Medicare Disability Coverage for Those Under 65

Medicare isn't available to most people until age 65, but if you have a long-term disability or have been diagnosed with certain diseases, Medicare is available at any age.

According to Kaiser Family Foundation data, 14% of all Medicare beneficiaries are under age 65. As of April 2021, 63.3 million Americans were enrolled in Medicare. So roughly 9 million of those beneficiaries are under age 65 and eligible for Medicare because of a disability, as opposed to age.

Long-Term Disability and SSDI

If you can establish that you have a long-term disability that prevents you from working, you may qualify for monthly Social Security Disability Insurance (SSDI) payments, which will also automatically qualify you for Medicare.

However, getting approved for SSDI can be a long process, and even after you're approved, you'll have to wait 24 months before your Medicare benefits begin (with exceptions for end-stage renal disease and amyotrophic lateral sclerosis, described in more detail below).

You can apply for Social Security disability benefits online, over the phone, or at a local Social Security office. To be eligible, you must have worked enough hours to qualify for Social Security benefits, or be the spouse or a dependent of someone who has.

Definition of a Disability

The Social Security Administration (SSA) has a very strict definition of disability. To be considered disabled:

• You must be unable to do any substantial work because of your medical condition(s)
• AND your medical condition(s) must have lasted or be expected to last at least one year, or be expected to result in your death

According to the law, your SSDI payments cannot start until you have been disabled for at least five full months. Your payment will usually start with your sixth month of disability, although a recent change in the law expedited this process for people with ALS.

Speeding Up an SSDI Application

Your application for SSDI is likely to move more quickly if you select one healthcare provider as the lead contact for your case. It's best to go with one who:

• Has experience with disability cases
• Responds promptly to requests for information
• Is familiar with your overall health situation

It's also a good idea to keep a detailed log of your everyday activities and experiences.

For example, document any difficulties you have with mobility or side-effects you are experiencing from medications. This will help when you have your interview with a Social Security representative. The interview may take place on the phone or in person at your local Social Security office.

The SSA website provides an easy-to-use Disability Starter Kit that includes FAQs, a checklist, and a worksheet to help you get ready for your interview. You can save time during your interview if you fill out the needed applications online before your appointment.

According to the SSA, most applications are processed within three to five months.

Medicare Eligibility

When you become eligible for Medicare, you'll be able to enroll in both Medicare Part A—hospital coverage—and Medicare Part B—healthcare provider and outpatient services. You'll get Medicare cards in the mail three months before your 25th month of disability.

If you don't want Medicare Part B, you can send back the card. If you keep the card, you'll keep Part B and will pay Part B premiums. In 2021, the Part B premium is $148.50 per month for most enrollees.

You'll also be eligible to join a Medicare Part D prescription drug plan. You can join a Part D plan within the three months before or after your 25th month of disability.

You can opt instead for a Medicare Advantage plan. Prior to 2021, those weren't available to those with kidney failure/end-stage renal disease (ESRD), but the law now requires Advantage plans to accept any Medicare beneficiary, including those with ESRD.

An Advantage plan will wrap the Part A and Part B benefits into one plan, and most of them also include Part D coverage.

Medigap Coverage

Federal law does not require private insurers to sell Medigap insurance to Medicare beneficiaries who are under age 65. Medigap, also known as Medicare Supplemental coverage, pays for out-of-pocket expenses that an Original Medicare beneficiary (i.e., those who don't have Medicare Advantage) would otherwise have to pay themselves.

However, about two-thirds of U.S. states have their own rules for Medigap insurers, requiring them to offer Medigap coverage to Medicare beneficiaries under age 65.

In many of these states, however, the insurers are only required to offer one plan to disabled Medicare beneficiaries or can charge much higher premiums for those below the age of 65.

Some of the state rules protecting access to Medigap coverage for disabled beneficiaries don't apply to people with ESRD.

ALS and ESRD Exceptions

If you're younger than 65 and have amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), you'll automatically get Medicare Part A and Part B the month your disability benefits begin.

There used to be a five-month waiting period between diagnosis with ALS and the start of disability benefits. But legislation (S.578) that was enacted in late 2020 eliminated that waiting period. This means that disability benefits—and Medicare coverage—can begin as soon as a person is diagnosed with ALS.

If you're undergoing dialysis for ESRD, your Medicare coverage usually starts the first day of the fourth month of dialysis treatments.

However, if you go through training for a home dialysis program and your healthcare provider thinks you'll be able to do your own dialysis at home, coverage can start as early as the first month of dialysis.

Depending on where you live, you may be able to join a Medicare Special Needs Plan for people with ESRD, if there's one in your area.

Coordination of Coverage With ESRD

If you have employer-sponsored or union-sponsored insurance and you become eligible for Medicare due to ESRD, Medicare will coordinate with your existing coverage for 30 months.

During that time, your private insurance will be your primary coverage, and Medicare will pick up a portion of the remaining costs. After those 30 months, if you still have coverage under your group health plan, it will become secondary coverage and Medicare will become primary.