Qualifying for Medicare Through Disability or Illness
This article was updated on: 07/06/2018
Most people think of Medicare as a health-care program for older adults. However, if you have a disability or certain health conditions, you may be eligible for Medicare before you turn 65.
You may qualify for Medicare before age 65 if:
- You’re disabled and have received disability benefits from the Social Security Administration (SSA), or certain Railroad Retirement Board (RRB) disability benefits, for at least two years.
- You have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS).
- You have end-stage renal disease (ESRD).
If you’re under 65 and think you may qualify for Medicare because of one of the above scenarios, I’d like to explain how it works and what you need to do.
How to qualify for Medicare by disability
As mentioned, you may qualify for Medicare under 65 if you’ve been receiving Social Security disability benefits, or certain Railroad Retirement Board benefits, for at least 24 months. You’ll need to meet Social Security’s definition of disability and have worked long enough under SSA-covered employment to qualify for benefits. In general, Social Security defines disability as being unable to do the work you used to do because of a condition that is expected to last at least a year or result in your death. You must also be unable to do other work, even with accommodations.
The Social Security Administration determines whether you qualify for disability payments, and that determines if you qualify for Medicare. For more information on eligibility for disability benefits, you can visit the Social Security website or call the SSA at 1-800-772-1213. TTY users can call 1-800-325-0778. Phone lines are open Monday through Friday, from 7AM to 7PM (all U.S. time zones). If you worked for a railroad and want information on disability benefits, call the Railroad Retirement Board at 1-877-772-5772, Monday, Tuesday, Thursday, and Friday, from 9AM to 3:30PM and Wednesdays 9AM – noon (all time zones). TTY users call 1-312-751-4701.
How to sign up for Medicare if you’re disabled
In many cases, enrollment into Original Medicare, Part A and Part B, is automatic if you qualify because of disability. If you collect Social Security or Railroad Retirement Board disability benefits, you’re automatically enrolled in Original Medicare after your 24th month of collecting benefits.
How to qualify for Medicare with other health conditions
Medicare coverage may also be available if you have two specific health conditions: amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ESRD). If you have ALS (also known as Lou Gehrig’s disease), you’re eligible for Medicare the same month that you start collecting disability benefits. Unlike qualifying for Medicare because of another disability, there’s no waiting period; you don’t need to receive disability benefits for two years before your Medicare coverage starts.
But it’s a little more complicated if you have end-stage renal disease, also known as kidney failure. You may qualify for Medicare, regardless of age, if your kidneys are no longer working and you’ve either had a kidney transplant, or you need routine dialysis. In addition, one of the following scenarios must apply:
- You’ve worked long enough under SSA- or RRB-covered employment, or you’re a government employee.
- You’re currently receiving or qualify for SSA or RRB benefits.
- You’re married to or the child of someone who meets one of the above requirements.
Keep in mind that if you have end-stage renal disease (ESRD), enrollment isn’t automatic, and you’ll need to sign up through either Social Security or the Railroad Retirement Board. In addition, even if you’re eligible for Original Medicare, you’re usually not eligible for a Medicare Advantage plan if you have ESRD, except in special situations. You can sign up for Original Medicare as soon as you meet the qualifications noted above; however, coverage doesn’t start immediately (see below).
When your Medicare coverage starts
As mentioned, if you meet the Medicare eligibility requirements described above, in most cases your Medicare coverage begins automatically at the start of your 25th month of collecting disability benefits.
If you have ALS, your Medicare coverage begins the same month that you start collecting disability benefits.
If you have ESRD and you’re on dialysis, your coverage generally begins on the first day of the fourth month of your dialysis, even if you haven’t signed up for Medicare. But your Medicare coverage can start as early as the first month of dialysis if you meet all of the following conditions:
- You’re currently in a home dialysis training program at a Medicare-certified facility where you’re learning how to do your own dialysis treatments at home.
- You’re on track to complete the training and be able to do your own dialysis treatments, according to your doctor’s judgment.
- You’d be getting regular dialysis treatment during the waiting period if it applied.
For additional or different Medicare coverage options
Once you have Medicare Part A and Part B, you may be able to expand or change your Medicare coverage. For example, you might want to add Medicare prescription drug coverage, which isn’t included in Original Medicare except in limited circumstances,* and is available through a stand-alone Medicare Prescription Drug Plan. Depending on the state you live in and its rules, you might be able to purchase a Medicare Supplement plan to help with certain Original Medicare out-of-pocket costs. In some states, you can’t get a Medicare Supplement plan before age 65, even if you qualify for Medicare because of a disability.
Or, you can see whether switching from Original Medicare to a Medicare Advantage plan might work for you; these plans provide an alternative way to get the same Part A and Part B benefits, but may also cover extra benefits not normally covered through Original Medicare, such as routine vision or dental, hearing, or wellness programs (keep in mind that this may not be an option if you have ESRD, depending on your situation).
*Medicare Part A generally covers prescription drugs given to you as part of your inpatient treatment, for example in a hospital. Medicare Part B may cover prescription drugs administered to you in an outpatient setting.
Do you have questions about your Medicare plan options? I’d be happy to answer them.
- You can set up an appointment to talk with me about your needs, or have me email you some plan options; the links for both options are below.
- Want to check out some plan options on your own schedule? Simply click on the Compare Plans button on this page.