Getting Medicare Disability Coverage When You Are Not Yet 65

Medicare is the federal health insurance program for older adults and people with disabilities, including certain chronic conditions. According to the Center for Medicare Advocacy, more than 65 million individuals participate in the program.

Disability and Medicare

The age to qualify for Medicare is 65. Although most Medicare enrollees are 65 and older, many younger people with long-term disabilities also receive Medicare. Roughly 12 percent of Medicare recipients are eligible because of their disability rather than age, per the Kaiser Family Foundation.

People with a disability who enroll in Medicare receive the same full range of benefits as those who are eligible because of their age. They may choose basic coverage through traditional Medicare Parts A and B or opt for additional benefits through Part D or Medicare Advantage.

Traditional Medicare has several components. Medicare Part A covers inpatient hospital care, skilled nursing, and home health care. Part B covers outpatient services. Individuals with disabilities can also enroll in Part D, prescription drug coverage.

Medicare Advantage plans, known as Medicare Part C, are an alternative to traditional Medicare. Private companies contract with Medicare to create these plans. They can offer additional benefits, such as vision, hearing, and dental services. The Social Security Administration (SSA) deducts Medicare premiums from your monthly SSDI payments.

For younger SSDI recipients, there is one major downside when it comes to seeking Medicare disability coverage. They must wait out a period of 24 months before they can apply for Medicare. Estimates state that about 1.6 million Americans are in the midst of the waiting period.

Congress has removed the waiting period for just two specific health conditions. For example, patients with amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease, can immediately receive Medicare benefits upon qualifying for SSDI.

What Disabilities Qualify for Medicare Under 65?

When individuals experience disabilities that prevent them from working, they can obtain Social Security Disability Insurance (SSDI). SSDI provides monthly income to disabled workers and their families.

People under 65 who qualify for Social Security disability benefits can, in turn, receive Medicare benefits. However, they typically can do so only after a waiting period. Two years after receiving approval for SSDI benefits, they can seek Medicare disability coverage. Medicare eligibility involves earning enough work credits and having a disability that meets the SSA’s definition.

The SSA has a strict definition for what meets the criteria of a disability. It defines disability as being unable to perform substantial gainful activity because of a medically determinable physical or mental impairment. The impairment must be severe enough to prevent someone from doing the work they used to do or adjusting to new work. The disability must last for a year or more or be terminal.

The SSA maintains a list of impairments it uses in evaluating disability claims. If a condition is not on the list, it must be as severe as a listed one.

The SSA recognizes 14 categories of conditions, which include the following:

• Disorders affecting the bones, joints, and muscles, such as amputation, chronic joint pain, and spinal disorders
• Sense and speech conditions, such as blindness, deafness, and speech impairments
• Illnesses hindering respiration, including asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis
• Heart diseases, such as arrhythmia, congenital heart disease, and heart failure
• Problems with the digestive system
• Kidney disease
• Blood disorders, including sickle cell disease and bone marrow failure
• Skin conditions like burns and ichthyosis
• Endocrine disorders, including diabetes and thyroid problems
• Congenital disorders affecting multiple body systems, like Down syndrome
• Nervous system disorders like ALS, epilepsy, multiple sclerosis, Parkinson’s disease, and traumatic brain injuries Parkinson’s
• Mental and cognitive illnesses, including bipolar disorder and depression, as well as dementia
• Cancer
• Diseases of the immune system, including HIV, lupus, and rheumatoid arthritis

The Two-Year Waiting Period

Again, most SSDI applicants under 65 do not automatically receive Medicare coverage. Once they have received approval for SSDI benefits, they typically must then wait 24 months before they can enroll in Medicare.

Congress enacted this waiting period in the early 1970s. At the time, the idea behind implementing it was to keep costs down. Today, this two-year wait has proven detrimental for many.

During this time, workers experiencing a disability may be able to get health insurance through a previous employer. Others may seek private coverage. Costs for this type of coverage, however, can prove far too steep for many. Some people who are living on a limited income may be able to qualify for other health insurance through Medicaid.

However, many people end up having to remain uninsured during these two years. Unfortunately, some people do not survive the waiting period. Others cannot afford their incredibly high medication costs or other medical expenses.

Lawmakers and disability advocates have long sought to shorten or eliminate this wait. Regardless, bipartisan bills proposed as recently as 2023 have not yet managed to come to a vote.

As mentioned above, benefits start sooner for those with certain conditions. People with ALS receive benefits immediately upon qualifying for SSDI. Coverage also goes into effect for those with end-stage renal disease (ESRD) following a kidney transplant or after several months of dialysis treatment.

Speak to a Special Needs Planning Attorney

If you have a disability that prevents you from working, you may be able to receive Medicare coverage through SSDI. Consider consulting a qualified special needs planner in your area for assistance in applying for benefits. An attorney can help you understand the rules governing disability benefits and Medicare.

Additional Reading

Only a small percentage of SSDI applicants receive approval for benefits. To learn more about how to improve your chances of securing these benefits, check out the following articles:

• What You Need to Know Before Applying for SSDI
• 5 Reasons Why Your SSDI Claim May Be Facing a Denial