What Disabilities Qualify for Medicare Under 65?

Oct 5, 2022

Did you know that you can potentially be eligible for Medicare years (or even decades) before your 65th birthday?

It turns out that some disabilities qualify for Medicare coverage, regardless of how old you are. In this article, you’ll discover which of these disabilities are eligible for Medicare coverage.

What Is Medicare?

First things first. You might be asking yourself, “What is Medicare?” In short, Medicare is a government-funded health care program that provides health insurance for people over the age of 65.

The health insurance program expanded under federal law in 1973 to extend benefits to disabled persons eligible for Social Security Disability Insurance (SSDI). In all, 16% of Medicare recipients are people under age 65.

How to Get Medicare if You Are Under Age 65

There are three distinctive ways to qualify for Medicare’s federal program if you have not reached your 65th birthday.

  1. Be disabled and receive SSDI funding for 24 consecutive months (with an additional five-month waiting period)
  2. Have end-stage renal disease (ESRD)
  3. Be diagnosed with amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease)

If you have a disability, the first step in qualifying for Medicare under age 65 is to apply for disability benefits through the Social Security Administration. In other words, you are not automatically eligible and have to go through some steps, especially in the area of disability determination.

Keep in mind that you will have to wait 24 months from the date your disability benefits begin to receive Medicare eligibility. Then, an additional five months must pass before you get your Medicare card.

To be eligible to receive SSDI benefits, the threshold is whether one can participate in “substantial gainful activity.” In short, can you work enough to earn up to a certain amount? If you are impaired physically or mentally for an extended period of at least 12 months, then you could qualify for SSDI, and, therefore, Medicare benefits after the 29-month period has passed.

People with disabilities must verify their health status with a medical provider, and the health statuses that make up the bulk of Medicare beneficiaries under age 65 include:

  • Mental illness, memory loss, and other cognitive impairments
  • Physical disabilities that limit mobility and daily function
  • Heart disease
  • Multiple sclerosis
  • Lupus
  • Cystic fibrosis
  • Parkinson’s disease

The above list is not exhaustive. Though not every disability qualifies for Medicare benefits due to a disability, the true test is whether the disability prohibits substantial gainful activity.

Is Medicare Free for Those Under Age 65?

It’s a common misconception that Medicare is 100% free, but that is not usually the case. While Medicare Part A is free for most beneficiaries, there is a monthly cost associated with Part B, which covers outpatient treatments. However, the cost of Part B is typically deducted from payments received for social security disability benefits.

How Younger Medicare Beneficiaries Increase Health Insurance Coverage

Just like people over age 65, younger, disabled Medicare beneficiaries typically find that traditional Medicare coverage doesn’t cover all of their medical costs, causing a coverage gap that causes them to incur out-of-pocket costs.

The health care services provided under traditional or original Medicare are Medicare Parts A and B. Part A functions as hospital insurance, and when you purchase Medicare Part B, it covers outpatient services. There are still coverage gaps for other medical services, including dental and vision benefits and prescription coverage.

Not having adequate healthcare coverage, especially for people with disabilities, can be problematic because it can lead to failure to get both preventive services and necessary treatment for conditions.

Individuals with lower incomes may qualify for Medicaid, while others choose supplemental insurance such as Medigap, Medicare Advantage plans, or Medicare Part D drug coverage.

In terms of numbers, 2% of Medicare recipients under age 65 have Medigap, and 27% have enrolled in Medicare Advantage plans. Medigap makes up a smaller percentage because insurance companies are not required to sell Medigap policies.

Due to the cost and importance of prescription drugs, the bulk (75%) of Medicare recipients under age 65 have Medicare Part D to help cover the cost. This plan can be purchased individually, or it can be part of a Medicare supplement. For those who have a Medigap plan, prescription drug coverage will need to be purchased separately.

Supplemental Medicare Options

When you enroll in Medicare, you can choose whether a Medigap policy or Medicare Advantage is a better choice. If you didn’t make this choice during your initial enrollment period, Medicare beneficiaries can adjust their plans during the open enrollment periods.

Typically, Medigap policies are more costly for disabled persons under age 65, so a Medicare Advantage plan is usually the best option. The following “advantages” often apply:

  • Prescription drug coverage may be included
  • Additional services, including dental and vision benefits may be available
  • There is an annual cap on out-of-pocket expenses
  • It tends to be less expensive
  • Monthly premiums are relatively low or nonexistent

Medicare also includes unique plans for people with disabilities, called Special Needs Plans (or SNPs for short). These plans are not available everywhere, but an agent specializing in Medicare can check local availability.

Though Medicare Advantage is often the preferable choice for people under the age of 65, there are still costs to be aware of, including:

  • Copays
  • Coinsurance
  • Out-of-pocket expenses

Further, you may be restricted by your plan’s provider network, so make sure you know where you can for medical care when needed.  

The Bottom Line

Medicare is a valuable safety net for people of all ages, but those with disabilities, ERSD, and ALS are particularly vulnerable to high medical bills without having the financial resources to cover those costs.

A Medicare supplement plan can help ease the burden of medical bills, reducing stress and offering peace of mind. You can learn more about Medicare supplement plans here or contact us to get a quote.