Disability Requirements for Medicare

Not Every Disability Will Qualify You

Not everyone who is eligible for Medicare is 65 years and older. While senior citizens tend to have increased medical needs, the federal government recognizes that there are a significant number of younger individuals who also have serious health problems. People with disabilities factor into this equation.

A man with a disability sitting in his wheelchair

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The question is: What counts as a disability for the purposes of Medicare eligibility?

Defining Disability

When someone breaks his leg, he may be put in a cast and given medical advice not to bear weight on the leg. Is he disabled? Perhaps in the short-term but with an expected recovery only weeks away, it can be a hard argument to make for the long haul. For the purposes of Social Security Disability Insurance, impairments must last at least more than 12 months in duration.

Definitions of disability can vary from person to person but Medicare guidelines leave no room for interpretation. Someone must be incapacitated for the long term. You will meet disability criteria for Medicare eligibility only if you fall into one of the following three categories.

You have amyotrophic lateral sclerosis (ALS): Also known as Lou Gehrig’s disease, ALS is a debilitating neurologic disease that can lead to muscle atrophy, breathing difficulties and even death. It is estimated that as many as 16,000 Americans have ALS at any one time. The severity and rapid progression of the disease requires a higher level of medical care and services.

You are immediately eligible for Medicare and should apply as soon as possible. There is no waiting period.

You have end-stage renal disease (ESRD): About 15 percent of Americans are estimated to have chronic kidney disease, according to the Centers for Disease Control and Prevention. More than 100,000 people go on to develop kidney failure, also referred to as end-stage renal disease, each year. When your kidneys fail, your body cannot filter toxins out of the body. You will require dialysis treatment or a kidney transplant to stay alive.

Your coverage benefits begin three months after you start dialysis treatment. If you get a kidney transplant, Medicare coverage may not be long term. The program will provide coverage for 36 months after a Medicare-approved transplant. After that, if your new kidney remains functional, you will no longer be eligible for Medicare, and you will lose your coverage.

You receive Social Security Disability Insurance (SSDI) for a disability: A number of other medical conditions can qualify as disabilities. In order to be recognized as Medicare eligible, the person must have gone through the rigorous application process of applying for Social Security Disability Insurance. This process alone can take several months to complete.

It may take three to six months for the Social Security Administration to approve your application. The application process could be expedited if your medical condition is on the list of Compassionate Allowances Conditions.

The approval of your application is followed by a five-month waiting period before you actually receive SSDI benefits.

You are not eligible for Medicare until you have received SSDI benefits for at least 24 months. Adding up all these timelines, you will wait a minimum of 29 months, in the best-case scenario, to as long as 35 months in the worst-case scenario before you actually receive Medicare benefits.

This assures the government that the disability is severe enough to warrant Medicare coverage.

A Word from Verywell

Medicare is not only for senior citizens. Anyone who is disabled due to ALS, end-stage renal disease, or an SSDI-approved disability, regardless of their age, is eligible for Medicare. There may be different waiting periods depending on the disability in question, but it is important to apply as soon as possible to prevent any delays in coverage. Take the necessary steps towards getting the health coverage you need.

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Article Sources
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  1. Social Security. Social security handbook: 602. impairment lasting or expected to last at least 12 months. Updated April 19, 2017.

  2. The ALS Association. What is ALS?

  3. Center for Medicare Advocacy. Medicare coverage for people with disabilities.

  4. Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2019. Updated March 11, 2019.

  5. Social Security. Compassionate allowances conditions.

  6. Social Security. Is there a waiting period for Social Security disability benefits? Updated June 30, 2019.

  7. Social Security. Medicare information.