Disability & Medicare eligibility and enrollment – What you need to know in 2023
Some people can qualify for Medicare due to disability. In this case, if you have a qualifying disability, you are eligible for Medicare even if you are not yet age 65. To find out if your disability qualifies for disability benefits or for Medicare, you’ll need to speak with Social Security directly, but in general, you become eligible the 25th month of receiving Social Security Disability Insurance benefits (SSDI).
If you have a qualifying disability, you must first file for disability benefits through Social Security before you can even be considered eligible for Medicare due to disability. Approval of the request by Social Security is an important first step. It is also important to note that these benefits are different from Supplemental Security Income (SSI) benefits, and that SSI benefits do not qualify you for Medicare.
Enrolling in Medicare with a disability
Just like when you become eligible for Medicare at age 65, when you are eligible with disability, you have an Initial Enrollment Period of 7 months.
Your Initial Enrollment Period will begin after you have received either disability benefits from Social Security for 24 months or certain disability benefits from the Rail Road Retirement Board for 24 months.1 In other words, your IEP starts on the 25th month of disability benefits.
You will be automatically enrolled in Medicare Part A and Part B, but if you decide you want to get a Medicare Advantage (Part C) or Part D prescription drug plan, you will need to enroll yourself directly with the private plan provider. You will need to enroll during your IEP to avoid late enrollment penalties.
NOTE: If you become eligible for Medicare because of ALS or ESRD, your situation is different. See the below special sections for eligibility and enrollment for ALS and ESRD.
Do I have to take Part B?
You are not required to take Part B, and some people choose to delay. Deciding to opt out of Part B at this time is a personal choice and depends on your unique situation. Click here to read more about whether or not you should take Part B when you qualify for Medicare with a disability. Some people who qualify for Medicare under age 65 due to disability but are covered under an employer’s plan or a spouse’s employer plan, may opt to delay.2
If you get Medicare for disability and then return to work
If you get Medicare due to disability and then decide to go back to work, you can keep your Medicare coverage for as long as you’re medically disabled.3 And, if you do go back to work, you won’t have to pay the Part A premium for the first 8.5 years.
Part A is premium-free for those with a disability and under 65 only if you get Social Security or Railroad Retirement Board benefits for 24 months or have ESRD and meet certain requirements.4
If you’re 65 or older, Part A is premium-free if you or your spouse worked and paid Medicare taxes for at least 10 years, you already get retirement benefits from Social Security or the Railroad Retirement Board, or you’re eligible for these benefits but haven’t filed for them yet.5
What happens when you turn 65?
When you turn 65, you essentially lose your entitlement to Medicare based on disability and become entitled based on age. In short, you get another chance to enroll, a second Initial Enrollment Period if you will.6
If you decided not to take Part B when you were eligible for disability under 65, when you do turn 65, you’ll now be automatically enrolled in Part B. Your Medicare card will then be mailed to you about 3 months before your 65th birthday.
You can also decide during this time to enroll in a Medicare Advantage or Part D prescription drug plan. Additionally, once you have Part B, you can enroll in a Medigap plan if you so wish.
Special circumstances: Medicare with ALS (Lou Gehrig’s Disease) or End-Stage Renal Disease (ESRD)
Medicare eligibility rules for people with ALS (Lou Gehrig’s disease) or end-stage renal disease (ESRD) are different. Individuals who qualify for Medicare with ALS or ESRD do not have to wait for your 25th month of disability to be eligible for Medicare.
If you qualify with ALS: You will automatically get Medicare Part A and Part B the month your disability benefits begin.7
If you qualify with ESRD:8
- For most people, Medicare coverage will start on the 1st day of the 4th month of dialysis treatment.
- If you have an employer group health plan, Medicare will begin on the fourth month of dialysis.
- Treatments if you have employer coverage.
- If you participate in an at-home dialysis training program, your coverage may begin the first month of a regular course of dialysis provided the following are true:
- You participated in training from a Medicare-approved training facility for the first three months of your regular dialysis
- Your doctor expects you to finish training and be able to do your dialysis treatments yourself
Note, according to Medicare in order to qualify with ESRD all of the below must apply:9
- Your kidneys no longer work
- You need dialysis regularly or have had a kidney transplant
- One of the following must be true for you:
- You’re already eligible for or are currently getting Social Security or Railroad Retirement Board (RRB) benefits
- You have worked the required amount of time under Social Security, the RRB or as an employee of the government
- You are either the spouse or dependent child of someone who meets either of the above requirement
For further information related to ALS and Medicare, visit www.alsa.org.
For further information related to ESRD and Medicare, visit www.medicare.gov.
Important note about Part B & ESRD: According to Medicare, if you’re already enrolled in Medicare based on age or disability, and are currently paying Part B late enrollment penalties, those will stop when you become eligible for Medicare based on ESRD.10 You can also enroll in Part B without penalty even if you did not when first eligible by age or disability.
Getting Medicare enrollment assistance
If you have questions about or need help with Medicare eligibility or enrollment due to disability, you will want to talk with Social Security office. You can also go to your local State Health Insurance Assistance Program (SHIP) office for Medicare counseling.
If you get approved for disability benefits but aren’t yet eligible for Medicare yet (less than 24 months on SSDI), you can reach out your local state human services agency to see if Medicaid may be an option for you.11
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