Medicare Disability Coverage for Those Under 65

A disability and a long wait are required for early Medicare enrollment

Doctor comforting patient in wheelchair

Ariel Skelley / Blend Images / Getty Images

Medicare won't be available to most of us until we turn 65, but for some people—those with long-term disabilities or those who have been diagnosed with specific diseases— Medicare is available at any age.

According to Kaiser Family Foundation data, 15% of all Medicare beneficiaries were under age 65 as of 2016. Given the number of those currently enrolled in Medicare, that amounts to a significant amount. As of 2019, there were 65 million Medicare beneficiaries in the U.S.

Long-Term Disability Medicare Coverage Requires SSDI First

If you can establish that you suffer from 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, it can be a long process and even after you're approved for SSDI, you will have a long waiting period (24 months) before your Medicare benefits begin.

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

Definition of a Disability

The Social Security Administration (SSA) has a very strict definition of disability. To be found disabled, the following must be true:

  • 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.

How to Speed up Your SSDI Application

Your application for SSDI is likely to move more quickly if you select one doctor as the lead contact for your case. It's best to go with the one who has experience with disability cases, responds promptly to requests for information, and 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 representative from Social Security. 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. For most applicants, however, the wait for Medicare benefits is just beginning, even if their application is approved.

Waiting Periods for Medicare Coverage

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. And, if you have been approved for SSDI, you must wait a full two years after that period passes for your Medicare coverage to start. (As described below, there are exceptions for people who have ALS or kidney failure.)

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—physician and outpatient services. You will 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 will keep Part B and will pay Part B premiums (in 2020, the Part B premium is $144.60/month for most enrollees).

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

You can opt instead for a Medicare Advantage plan, unless you have kidney failure/end-stage renal disease (ESRD), in which case most Advantage plans are not required to accept your application; this will change as of 2021, when Advantage plans will be required 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—the type of coverage that pays for appropriate services and out-of-pocket expenses not paid for by Medicare—to people under 65, even if they are disabled.

However, about two-thirds of the U.S. requires insurance companies to sell you a Medigap policy if you have Medicare and you're under age 65, although some limit plan availability or allow insurers to charge much higher premiums when the applicant is under 65. There are also varying rules on Medigap access for people with ESRD.

Medicare Coverage for Lou Gehrig's Disease or End-Stage Renal Failure

If you're younger than 65 and have been diagnosed with amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig's disease, you will automatically get Medicare Part A and Part B the month your disability benefits begin.

If you're undergoing dialysis for ESRD, your Medicare coverage usually starts the first day of the fourth month of dialysis treatments. But if you go through training for a home dialysis program and your doctor expects you to be able to do your own dialysis at home, your Medicare coverage can start as soon as the first month of your dialysis treatment.

Note that Medicare Advantage plans are generally not available to people under 65 who are enrolling in Medicare as a result of ESRD (as mentioned above, this is changing as of 2021), but you may be able to join a Medicare Special Needs Plan for people with ESRD, if there's one in your area.

Coordination With Existing Coverage When You Have 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 the portion of the remaining costs. At the end of the 30 months, assuming you still have coverage under your group health plan, it will become secondary coverage and Medicare will become primary.

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Article Sources
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  1. Kaiser Family Foundation. An overview of Medicare. February 13, 2019.

  2. Kaiser Family Foundation. Medicare Advantage. June 6, 2019.

  3. Social Security Administration. Disability evaluation under Social Security.

  4. Social Security Administration. Adult disability starter kit.

  5. Social Security Administration. What you need to know when you get Social Security disability benefits. July 2019.

  6. Medicare.gov. Part B costs.

  7. Congressional Research Service. Medicare coverage of end-stage renal disease (ESRD). August 16, 2018 

  8. Medicareresources.org. How to choose between Medicare Advantage, Medigap and Part D. December 9, 2019.

  9. Medicare.gov. Getting Medicare if you have a disability.

  10. Medicare.gov. Signing up for Medicare if you have ESRD.

  11. Medicare.gov. Special Needs Plans (SNP).

  12. Centers for Medicare & Medicaid Services. End-stage renal disease (ESRD).