Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

Medicare Coverage for People with Disabilities

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Medicare is available for certain people with disabilities who are under age 65. These individuals must have received Social Security Disability benefits for 24 months or have End Stage Renal Disease (ESRD) or Amyotropic Lateral Sclerosis (ALS, also known as Lou Gehrig’s disease). There is a five month waiting period after a beneficiary is determined to be disabled before a beneficiary begins to collect Social Security Disability benefits.  People with ESRD and ALS, in contrast to persons with other causes of disability, do not have to collect benefits for 24 months in order to be eligible for Medicare.

The requirements for Medicare eligibility for people with ESRD and ALS are:

  • ESRD – Generally 3 months after a course of regular dialysis begins or after a kidney transplant
  • ALS – Immediately upon collecting Social Security Disability benefits.

People who meet all the criteria for Social Security Disability are generally automatically enrolled in Parts A and B.  People who meet the standards, but do not qualify for Social Security benefits, can purchase Medicare by paying a monthly Part A premium, in addition to the monthly Part B premium.

HOW DO PEOPLE WITH DISABILITIES ENROLL IN MEDICARE?

People who qualify for Social Security Disability benefits should receive a Medicare card in the mail when the required time period has passed. If this does not happen or other questions arise, contact the local Social Security office.

WHAT MEDICARE BENEFITS ARE AVAILABLE FOR PEOPLE WITH DISABILITIES?

Medicare coverage is the same for people who qualify based on disability as for those who qualify based on age. For those who are eligible, the full range of Medicare benefits are available. Coverage includes certain hospital, nursing home, home health, physician, and community-based services.  The health care services do not have to be related to the individual’s disability in order to be covered.

PEOPLE WITH DEMENTIA, MENTAL ILLNESS, AND OTHER LONG-TERM AND CHRONIC CONDITIONS CAN OBTAIN COVERAGE

There are no illnesses or underlying conditions that disqualify people for Medicare coverage.

Beneficiaries are entitled to an individualized assessment of whether they meet coverage criteria.

Although there are criteria that must be met to obtain coverage for particular kinds of care, Medicare should not be denied based on the person’s underlying condition, diagnosis, or other “Rules of Thumb.”  For example:

  • Beneficiaries should not be denied coverage simply because they will need health care for a long time.
  • Beneficiaries should not be denied coverage simply because their underlying condition will not improve.

COVERAGE SHOULD NOT BE DENIED SIMPLY BECAUSE THE SERVICES ARE “MAINTENANCE ONLY” OR BECAUSE THE PATIENT HAS A PARTICULAR ILLNESS OR CONDITION

Physical therapy and other services can be covered even if they are only expected to maintain or slow deterioration of the person’s condition, not to improve it.

People with certain conditions are at particular risk for being unfairly denied access to Medicare coverage for necessary health care.

People with these and other long-term conditions are entitled to coverage if the care ordered by their doctors meets Medicare criteria:

  • Alzheimer’s Disease
  • Mental Illness
  • Multiple Sclerosis
  • Parkinson’s Disease

If it seems that Medicare enrollment or coverage has been unfairly denied, ask the individual’s doctor to help.

Medicare Coverage for Working People with Disabilities

Medicare eligibility for working people with disabilities falls into three distinct time frames.  The first is the trial work period, which extends for 9 months after a disabled individual obtains a job.  The second is the seven-and-three-quarter years (93 months) after the end of the trial work period.  Finally, there is an indefinite period following those 93 months.(See the statute at 42 U.S.C. § 422(c), and regulation at 20 C.F.R. § 404.1592). Keep in mind that Medicare eligibility during each of these periods applies only while the individual continues to meet the medical standard for being considered disabled under Social Security rules.

  • Trial Work Period (TWP)

An individual who is receiving Social Security disability benefits is entitled to continue receiving Medicare as well as Social Security income during a maximum 9 month “trial work” period during any rolling 5 year time period.  To qualify, an individual must meet a monthly gross earnings threshold (see http://www.ssa.gov/oact/cola/twp.html) or work more than 80 hours of self-employment per month.  The nine months of the trial work period do not necessarily have to be consecutive.  During the trial work period, the ability to perform such work will not disqualify the individual from being considered disabled and receiving Social Security and Medicare benefits.   However, independent evidence that the individual is no longer disabled could end benefits during the trial work period.  After the nine month trial work period has ended, the work performed during it may be considered in determining whether the individual is no longer disabled, and thus no longer eligible for Social Security income and Medicare benefits.

  • Extended Period of Eligibility (EPE)

Individuals who still have the disabling impairment but have earned income that meets or exceeds the “Substantial Gainful Activity” level can continue to receive Medicare health insurance after successfully completing a trial work period.  Substantial Gainful Activity Levels can be found at http://www.socialsecurity.gov/oact/cola/sga.html.

This new period of eligibility can continue for as long as 93 months after the trial work period has ended, for a total of eight-and-one-half years including the 9 month trial work period.  During this time, though SSDI cash benefits may cease, the beneficiary pays no premium for the hospital insurance portion of Medicare (Part A).  Premiums are due for the supplemental medical insurance portion (Part B).  If the individual’s employer has more than 100 employees, it is required to offer health insurance to individuals and spouses with disabilities, and Medicare will be the secondary payer.  For smaller employers who offer health insurance to persons with disabilities, Medicare will remain the primary payer.

  • Indefinite Access to Medicare

Even after the eight-and-one-half year period of extended Medicare coverage has ended, working individuals with disabilities can continue to receive benefits as long as the individual remains medically disabled.  At this point the individual – who must be under age 65 – will have to pay the premium for Part A as well as the premium for Part B. The amount of the Part A premium will depend on the number of quarters of work in which the individual or his spouse have paid into Social Security.  Individuals whose income is low, and who have resources under $4,000 ($6,000 for a couple), can get help with payment of these premiums under a state run buy-in program for Qualified Disabled and Working Individuals.

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