Medicare and Social Security Disability Benefits

Medicare and Social Security Disability Insurance (SSDI) benefits work together to provide financial and medical assistance to people with disabilities. Medicare is a federal health insurance program for individuals 65 and older and some people with disabilities, irrespective of age. SSDI provides monthly payments from the Social Security Administration (SSA) to people who can't work because of a disability.

A special needs planning attorney can help coordinate your Medicare and Social Security disability benefits effectively. This may include ensuring your Medicare coverage properly aligns with your health care needs and communicating any changes in your disability status or benefits to both programs.

Social Security Disability Insurance (SSDI)

SSDI pays a monthly cash benefit to individuals who have a qualifying disability that prevents them from engaging in substantial gainful activity (SGA).

• To qualify for SSDI, you must have a work history and enough credits earned through Social Security taxes paid on your earnings.
• The waiting period for SSDI payments to begin is five full months after the month the SSA determines your disability began.
• Certain conditions, including cancers, adult brain disorders, and Lou Gehrig's disease, may qualify you for Compassionate Allowance, which will fast-track your application and benefit payments.
• After being an SSDI recipient for two years, an individual becomes eligible for Medicare.

Medicare Eligibility

Although Medicare is a federal health insurance program primarily designed for those aged 65 and older, certain individuals with disabilities are covered if they have received benefits through SSDI for two years.

Medicare has four distinct parts:

Medicare Part A

Part A coverage helps pay for inpatient hospital stays, skilled nursing facility care, hospice care, and limited home health care.

Medicare Part B

Medicare Part B coverage helps cover doctor visits, outpatient care, medical supplies, and preventive services.

Medicare Part C

Medicare Advantage plans that offer alternative ways to receive Medicare benefits through private insurance companies approved by Medicare.

Medicare Part D

Prescription drug coverage through Medicare focuses on covering the costs of most prescription medications.

How the SSDI and Medicare Programs Interact

After receiving Social Security disability benefits for 24 months, individuals are generally eligible for Medicare regardless of age. In the case of Compassionate Allowance, eligibility typically occurs much sooner.

• Medicare becomes the primary health insurance for SSDI recipients. This means it pays first for covered services before other insurance coverage.
• Individuals may still be able to keep other health insurance, such as employer-sponsored coverage, in conjunction with Medicare. This makes Medicare the secondary payer.
• While Medicare covers a range of medical services, it doesn’t cover all costs. Individuals may still have deductibles, copayments, and coinsurance for various services.

What if Your Disability Allows You to Return to Work?

Medicare coverage that links to receiving SSDI benefits will cease if your condition improves to the point that the SSA no longer considers you disabled. SSDI may also end even if you meet the medical criteria for disability, but your income exceeds SGA. The 2024 SGA income limit is $1,550 monthly or $2,590 if you are blind. Earning more than these amounts means you can lose your benefits.

Although you might lose SSDI benefits, you may not lose Medicare coverage because of work incentives the SSA offers to help beneficiaries with disabilities transition back to the workforce. For example, you will lose neither SSDI nor Medicare benefits during a trial work period. The trial work period is an incentive allowing you to earn above the SGA limit for any nine months during a rolling five-year period.

If you work equal to or above the SGA after the trial period, you will lose SSDI benefits. However, you may remain on Medicare and pay no Part A premiums for seven years and nine months (93 consecutive months) as long as you still have a qualifying disability. After such time, you can remain on Medicare but must pay for Part A until you turn 65.

Important Details

Medicare eligibility is not linked to Supplemental Security Income (SSI), a different SSA-administered benefit for those with disabilities and low income. SSI recipients in most states automatically qualify for Medicaid, the federal-state health insurance program for low-income people. SSDI recipients waiting for Medicare to begin can sometimes fill gaps in health care coverage by signing up for Medicaid if they are eligible.

If an employer offers health insurance, you may be able to stay on Medicare as long as you have a medical disability. Depending on your workplace’s size, Medicare may become the secondary payer. In this situation, providers only bill Medicare for the services your work-based insurance doesn’t cover.

A Special Needs Planning Attorney Can Help

Not everyone eligible for Social Security disability benefits is eligible for Medicare, and vice versa. A special needs planning attorney can help you understand the requirements you must meet for both programs and ensure you are applying for the right benefits for your situation. They also help you understand how Medicare and SSDI interact.

Applying for Social Security disability benefits and Medicare can be a complex process. If your initial application for disability benefits is denied or you face challenges, a special needs planner can provide legal representation and guidance. They may be able to assist in filing appeals, gathering necessary documentation, and representing your interest during hearings or appeals processes. With their expertise, you can balance these benefits to your advantage, ensuring you receive the maximum assistance while minimizing potential issues or gaps in coverage.