What Disabilities Qualify for Medicare Under 65?
If you’re under 65 but have been diagnosed with certain medical conditions, then you may be eligible for Medicare. If you get disability insurance from Social Security (SSDI), you’ll be automatically enrolled in Part A and Part B after 24 months.
Medicare will mail you a card three months before your coverage starts. However, if you turn 65 before this period, then you’ll be eligible for Medicare when you turn 65.
Knowing how Medicare covers people with disabilities can help you access hospital services, doctor’s visits, and lab tests. It can also help you determine if you require additional coverage, such as prescription drug coverage.
In this article, we’ll explain who qualifies for Medicare under 65. We’ll also look at coverage available to you and ways to get extra support.
Key Takeaways:
You can get Medicare benefits sooner if you have Lou Gehrig’s disease or end-stage renal disease. There’s no 24-month waiting period.
People on Social Security Disability Insurance will be automatically enrolled in Medicare Part A and Part B after 24 months.
Receiving Medicare for disability qualifies you for Original Medicare (Part A and B), Medicare Supplement plans, Part D (prescription drug) plans, and Medicare Advantage plans.
Qualifying disabilities for Medicare under 65
To get Medicare for disability while under 65, you need to receive Social Security Disability Insurance for 24 months first. The Social Security Administration (SSA) has some rules to qualify you for Social Security Disability Insurance (SSDI). This includes a disability that impacts your ability to work for over a year or that will result in death. You also need to have enough work history. Usually, this means that you have worked at least 5 out of the last 10 years.
Physical conditions that typically qualify
To qualify for Medicare under the age of 65 due to disability, a physical condition needs to be diagnosed and documented. This physical condition needs to limit your ability to perform work-related tasks and is long-term (lasting over a year) or terminal. It also needs to impact your ability to perform substantial gainful activity (SGA), meaning the ability to work for profit.
Some physical conditions that typically qualify include:
Musculoskeletal conditions like arthritis or spinal injuries
Cardiovascular diseases like heart failure, arrhythmias, peripheral artery disease, and congenital heart disease
Neurological conditions like epilepsy, multiple sclerosis, and stroke
Respiratory conditions like chronic obstructive pulmonary disease (COPD) and asthma
Digestive disorders like chronic liver disease (CLD) and inflammatory bowel disease (IBD)
Urinary tract conditions like chronic kidney disease
Hematological conditions like sickle cell anemia, thrombosis, and hemostasis
Endocrine disorders like diabetes, thyroid conditions, and pituitary gland conditions
Immune system disorders like lupus, scleroderma, and inflammatory arthritis
Mental health conditions that may qualify
Mental health conditions, like physical ones, need to be diagnosable to qualify for Medicare under 65. They also need to impact the individual’s ability to work.
Some mental health conditions that may qualify include:
Neurocognitive disorders, like Alzheimer’s and dementia
Psychotic disorders, like schizophrenia and schizoaffective disorder
Depression and bipolar disorder
Intellectual disorder, such as autism spectrum disorder or neurodevelopmental disorders
Anxiety disorders, including panic disorder, generalized anxiety disorder, agoraphobia, and obsessive-compulsive disorder (OCD)
Somatic disorders, like somatic symptom disorder and conversion disorder
Personality and impulse-control disorders, like paranoid, borderline, and avoidant personality disorders
Eating disorders, like anorexia nervosa, bulimia nervosa, and binge-eating disorder
Trauma-related disorders, like post-traumatic stress disorder (PTSD)
Compassionate allowance conditions
Compassionate allowance conditions allow individuals with serious disabilities to qualify quickly.
Examples of compassionate allowance conditions include:
Cancers, like pancreatic cancer, leukemia, and liver cancer
Neurological conditions, like early-onset Alzheimer’s and primary progressive aphasia
Rare disorders that impact children, like Batten disease or Tay-Sachs disease
Rare genetic diseases, like Wolman disease and Hutchinson-Gilford Progeria Syndrome
Individuals who are waiting for an organ transplant, including heart, liver, and lung transplants
Specific conditions that qualify for Medicare under 65
You can qualify for Medicare benefits under 65 if you have amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease, or end-stage renal disease. There’s no 24-month waiting period for either of these conditions.
If you’ve been diagnosed with ALS, you’ll be enrolled in Medicare as soon as you start receiving Social Security Disability Insurance. For people with end-stage renal disease, meaning they need dialysis or a transplant, Medicare starts on the first day of the fourth month of dialysis. Coverage can begin the month of your kidney transplant or sooner, depending on the condition.
Medicare coverage options for disability recipients
Individuals who qualify for Medicare under the age of 65 due to disability receive the same benefits as those 65 and older. You will get Original Medicare (Part A and B). You can also buy additional insurance, like prescription drug coverage, a Medicare Supplement plan, or a Medicare Advantage plan.
Medicare Part A and B benefits
People under 65 who qualify for Medicare because of a disability get the same Original Medicare (Part A and B) benefits as those 65 and older.
Medicare Part A covers hospitalizations. This typically includes:
Inpatient care in the hospital
Hospice care
Skilled nursing facility care
Inpatient nursing home care
Medicare Part A may also cover some home health care.
Medicare Part B covers medical care. When you’re enrolled in Medicare Part B, you’ll pay a monthly premium. Once you meet your deductible, Medicare Part B covers 80% of the cost of approved services. This means that your out-of-pocket costs will be 20%.
Common services covered by Part B include:
Doctor’s visits and treatments
Outpatient care, such as day surgeries and treatments like chemotherapy and injectable medications
Diagnostic tests, including X-rays and bloodwork
Emergency ambulance transportation
Preventative health care, like screenings, vaccinations, and counseling
Durable medical equipment like wheelchairs and braces
Medicare Part D prescription coverage
Original Medicare (Part A and B) doesn’t cover prescriptions. But you can get extra coverage for prescription medications through Part D (prescription drug) insurance.
To get Part D insurance, you’ll need to enroll in and pay for this additional coverage. You can stick with Original Medicare and add Part D insurance as a separate plan. Or, you may decide to switch to a Medicare Advantage plan, which typically includes Part D coverage.
It’s important to note that Medicare Part D insurance coverage differs. When comparing plans, you’ll want to consider the drugs covered, copays, and deductible amounts.
Medicare Advantage plans for disability recipients
Medicare Advantage plans are offered by private insurance companies. By law, they’re required to provide the same amount of coverage as Original Medicare, and they often include additional coverage and benefits. These may include Part D prescription drug coverage and routine vision and dental care. As all Medicare Advantage plans are different, you’ll want to compare coverage and costs.
If you qualify for Medicare under 65 due to a disability, then you may qualify for a Special Needs Plan (SNP). SNPs are plans that are designed for those with certain healthcare needs. There are three main types of SNPs, including:
Chronic Condition Special Needs Plan (C-NSP): These plans target people with chronic health conditions, like diabetes or heart failure. These plans cover the ongoing care needed to support those with these conditions.
Institutional Special Needs Plan (I-SNP): I-SNPs help people who are in or moving to long-term care. These include nursing homes or skilled nursing facilities. Coverage is designed to support the unique needs of living in a long-term care facility.
Dual Eligible Special Needs Plan (D-SNP): D-SNP plans are designed for those who qualify for both Medicare and Medicaid. These plans are designed to help coordinate coverage and reduce your costs.
Medicare Supplement (Medigap) considerations
Medigap is extra insurance that you can purchase alongside Original Medicare. A Medigap plan helps to cover the out-of-pocket costs Medicare doesn’t pay. Typically, anyone who has Original Medicare can purchase a Medigap plan.
Additional assistance programs to consider
If you’re on Medicare and need help with the costs, you may be eligible for an assistance program. These programs help lower-income individuals pay for the premiums, deductibles, and copays associated with Medicare. Programs include:
Qualified Medicare Beneficiary Program: This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and copays. To qualify, you need to have a limited monthly income and limited resources, which include savings. You can contact your state’s Medicaid office to see if you qualify.
Specified Low-Income Medicare Beneficiary Program: This program helps pay for Medicare Part B premiums. Your state Medicaid office can help you determine if your income and resources make you eligible.
Qualifying Individual Program: This program helps pay for Medicare Part B premiums for those with a low monthly income and limited resources.
Qualified Disabled & Working Individual Program: This program helps pay for Part A premiums. Individuals who are disabled and working but have lost their Social Security benefits due to returning to work qualify.
Extra Help: Extra Help helps individuals with low incomes pay for Part D deductibles, premiums, and co-pays. Under Extra Help, you’ll pay no more than $12.15 for each prescription. Qualification for Extra Help is based on the poverty level.
Bottom line
If you get Social Security disability insurance, you’ll be automatically enrolled in Original Medicare after receiving 24 months of benefits. This can help you get coverage for hospital stays, doctor visits, medical tests, and preventative health services. While you’ll still need to meet deductibles and pay premiums, there are programs available to help if you are unable to afford the care you need.
People with ALS or end-stage renal disease can get Medicare benefits earlier. If you qualify for Medicare, you can also get extra coverage through Part D, Medicare Advantage plans, and Medigap.
Because there are so many plans available and so many unique situations, it can be overwhelming to determine the best option for you. A Chapter agent can help guide you through the Medicare enrollment process. Get in touch by calling us at (855) 900-2427 or scheduling a free consultation.
Frequently asked questions
Do all disabilities qualify for Medicare under age 65?
Disabilities that qualify you for Social Security Disability Insurance also qualify you for Medicare. To qualify for Medicare before age 65 because of a disability, you need to have received Social Security disability benefits for 24 months. However, individuals with ALS or end-stage renal disease can receive Medicare coverage sooner.
How long does the Medicare disability application process take?
After 24 months of getting Social Security disability benefits, you will be automatically enrolled in Medicare. However, the process to qualify for Social Security disability benefits can take longer.
Can I work part-time and still qualify for disability Medicare?
Yes, individuals can still work and qualify for Medicare due to disability. However, they must continue to meet the definition of being disabled. Individuals who return to work won’t have to pay their Part A premium for 8.5 years while working. After that, they’ll be able to purchase Part A coverage.