Illnesses or conditions that prevent you from receiving a certain amount of monthly income and are expected to last a year or longer are considered disabilities. If you are disabled, you may qualify for Medicare before you reach 65. Those with disabilities who are approved for Medicare can choose a Medicare Advantage plan or Original Medicare. In many instances, Medicare beneficiaries under the age of 65 prefer Medicare Advantage plans because they often offer the most affordable options for them.
What Disabilities Qualify for Medicare Under 65?
If you have a disability and have not reached the age of 65, you must meet certain conditions to qualify for early enrollment in Medicare. You are eligible as soon as you start receiving Social Security Disability Insurance (SSDI) payments if:
- You have been diagnosed with end-stage renal disease (ESRD) and require a kidney transplant or need dialysis.
- You have been diagnosed with amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig’s disease.
Additionally, you qualify for Medicare early if you have been receiving Social Security Disability Insurance checks for two years or more. Keep in mind that to receive SSDI, the Social Security Administration must first establish that you are disabled. You may meet SSA’s disability criteria if you have debilitating chronic conditions, such as:
- Multiple sclerosis
- Parkinson’s disease
- Cystic fibrosis
- Amyotrophic lateral sclerosis
- Heart disease
- Mental illness
- End-stage renal disease
If you qualify for SSDI for several months, become ineligible, and then regain your eligibility later, the months that SSDI benefits should have paid count toward your two-year waiting period. Nevertheless, there will be a gap in your Medicare coverage. You are unable to receive Medicare benefits while your appeal is pending.
What Medicare Advantage Plans Are Available for Disabled Beneficiaries Under the Age of 65?
If you are under the age of 65 and qualify for Medicare because of a disability, there are several types of Medicare Advantage plans that may meet your needs. They include Social Security Disability Advantage Plans and Medicare Advantage Special Needs Plans:
- Social Security Disability Advantage Plans: These options combine the coverage of Medicare Part A and Part B with additional benefits, such as vision, prescription drug, and dental coverage. You may also choose from PPO (Preferred Provider Organization) or HMO (Health Maintenance Organization) plans.
- Medicare Advantage Special Needs Plans: To be eligible for a Medicare Advantage Special Needs Plan (SNP), you must meet certain requirements, such as having a specific disabling, chronic health condition or being qualified for both Medicaid and Medicare. A Special Needs Plan is designed to meet the individual healthcare requirements of the beneficiary. However, this type of plan may or may not be available in your area.
If you qualify for SSDI benefits, you may also qualify for the Medicaid program in your state. It is important to note that having Medicaid does not prevent you from enrolling in Medicare. If you have Medicaid and choose an Advantage plan under Medicare, the two plans together will likely cover most— if not all— of your healthcare charges. Nonetheless, Medicare still requires the payment of its monthly premium.
Individuals who are eligible for Medicaid and Medicare are known as dual-eligible beneficiaries and can enroll in Dual Eligible Special Needs Plans (D-SNPs). These plans have low costs and often provide the beneficiaries with transportation to their medical appointments and back home. They may also offer meal delivery.
Are There Special Enrollment Periods for Medicare Advantage Plans?
If you have not reached 65, you may still enroll in a Medicare Advantage plan:
- At the time of your Initial Enrollment Period, which lasts six months. The Initial Enrollment Period starts three months before your enrollment in Medicare and concludes three months after the month in which your benefits start.
- At the time of your Annual Enrollment Period. This period starts on October 15th and ends on December 7th every year.
If you decide to drop your Advantage Plan coverage or switch your coverage to a different Medicare Advantage plan, you can make the changes between January 1st and March 31st, which is your Medicare Advantage Open Enrollment Period.
Is Medigap Coverage Available for Beneficiaries Under 65 With Disabilities?
If you are a disabled Medicare beneficiary under the age of 65, you may be concerned about covering the cost that remains after Medicare has paid its portion. However, it may be difficult to find a suitable Medicare Supplement (Medigap) plan if you are still under 65.
The availability of Medigap coverage differs from state to state and it is important to recognize the following:
- In some states, insurance companies are required to provide at least one Medicare Supplement Plan to beneficiaries under 65.
- In other states, there is no requirement.
- Some states don’t offer Medigap plans at all if you haven’t reached 65. Also, certain states only offer Medigap plans to beneficiaries with certain types of diseases, such as end-stage renal disease.
Is Medigap Coverage Expensive for Those Under 65?
Medigap rates typically increase each year. Additionally, you may have to answer questions about your health that could increase the cost of your coverage.
Original Medicare costs the same for beneficiaries, regardless of age. However, the cost of a Medigap policy can be much greater for disabled beneficiaries. In most cases, a Medicare Advantage plan is the best option for beneficiaries who are under 65 and disabled.
It’s important to note that when you reach 65, you will be eligible to enroll during the Medicare Supplement Open Enrollment Period. At that time, you can purchase a policy without answering health-related questions.
Can a Medicare Beneficiary Under 65 Choose Part D Coverage?
Part D coverage is available for disabled beneficiaries under age 65. The plan helps cover the cost of prescription drugs.
Although the plan is beneficial, you are still required to pay premiums and copays for the coverage. If the out-of-pocket costs are too expensive for your budget, you may be able to qualify for Extra Help, which is an asset and income-based assistance program. Enrollees on Medicaid qualify automatically.
Why Is a Medicare Advantage Plan the Best Choice for Beneficiaries Under 65 With Disabilities?
Medicare Advantage plans (Medicare Part C) may be the best choice for the following reasons:
- Medicare Advantage plans are convenient and less expensive than alternatives that offer the same amount of coverage.
- With Medicare Advantage plans, beneficiaries with disabilities can avoid certain costs and choose a plan that meets their individual needs.
- Medicare Advantage plans combine the coverage of Original Medicare with other benefits, such as prescription drug coverage. As a result, there is no need to buy Part D or Medigap plans.
- Many Medicare Advantage Plans also offer vision and dental coverage.
- they have annual out-of-pocket limits of about $7,550. For disabled enrollees, the limits could be particularly important as they may regularly incur costs for receiving treatment for their health conditions.
- With Original Medicare, there are no out-of-pocket limits for healthcare costs.
Can Disabled Children Qualify for Medicare?
If a child is under 20 and has end-stage renal disease, they can qualify for Medicare. However, they must require dialysis treatment regularly and have at least one parent who is eligible to receive retirement benefits from Social Security.
Young adults who are over 20 are eligible for Medicare after they have received SSDI benefits for 24 months or longer.
If a child is at least 19 years old but is not eligible for Medicare, they may still qualify for Medicaid. Moreover, children under 18 may qualify for the Children’s Health Insurance Program (CHIP) in their state if their family meets the low-income requirements.