Obamacare vs. Medicare for People with Disabilities

Last Updated : 05/28/20195 min read

You might be eligible for Medicare in some cases if you have a disability. But just because you can get Medicare coverage, does that mean you have to take it instead of a major medical health plan under Obamacare? That’s what this article is all about.

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Some people qualify for Medicare before they turn 65, because they receive disability benefits through Social Security or the Railroad Retirement Board.

Obamacare vs. Medicare: comparing disability coverage

Obamacare refers to the Affordable Care Act (ACA) passed in 2010. Under Obamacare, if you have a disability – or any pre-existing health condition – health plans sold in the federal Marketplace or state exchanges can’t turn you down when you apply.  Every health plan that complies with the ACA, including those sold on the Marketplace under Obamacare, must include certain benefits, such as prescription drugs, preventive care, mental health services, outpatient care, and hospital care. Read more about the required benefits under the ACA.

Original Medicare (Part A and Part B) generally also accepts eligible applicants regardless of disability or pre-existing condition. Part A and Part B generally cover most of the services and items that Obamacare covers, with at least one exception: prescription drugs. Health plans under Obamacare include prescription drug coverage, while Original Medicare generally doesn’t cover prescriptions you’d take at home.

Medicare Part A generally covers prescription drugs given to you as part of your hospital inpatient treatment. Medicare Part B may cover certain medications administered to you in an outpatient setting.

In a nutshell:

  • Obamacare plans typically include prescription drug coverage while Original Medicare doesn’t, in most situations.

Obamacare vs. Medicare: comparing costs (disability or not)

There are many variables when it comes to your out-of-pocket costs, whether you’re covered by Medicare or under Obamacare (also known as the Affordable Care Act). Disability generally doesn’t affect these costs.

Under Original Medicare, most people don’t pay a premium for Part A. If you’ve worked at least 40 quarters (10 years) while paying Medicare taxes, in most cases you don’t pay a Part A premium. However, most people pay a Part B premium. The amount can vary depending on your situation, but the average Part B premium is $135.50 in 2019. There are also deductible amounts and coinsurance or copayment amounts you may have to pay. The Part A deductible is $1,364 in 2019 (per benefit period). The Part B deductible is $185 in 2019 (per year). Read more about Medicare out-of-pocket costs.

Marketplace plans under Obamacare usually also have premiums, deductibles, copayments, and coinsurance amounts. They typically also have out-of-pocket maximum amounts. This means that after you’ve spent a certain amount on certain health-care costs, the plan generally doesn’t charge you for covered health-care services for the rest of the year. In contrast, Medicare Part A and Part B don’t have out-of-pocket maximum amounts.

In a nutshell:

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  • You may not need to pay a premium for Medicare Part A.
  • Obamacare plans typically have out-of-pocket maximum amounts whereas Original Medicare plans do not.

Can I choose Obamacare instead of Medicare if I’m disabled?

Whether you can enroll in an Obamacare plan (or another major medical plan) instead of Medicare may depend on whether you qualify for premium-free Medicare Part A.

Medicare instead of Obamacare if you’re disabled and receive premium-free Medicare Part A

In most cases, you can’t choose an Obamacare plan over Medicare if you’re disabled and getting premium-free Part A. If you have premium-free Part A and you decide to drop Medicare, you can lose your SSA or RRB disability benefits. You’d even have to reimburse the government for past disability and Medicare benefits.

If you have insurance coverage through an employer’s group health plan, and you qualify for Medicare, in some cases you can be enrolled in Medicare and the group health plan at the same time. If the employer has at least 100 employees, Medicare would generally be the “secondary payer” in the coordination of benefits. This means that the employer plan would pay its share first, before the claim is sent to Medicare.

If your employer has fewer than 100 employees, Medicare is the primary payer.

In a nutshell:

  • Many people who qualify for Medicare through disability can’t replace this coverage with an Obamacare plan.

Obamacare instead of Medicare is OK if you’re disabled and you pay a premium for Medicare Part A

If you pay a premium for Medicare Part A (because you have worked for less than 10 years or 40 quarters while paying Medicare taxes), you may be able to enroll in an Obamacare (also known as the Affordable Care Act) plan instead of Medicare. However, be aware that if you decide to enroll in Medicare later, you might have to pay a late-enrollment fee.

In a nutshell:

  • You may be able to opt for an Obamacare plan if you don’t qualify for premium-free Medicare Part A.

Obamacare instead of Medicare is OK if you have ESRD

ESRD stands for end-stage renal disease: permanent kidney failure requiring regular dialysis or a kidney transplant. The disease might make you eligible for Medicare at any age. If you’re newly eligible for Medicare because you have ESRD, you don’t have to enroll in Medicare. You’re free to sign up for an Obamacare plan.

Note that you’re not automatically enrolled in Medicare if you have ESRD.

If you have Medicare coverage and have ESRD, you might be able to withdraw your Medicare application. You might then have to reimburse the government for past disability and Medicare benefits.

In a nutshell:

  • If you have ESRD, you may be able to get an Obamacare plan instead of Medicare.

If you have questions about Medicare coverage related to your disability, I am happy to help. The Compare Plans or Find Plans buttons can show you some of the plan options you may be eligible for in your area. Click the links below to request a phone call or personalized email.

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