Medicare and
Disability: A Brief Overview
Medicare was designed
to cover both adults over age 65 and some people younger than 65 who have
disabilities that meet certain criteria.
There are several
pieces of Medicare, including:
Part
A. This part covers inpatient care in hospitals, skilled nursing
facility care and some home health care or hospice care.
Part
B. Services from doctors and health care providers fall under Part B.
Coverage includes outpatient care, physical therapy, various preventive services
and durable medical equipment, such as wheelchairs and
walkers.
Part
C. Also called Medicare Advantage, this part includes plans offered
by private companies that are approved by Medicare. These plans bundle Part A,
Part B and usually Part D coverage into a single plan.
Part
D. This part is the prescription medication piece of
Medicare.
Medigap.
This supplemental insurance includes "Original Medicare" – Part A and Part B –
and a plan to pay for coinsurance deductibles.
Medicare vs.
Medicaid for people with disabilities
Medicare was originally
established to provide coverage for older adults who lost employer-based
insurance when they retired at age 65. As of the 1970s, it also covers those
under 65 who receive Social Security disability benefits. Medicare is funded
through federal Social Security taxes and does not have any income limits you
must meet to qualify.
Medicaid, on the other
hand, is a needs-based program that serves low-income individuals. It’s funded
through a mix of federal, state and local taxes. There are no age restrictions
to qualify for Medicaid, and the program is administered at the state
level.
Because Medicaid is a
needs-based program, applicants must meet specific income and asset levels to
qualify. Priority is usually given to older adults, those with disabilities,
pregnant women, children and families in need. To apply for Medicaid, you’ll
need to go through your local state agency that processes those
requests.
Keep in mind that, in
most states, if you have a disability and you receive Supplemental Security
Income, also known as SSI, you're automatically eligible for Medicaid. More than
one-third of Medicaid beneficiaries qualify this way, according to the Medicaid
and CHIP (Children's Health Insurance Program) Payment and Access
Commission.
When it comes to
considering Medicare versus Medicaid disability benefits, there can be overlap
between which program you qualify for, so it’s best to ask a caseworker in your
state to clarify your options.
Medicare
Eligibility Criteria for Individuals Under Age
65
In general, if you're
under the age of 65 and have a disability, you must be receiving Social Security
Disability Insurance, also referred to as SSDI, benefits for two years before
you become eligible for Medicare.
Both SSDI and SSI are
administered by the Social Security Administration and provide assistance to
people who meet the federal agency's requirements for
disabilities.
SSDI.
You and certain family members – including a spouse, divorced spouse, children
under the age of 16 and adult children who were disabled before age 22 – can
receive benefits if you are insured. Your eligibility is based on how long and
how recently you worked and whether you paid Social Security taxes on those
earnings.
SSI.
Adults and children who meet the SSA’s requirements for a qualifying disability
and have limited income and resources can receive benefits from this
program.
The two programs are
different but have the same medical requirements. However, if your situation
meets the non-medical requirements established by the SSA, then you may be
eligible for monthly benefits if your medical condition is expected to last at
least a year or is terminal. You can apply for benefits via the SSA’s
website.
Another federal
benefits program, the Railroad Retirement Board, or RBR, was established in the
1930s for railroad workers to support them when financial upheaval from the
Great Depression threatened existing retirement and pension
programs.
The RRB is an
independent federal agency based in Chicago. It’s similar to the SSA in that the
agency works directly with recipients via more than 50 field offices across the
U.S. Both organizations also use the same definition of total disability and the
same formula to calculate payments. To be eligible for RRB benefits, you must
have worked for at least 10 years in covered service for the railroad industry
or at least five years after 1995.
Disabilities
That Qualify for Medicare Under Age 65
The term "disabled"
refers to almost any condition that results in a demonstrable disability in
which you cannot perform regular, continuous work activity on a full-time basis
and that has persisted or is expected to last at least 12 months, explains
Kathleen Holt, a Connecticut-based attorney and associate director for the
Center for Medicare Advocacy.
“It’s not a specific
condition,” she notes. “You could have multiple sclerosis and continue to work,
or you can have MS and be so incapacitated that you reach a point where you meet
that criteria and you’re unable to perform regular work activity for a 40-hour
workweek.”
The key to becoming
eligible for Medicare benefits is having a medical condition that makes it
impossible for you to work enough to access employer-sponsored health care
benefits. Holt notes that about 15% of Medicare beneficiaries are people with
disabilities who are younger than 65.
Navigating the
Application Process
To become eligible for
Medicare under the age of 65, there are a few steps you must
follow:
- Apply for SSDI
benefits.
- Wait 24
months.
- Enroll in
Medicare.
Apply for SSDI
benefits
It's important to apply
for Social Security because this is the pathway to getting Medicare coverage.
You must satisfy the Social Security office that you are disabled and need to
draw benefits.
To apply for SSDI,
you’ll need the following documents and information:
- Your Social Security
number.
- Medical records from
your doctors, therapists, hospitals, clinics and caseworkers that substantiate
your medical issue and disability status.
- Laboratory and test
results.
- Names, addresses, phone
and fax numbers of your doctors, clinics and hospitals.
- Names of all
medications you are taking.
- Names of your employers
and job duties for the last 15 years.
Wait 24
months
There is a 24-month
waiting period after you start drawing disability benefits before you become
eligible for Medicare coverage. However, if you have either ALS, also known as
Lou Gehrig’s disease, or end-stage renal (kidney) disease, the waiting period is
waived.
For those who do need
to wait two years, this period can be a hardship, Holt notes, but during those
24 months, you can access health coverage because of the Affordable Care Act,
which was signed into law in 2010.
This program, also
referred to as Obamacare, provides private insurance options to individuals
outside of traditional employer-sponsored health care. A critical piece of these
plans is that you can’t be disqualified for a preexisting condition, and the
disability for which you’re awaiting Medicare would be, Holt says. That way,
while you’re waiting for Medicare to kick in, you can get coverage through your
state’s health insurance exchange.
Enroll in
Medicare
Once you’re in the SSDI
system and have fulfilled the 24-month waiting period, you’ll be automatically
enrolled in Medicare.
As you go through the
Medicare process, Dr. Meena Seshamani, deputy administrator and director of the
Center for Medicare at the Centers for Medicare & Medicaid Services in
Washington, D.C., recommends visiting Medicare.gov's "Get Started With Medicare"
page, where you’ll be guided through a series of questions about your situation
to determine your eligibility and help you get enrolled.
“Our website makes it
very easy for someone to walk through (enrollment) and figure out their
eligibility,” Seshamani says.
CMS also staffs a 24/7
call center at 1-800-Medicare (1-800-633-4227) where you can ask questions and
get support.
“People can call and
say, ‘Hey, I want to check, am I eligible for Medicare? How can I sign up?’ and
somebody can help you walk through that,” she explains.
Making sure people are
able to enroll quickly and with minimal difficulty is a key focus of her work at
CMS. “It’s really a priority for us to help people figure out what option is
best for them,” Seshamani adds.
Comparing
Medicare and Social Security
When considering Social
Security versus Medicare, it’s important to recognize that these are two
separate benefit programs from the federal government. Social Security provides
financial support, whereas Medicare is health insurance coverage. These two
safety net programs work together to support people with disabilities to remain
as healthy as possible.
As mentioned, for
someone looking to gain health insurance coverage via Medicare because of a
disability, they must first apply for disability benefits from Social
Security.
Help Is
Available
Regardless of age or
disability status, many people can benefit from guidance when first getting
enrolled in Medicare or when making changes during an open enrollment period.
The great news is that this type of help does exist and is free.
In addition to the
services available at CMS, the State Health Insurance Assistance Program – a
grant-based program in every state, Washington, D.C., Puerto Rico, Guam and the
U.S. Virgin Islands – can help enrollees. “The whole point of our SHIP programs
is to have individuals locally available to provide in-depth, one-on-one
assistance in navigating and enrolling in Medicare,” says Rebecca Kinney,
director for the Administration for Community Living Office of Health Care
Information and Counseling in Washington, D.C.
You can find your local
program and set up an appointment from SHIP's website. During your appointment,
a SHIP counselor will spend two to three hours with you, either in one sitting
or several, to help you understand the aspects of Medicare.
“There’s a lot of
choices, and things that can be really overwhelming," she explains. "That’s what
SHIP is there (for) – to help them try to sort through and
navigate.”
Source
https://health.usnews.com/health-news/medicare/articles/qualifiying-medicare-disabilties-for-medicare-under-65
