Everyone knows the importance of having health insurance coverage, especially in the United States. Without it, a medical event can result in huge medical bills that you’ll have pay out-of-pocket. This can be many thousands of dollars. In fact, medical costs are the number one cause of bankruptcies in the United States.
In short, having good health insurance is crucial. And while Medicare is definitely one of the best health insurance programs out there, it is mostly intended for people aged 65 and over. Medicare is also available for people under 65 who have received social security disability income for 24-months or more or have one of several chronic conditions. But Medicare supplements for disabled people under 65 is not guaranteed in many states.
How does it work? Who qualifies for Medicare Supplements for disabled under 65? These are some of the questions that will be answered below.
What Is Medicare?
As was already mentioned, Medicare is a federal health insurance program, which was established in 1965 and that, at the moment, covers over 61 million Americans. Although Medicare is mostly meant for people aged 65 and over, there are some instances in which you can be eligible for it even if you are under 65. In fact, over 9 million of those who are covered by Medicare have not yet turned 65.
In order to be eligible for Medicare coverage before you turn 65, you need to have a disability as well as meet other conditions. Those other conditions qualifying someone for Medicare under 65 are:
- having received Social Security Disability Insurance (SSDI) for at least 2 years. Once the two years have passed, an individual will automatically be enrolled in Medicare Part A and B.
- End-Stage Renal Disease (ESRD) or Lou Gehrig’s Disease also known as Amyotrophic Lateral Sclerosis (ALS)
When it comes to both End-Stage Renal Disease (ERSD) and Lou Gehrig’s Disease (ALS), an individual doesn’t have to collect the disability benefits for 24 months. Instead, they are enrolled as soon as they start receiving benefits. However, there is a five-month waiting period for those with ESRD. There was one also for those with ALS. However, as of 2020, it has been eliminated due to the ALS Disability Insurance Access Act of 2019.
It’s important to note that once you confirm that you are eligible for Medicare benefits, the offer that will be presented to you will be the same one that a person turning 65 gets. You will have a few different options when it comes to how you want to proceed, so let’s take a look at them together.
The most basic Medicare coverage is Original Medicare. Original Medicare consists of two parts; Part A and Part B.
Part A, also referred to as Hospital Insurance, is responsible for your inpatient care which includes things like a hospital stay, hospice or home healthcare. What’s more, Medicare Part A also covers care that you have received through facilities like critical access hospitals, acute care hospitals, inpatient rehabilitation facilities or through participation in a clinical research study (not all of them qualify, however, so just keep that in mind).
Part B, on the other hand, also known as Medical Insurance, covers most of the outpatient costs and physician services such as regular doctor visits or preventative screenings. It also covers medical supplies and equipment that help you function and perform daily activities known as Durable Medical Equipment or DME for short. DME includes wheelchairs, commode chairs, artificial limbs, oxygen supplies, pacemakers, and any appliances that make breathing easier, among other things.
What Is Not Covered by Medicare?
Although Medicare covers most health services, it doesn’t cover everything. There are certain health care services that don’t fall under Original Medicare coverage. In case you need to use one of them, you will have to pay for them from your own pocket. Health care services not covered by Medicare include:
- dentistry (most dental health procedures will involve out-of-pocket costs) For details on dental care and available insurance coverage please see Does Medicare Cover Dental?
- long-term care
- eye exams when you need them to get a prescription for glasses or contact lenses.
- cosmetic surgeries
- hearing aids, as well as the exams you need to make them fit you
Original Medicare also doesn’t include prescription drug coverage. For that, you need to purchase Part D.
Medicare Advantage Plans for Disabled Under 65
Medicare Advantage plans are plans offered by a private health insurance company that has been approved by CMS (Centers for Medicare and Medicaid Services) and that serve as an alternative to Original Medicare.
Advantage plans usually offer you the same services as Original Medicare in addition to some other benefits, like prescription drug coverage or limited dental and/or vision care.
Advantage and Medigap Differences
So, how exactly are Original Medicare plans and Medicare Advantage plans different from each other, aside from what we have already mentioned? Here is a short comparison of the most important aspects of both health insurance options for the disabled under age 65 and others over age 65:
- Access to Doctors: With regular Medicare, you can visit any doctor or hospital that accepts it across the whole of the US. With the Medicare Advantage plan, you will most likely have to visit a local doctor that is within the insurance company’s network.
- Referral: With regular Medicare coverage you don’t need to have a referral in order to visit a specialist. With Medicare Advantage, a referral might be needed depending on the plan..
- Out-of-pocket costs limits: With regular Medicare, there is no limit in terms of how much you’d have to pay out-of-pocket. With Medicare Advantage, there is a yearly limit on your out-of-pocket payments for services that fall under the Medicare Part A and Part B coverage. For in-network services in 2022, this equals $7,550, while for in-network and out-of-network services combined, the limit increases to $11,300. These limits can change annually.
- Service approval: With Original Medicare your doctor does not need approval for each procedure or service. With an Advantage plan the doctor is required to get approval from the insurance company for each procedure or service. Emergency procedures are exempt.
- Travel Health Care: Neither regular Medicare or Medicare Advantage cover care outside of the US.
Most Common Medicare Advantage Plans
Not all Medicare Advantage plans are created equal. In 2022 there were 3,834 Medicare Advantage plans offered across the U.S. Of these, more than 80% were either an HMO or PPO, including Special Needs Plans.
- Health Maintenance Organization (HMO): With an HMO health insurance plan, you can use the services of doctors, health professionals, and hospitals that are within a plan’s network. There is an exception for emergency care, out-of-area urgent care, or out-of-area dialysis. Those are covered by the HMO plan even when out-of-network.
- Prefered Provider Organization (PPO): With PPO coverage, you can not only use the plan’s network of doctors and other health professionals, but you may be able to take advantage of out-of-network services. The out-of-network doctor must accept your insurance. They are not required to do so. . Out of network services cost more.
- Special Needs Plans (SNP): Special Needs Plans provide health care coverage to older and younger Medicare beneficiaries that suffer from specific diseases or health care needs, or are on a limited income. A Special Needs Medicare Advantage plan is usually either an HMO or PPO plan with extra services tailored specifically to the group the Medicare beneficiary is a part of.. In order to be eligible for a Special Needs Plan, you need to live in the plan’s service area and meet one of the other requirements:
- You have one or more chronic illnesses included in the list of conditions qualifying for C-SNP also called Chronic Condition SNP:
- Chronic dependence (for instance alcohol)
- Autoimmune disorder
- Cancer (does not include pre-cancer conditions)
- Cardiovascular disorder
- Chronic Heart Failure
- Diabetes mellitus
- End-stage liver disease
- End-Stage Renal Disease (ESRD) when you need dialysis
- Severe hematologic disorders
- Chronic lung disorders
- Chronic and disabling mental health conditions
- Neurologic disorders
- You live in a facility (e.g. a nursing home) or you need nursing care in your home (this type of SNP is also called I-SNP or Institutional SNP)
- You are eligible for both Medicare coverage and Medicaid coverage (this type of SNP is also known as D-SNP or Dual Eligible SNP)
- You have one or more chronic illnesses included in the list of conditions qualifying for C-SNP also called Chronic Condition SNP:
Medicare Supplement Plan
A Medicare Supplement Plan adds to your Original Medicare. Also known as Medigap insurance, Medicare Supplement Insurance plans help you pay the deductibles, copay and coinsurance that Original Medicare leaves as your responsibility to pay. Medigap policies are sold by private insurers and brokers.
When it comes to how many plans you can choose from when you enroll in Medicare Supplement insurance, you have 12 standardized plans to choose from A, B, C, D, F, G, K, L, M, and N. Plan’s G and F have high deductible options. Depending on which plan you choose, you will be provided with different benefits.
Medicare Disability Supplemental Insurance Under 65 Around the Country
Unfortunately, there is no federal law that would make a Medigap policy accessible to all disabled Medicare beneficiaries. States can make their own decision when it comes to making Medigap plans available to those under 65. Those states that do allow under 65 Medigap plans only offer them during the first six months (180-days) that a person has Medicare Part B
In terms of accessibility to Medicare Supplemental Insurance for the disabled under 65, states can be divided into five categories:
- States in which there is no law that would guarantee Medigap accessibility to people under age 65 nor do there seem to be insurers that would provide such plans:
- New Mexico
- North Dakota
- Rhode Island
- South Carolina
- Washington DC
- States in which it is mandatory to offer at least one Medicare Supplement insurance to disabled Medicare beneficiaries under 65. This is typically Medicare supplement Plan A. Keep in mind that depending on the state, an insurer might be able to charge higher premiums:
- New Jersey
- North Carolina
- States in which insurance companies are required to make all their Medigap plans available to disabled people under age 65, but they can sell Medigap policies to them at a higher cost:
- New Hampshire
- States in which which insurance companies are required by state law to make all their Medigap policies available to disabled under age 65 and that either have measures in place that prevent the insurers from charging higher premiums or that have a limit on how high the additional premiums can be:
- Idaho – premiums are the same for those under 65 and at age 65.
- Illinois – premium cannot be higher than the highest rate for a beneficiary at age 65
- Kansas – premiums are the same for those under and age 65
- Maine – premiums aren’t affected by age
- Massachusetts – premiums aren’t affected by age; an applicant with ESRD can be rejected
- Minnesota – premiums aren’t affected by age
- Mississippi – premiums cannot be higher than 150% of that charged to Medicare beneficiaries at age 65 pay
- Missouri – premiums cannot be higher than the “weighted average aged premium rate”
- New York – premiums aren’t affected by age
- Oregon – premiums are the same for those under and at age 65
- Pennsylvania – premiums are the same for those under and at age 65
- South Dakota – premiums cannot be higher than those for a 75-year-old
Medicare for Disabled Under 65 – Frequently Asked Questions
What disabilities qualify for Medicare under 65?
If you are under age 65 you can qualify for Medicare on your 25th month of receiving Social Security disability income (SSDI) benefits.
Those with ALS (amyotrophic lateral sclerosis aka Lou Gerhig’s disease) will receive Medicare Part A and B automatically the same month that they start their Social Security disability benefits.
If you have ESRD (End Stage Renal Disease), your kidneys no longer function and you need regular dialysis or a kidney transplant you may be eligible for immediate Medicare benefits.
You can be eligible for premium free Medicare Part A if you or your spouse has worked and paid Medicare taxes for at least 40-quarters or you are already eligible for Social Security or Railroad Retirement benefits. There is a monthly premium for Medicare Part B.
In order to be eligible for SSDI benefits, you need to have a medical condition that is expected to last at least 12 months and that makes it difficult to perform basic working abilities, such as sitting or remembering things. Your work history will be taken into account, as you need to meet earning requirements.
With that being said, some of the disabilities that make you eligible for the Social Security Disability Insurance are:
- multiple sclerosis
- mood disorders, depression, PTSD
- hearing loss
- Parkinson’s disease
- cystic fibrosis
- autism spectrum disorder
Once you fill out your application and submit it (including your personal, work and medical history), you’ll need to wait for the approval. Once you receive it, there is a five-month waiting period before you can start receiving your disability benefits.
Can I have Medigap and Medicare Advantage policies at the same time?
The short answer is no, you can’t. In fact, it is illegal for an insurer to sell you Medigap insurance if they are aware that you are already enrolled in a Medicare Advantage plan and do not intend to cancel it. When applying for a Medicare supplement, you must attest to your intent to cancel any current creditable coverage or Medicare Advantage plan.
Medicare Advantage plans are a privatized version of Medicare Parts A & B. It is a means the intent is to get the same Part A and Part B benefits they would get if they purchased Original Medicare, as well as some additional benefits specified by the insurer (for example prescription drugs coverage). Although your Original Medicare is no longer responsible for your healthcare, you must still pay your Part B premium.
Like Advantage Plans, Medigap requires you to already have Parts A and B. Medigap Plans and pay the copays, coinsurance and deductibles that are not covered by Original Medicare. A Medigap plan adds to or supplements Original Medicare.
Can my partner and I have a joint Medigap policy?
Medicare Supplement insurance plans cover only one person, which means that if you and your partner want to have the same Medigap coverage, you need to purchase Medicare Supplement insurance separately.
The Bottom Line
Although Medicare is mostly dedicated to those over the age of 65, you can become a Medicare beneficiary under age 65 – if you are a disabled person that has been receiving Social Security Disability benefits for at least 24 months, or that has either ESRD or ALS.
Just like Medicare beneficiaries over age 65, you are given a choice. You can decide to go with Original Medicare and buy a Medigap policy as an addition, or you can opt for a Medicare Advantage plan. It is your decision, but your choice may be limited by your state laws.
Medicare for the disabled under 65 is actually quite simple, as long as you know what your medical needs are. But if you aren’t sure how to go about signing up for Medicare, do not hesitate to reach out to us. We will be more than happy to help you make the best decision possible for your health