starts the month you’re admitted to a Medicare-certified hospital for the transplant or related services before the transplant. However, this coverage is limited to two months before your transplant. If the transplant is scheduled for a later date or gets delayed, you qualify for Medicare coverage starting two months before the new date.
Lou Gehrig’s disease, or amyotrophic lateral sclerosis
If you receive SSDI benefits because you have Lou Gehrig’s disease, or ALS, then you qualify for Medicare the first month you get your disability benefits.
Medicare enrollment considerations for people with disabilities
When to sign up for benefits
Just like beneficiaries who qualify for Medicare based on age, you enter an initial enrollment period when you become eligible due to disability. This period is when you choose what kind of Medicare coverage to get.
The initial enrollment period begins before your 24-month waiting period is over. It starts the 22nd month you have SSDI benefits and lasts for seven months.
What kinds of Medicare plans are available?
You automatically get Original Medicare if you qualify based on disability. Original Medicare includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). However, you’re not required to stick with Original Medicare.
You’ll need to sign up if you want to add or switch to one or more of these options:
Medicare Advantage, also called Medicare Part C, plans.
Medicare Part D prescription drug plans.
Medicare Supplement Insurance, or Medigap.
Only Medicare Part A is free
Medicare Part A comes at no cost for those receiving SSDI benefits. Part B is technically voluntary, so you’ll have to pay premiums unless you opt out and delay Part B coverage.
You’ll also have to pay premiums if you sign up for a Medicare Advantage plan, Medicare Part D prescription drug plan or Medicare Supplement Insurance.
You may not be able to buy Medicare Supplement Insurance
If you have Original Medicare (Part A and Part B), you may want to buy Medicare Supplement Insurance, or Medigap, to cover some of your out-of-pocket expenses. However, insurance companies might not be willing to sell a Medigap policy to you if you’re under age 65.
Your state’s laws might determine which Medigap policies — if any — are available to you, if you qualify for Medicare for reasons other than age:
In about a third of states, there’s no law on the books requiring companies to sell Medigap to beneficiaries under age 65.
The other two-thirds of states do require companies to sell at least one kind of Medigap policy to certain Medicare beneficiaries under age 65. However, the specifics vary. Not all beneficiaries may qualify, and not all policy types may be required.
Insurance companies can still choose to sell you a Medigap policy in states where it’s not mandatory, so it may be worth looking to see what’s available in your area.
Medicare Special Needs Plans
You may qualify to buy a special kind of Medicare Advantage plan called a special needs plan, or SNP. SNPs offer benefits tailored to specific groups’ unique needs for care.
There are three types of SNPs:
Chronic Condition SNPs are available to beneficiaries with certain severe chronic conditions.
Institutional SNPs are available to beneficiaries who need the kinds of care offered by certain facilities, or who will live for at least 90 days straight in certain facilities.
Dual-Eligible SNPs, or D-SNPs, are available to beneficiaries who are eligible for both Medicare and Medicaid to coordinate benefits between the two programs.
You can find information on the kinds of plans available in your area, their benefits and membership requirements at medicare.gov/plan-compare.
You get another initial enrollment period when you turn 65
You’ll have another opportunity to make coverage decisions when you qualify for Medicare based on age. Even if you already had Medicare, you get another seven-month initial enrollment period around your 65th birthday. That period starts three months before the month you turn 65, includes your birthday month, and ends three months after the month you turn 65.
