Summary: You may qualify for Medicare under the age of 65 if you have a disability or have been diagnosed with ESRD or ALS. In this article, we’ll cover the requirements to qualify for Medicare earlier than 65 and what coverage options are available when you enroll. Estimated Read Time: 7 min
Qualifying for Medicare Under 65
Medicare is a federal health insurance program for individuals over 65 or those who have a qualifying disability. You may be eligible for Medicare before you turn 65 if you have End-Stage Renal Disease (ESRD), ALS (Lou Gehrig’s disease), or if you are receiving Social Security disability benefits for at least 24 months.
When you qualify for Medicare before you turn 65, you may automatically be enrolled. If you receive disability benefits, you will automatically be enrolled in Medicare once you’ve received benefits for 24 months. If you are not automatically enrolled in Medicare coverage, you must sign up through the Social Security Administration.
The timeframe in which you become eligible for Medicare before age 65 is known as your Initial Enrollment Period. During this period, you have the opportunity to make choices regarding your coverage, such as picking up a Medicare Part D Prescription Drug plan or delaying your Medicare Part B coverage. Once you turn 65, you will be given a second Initial Enrollment Period.
Getting Medicare Before 65 Due to a Disability
You are eligible for Medicare under 65 if you receive disability benefits from Social Security or the Railroad Retirement Board. You will automatically be enrolled in Medicare Part A and Part B after getting disability benefits for 24 months. There is typically a 5-month waiting period before you receive your first Social Security disability benefit, so there will be 29 months between qualifying for SSDI and receiving Medicare coverage.
To qualify for Social Security Disability Insurance (SSDI) benefits, you must:
- Have worked long enough (and recently enough) and paid Social Security taxes
- Have a medical condition that meets Social Security’s definition of a disability
Work credits for Social Security are based on your total yearly wages. You can earn up to four credits each year; typically, you need 40 credits to qualify for disability benefits. However, depending on your age, you may qualify with fewer credits.
Individuals diagnosed with ALS, also called Lou Gehrig’s disease, should apply for Social Security disability benefits to get Medicare coverage. If you have ALS, you will automatically get Medicare Part A and Part B the month your disability benefits start.
If you qualify for SSDI benefits, you may also be eligible for Medicaid. In some states, SSDI recipients automatically qualify for Medicaid, whereas other states will require you to fill out an application. You can contact your state’s Medicaid office for more information on their application process.
Medicaid can help cover some out-of-pocket costs of Medicare, such as deductibles, copayments, and coinsurance. Your state will pay your Medicare Part B monthly premiums if you qualify for full Medicaid coverage. Medicaid may also cover some services or prescriptions that Medicare doesn’t cover.
You may also qualify for Extra Help. You will automatically be enrolled in the Extra Help program if you receive full Medicaid benefits. This low-income subsidy helps lower drug costs for individuals with limited income and resources. If you are not enrolled in Medicaid, you can apply for Extra Help through Social Security.
Medicare Coverage Options for People Under 65 With a Disability
Three months prior to your coverage start date, you will be mailed a Medicare welcome package directly from Medicare that includes your Medicare card, a letter, and a booklet. At this time, you should review your Medicare coverage options and decide which options work best for your healthcare needs and budget.
If you’re getting Medicare before 65 due to a disability, you will get both Medicare Part A and Part B unless you delay or opt out of coverage. Many people do not have to pay a Medicare Part A premium due to paying Medicare taxes while working. However, most people must pay a monthly premium for their Medicare Part B coverage. If you have group coverage through your spouse, you may consider delaying your Medicare Part B until you lose your existing coverage.
Remember, if you’re receiving full Medicaid benefits from your state, you may not have to pay your Medicare Part B premium. Review your Medicaid coverage or contact your state’s Medicaid office to learn which Medicare costs are covered.
Once you enroll in Medicare, you will become eligible for other coverage options, including Medicare Part D Prescription Drug plans, Medicare Advantage plans, and Medicare Supplement plans.
Note about Medicare Supplement plans for individuals under 65: Companies are not required by federal law to offer Medigap plans to people under 65. Whether you can buy a Medigap policy before you turn 65 will depend on your state and plan availability. You can contact your State Insurance Department for more information.
Instead of getting your hospital and medical coverage through Original Medicare, you may choose to enroll in a Medicare Advantage plan. Depending on plan availability, you may be eligible to enroll in a Special Needs plan. These plans are specially tailored to meet the needs of people with specific diseases or healthcare needs. You may also qualify for a Special Needs plan (SNP) if you are enrolled in both Medicare and Medicaid and if SNPs are available in your area.
As mentioned above, if you want to enroll in a Medicare Part D prescription drug plan, you may qualify for Extra Help. For those eligible for Medicaid, you can still receive Extra Help if you meet certain income and resource requirements. If you need help paying for prescription drug coverage, you should apply for the Extra Help program, even if you exceed the income and resource limits.
Medicare Eligibility Due to ESRD
Individuals with End-Stage Renal Disease (ESRD) are eligible for Medicare regardless of age if specific requirements are met. End-Stage Renal Disease is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant.
To qualify for Medicare due to ESRD, the following must apply:
- Your kidneys no longer work
- You need regular dialysis or have had a kidney transplant
You must also have worked the required time to qualify for benefits through Social Security or the Railroad Retirement Board. You can also qualify through your spouse or parent if they worked long enough to be eligible for Social Security or RRB benefits.
You can sign up for Medicare Part A and Part B if you meet the above requirements. Though you are not required to sign up for either part of Medicare, you will need both Part A and Part B to receive the full benefits and coverage for certain dialysis and kidney transplant services.
Regardless of when you sign up and are approved for Medicare due to ESRD, you will not have to pay a late enrollment penalty for Medicare Part B. Suppose you already signed up for Medicare because of age or disability and are currently paying a late enrollment penalty for Part B. In that case, you must sign up again for Medicare (due to ESRD) to stop paying the penalty.
When you sign up for Medicare due to ESRD, your coverage could start up to 12 months before the month you apply. For example, if you became eligible for Medicare under ESRD in May but didn’t sign up for Medicare coverage until December, your Medicare coverage will start in May. This means any unpaid Medicare-covered services you received from May to December would be billed to Medicare. This is known as retroactive coverage.
If you have begun receiving dialysis treatments, your Medicare coverage usually starts on the first day of the fourth month of treatments. This four-month period begins even if you have not signed up for Medicare. So, if you sign up for Medicare after seven months of dialysis treatments, you will receive retroactive coverage for treatments you receive after the first four months. Your coverage may start earlier if you complete home dialysis training.
Get Help Signing Up for Medicare Before Age 65
Do you meet Medicare qualifications under 65? Most individuals who are eligible for Medicare before they turn 65 have just as many coverage options as those who qualify due to age. If you have questions regarding Medicare eligibility and the application process, give us a call. Our team of licensed insurance agents can help answer your Medicare questions.
Sources
End-Stage Renal Disease (ESRD), Medicare. Accessed August 2023.
https://www.medicare.gov/basics/end-stage-renal-disease
Disability Benefits | How You Qualify, Social Security. Accessed August 2023.
https://www.ssa.gov/benefits/disability/qualify.html
Medicare Information, Social Security. Accessed August 2023.
https://www.ssa.gov/disabilityresearch/wi/medicare.htm
How Do I Sign Up for Medicare, Medicare. Accessed august 2023.
https://www.medicare.gov/basics/get-started-with-medicare/sign-up/how-do-i-sign-up-for-medicare
