Medicare Advantage for Disabled Individuals

Tamera Jackson by Tamera Jackson | Licensed since 2007
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This article was updated on: 09/15/2018

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Are you wondering about Medicare benefits for disabled people? Are you considering a Medicare Advantage plan? It might help to know that if you receive Social Security or Railroad Retirement Board disability benefits:

  • You might be eligible for a Medicare Advantage plan, even before you turn 65 years old.
  • But first, you must be enrolled in the federal Medicare program.

Am I eligible for Medicare if I am disabled?

Medicare is available for certain people with disabilities even if they are under age 65. Typically you must have received Social Security disability benefits or certain disability benefits from the Railroad Retire Board (RRB) for 24 continuous months before you may qualify for Medicare. In most cases, you’ll be automatically enrolled in Medicare.

You might also qualify for Medicare under the age of 65 if you’ve been diagnosed with either of these conditions:

  • End-stage renal disease (ESRD), which is kidney failure requiring regular dialysis or a kidney transplant. In this case, you might qualify for Medicare, but you won’t be automatically enrolled. You’ll need to contact Social Security (contact information below).
  • Amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease). In this case, you’ll usually be enrolled in Medicare automatically the month you start receiving disability benefits.

Here’s the contact information for the Social Security Administration and the Railroad Retirement Board.

  • Call Social Security at 1-800-772-1213 (TTY users call 1-800-325-0778). Representatives are available Monday through Friday, from 7AM to 7PM (all U.S. time zones).
  • Call the Railroad Retirement Board at 1-877-772-5772 (TTY users call 1-312-751-4701). Monday, Tuesday, Thursday, and Friday, 9AM to 3:30PM (9AM – 12 noon Wednesdays) – all U.S. time zones, to speak to an RRB representative.

Medicare Advantage and disability

Medicare Advantage (Medicare Part C) is an alternative way to receive Medicare Part A and Part B coverage, usually whether you’re disabled or not. Medicare Advantage plans are offered by Medicare-approved private insurance companies to provide Medicare Part A (hospital insurance) and Part B (medical insurance) except for hospice care, which is still covered under Part A.

In general, if you qualify for Medicare due to disability, your Medicare benefits (including Medicare Advantage) will be the same as for any other beneficiary.

Please note that if you have end-stage renal disease (ESRD), in many cases you’re not eligible for most Medicare Advantage plans. However, you may be able to enroll in a type of Medicare Advantage plan, known as a Special Needs Plan, that’s tailored for beneficiaries with ESRD.

  • Special Needs Plan (SNP) beneficiaries typically receive services through a network of providers. These plans are limited to beneficiaries with certain chronic conditions (such as ESRD), people with both Medicaid and Medicare, or people living in certain facilities. These plans include Medicare prescription drug coverage.

Medicare Advantage plans often include prescription drug coverage. In general, Medicare Advantage plans may or may not charge a monthly premium. You’ll typically have to pay cost-sharing such as copayments for doctor visits, prescription drugs and other services. You’ll also need to continue paying your Part B premium.

If I’m disabled and I enroll in a Medicare Advantage plan without prescription drug benefits, how do I get these benefits? 

If you want Medicare prescription drug benefits, the way you can get them is generally the same whether you have a disability or not. Not all Medicare Advantage plans include prescription drug coverage, but Special Needs Plans do.

If you don’t qualify for a Special Needs Plan, you might be able to enroll in a stand-alone Medicare Part D Prescription Drug Plan, although you might want to check with your Medicare Advantage plan first because this is not allowed with every type of Medicare Advantage plan. Stand-alone Medicare Part D Prescription Drug Plans are offered by private companies approved by Medicare.  Medicare prescription drug benefits are optional, and generally available to all Medicare beneficiaries. However, unless you are new to Medicare or are entitled to a Special Enrollment Period, you can usually only enroll during the Medicare Advantage and Prescription Drug Annual Election Period, October 15 — December 7. Typically you pay a monthly premium if you enroll in a stand-alone Medicare Part D Prescription Drug Plan.

If you have limited income and assets/resources, assistance may be available to help pay Medicare Part D premiums, deductibles and copayments. You may be entitled to Low-Income Subsidy (LIS) Assistance or Extra Help through the Social Security Administration.

What kind of Medicare coverage is available for people with disabilities?

Medicare coverage is generally the same for people who qualify based on disability as for those who qualify based on age. The health-care services do not have to be related to your disability in order to be covered.

In addition, you might have the option of enrolling in a Medicare Advantage plan or a stand-alone Medicare Part D Prescription Drug Plan.

Do you have other questions about Medicare coverage for individuals with disabilities?    I would be happy to help you. Feel free to use the links below, which let you schedule a phone appointment or have me email you information about plans that could work well for you. To take a look at the plans available for your circumstances, click now on the Compare Plans buttons on this page.

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