Medicare and Disabilities: What You Should Know

April 26, 2023

Medicare and Disabilities: What You Should Know

For most beneficiaries, Medicare eligibility begins near. However, this is not the only qualifier for Medicare eligibility. Certain people with disabilities will qualify for Medicare enrollment before age 65. A few criteria must be met before one is eligible to receive Medicare before the age of 65.

End Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS)

Beneficiaries with either ESRD or ALS do not have to receive Social Security Disability benefits for 24 months to be eligible for Medicare.

A person with ESRD must wait three months after a regular course of dialysis or three months after a kidney transplant to become eligible for Medicare. For ESRD, there are some criteria you must meet to receive benefits. You must have worked the required time and paid Social Security. You can also join the Railroad Retirement Board or have been a government employee. Getting Social Security or Railroad Retirement Board benefits will also qualify you. These two criteria can enable you to be covered if your spouse also meets these criteria.

ALS is different because you are eligible for Medicare when collecting Social Security Disability benefits. There is typically a 5-month window between when a person is diagnosed with a disability and when they begin receiving Social Security Disability benefits.

How Can I Enroll in Medicare If I Have a Disability?

To enroll in Medicare with a disability, if you have been receiving Social Security Disability benefits for 24 months, you will automatically be enrolled. You will receive your Medicare card in the mail and a letter explaining that you are now enrolled in Medicare Part A and Part B. If you meet the standards but don’t qualify for Social Security Disability benefits, you can still purchase Medicare by paying a monthly premium for Part A and B.

What Are the Medicare Benefits People with Disabilities Receive?

The benefits people with disabilities receive through Original Medicare are the same as other beneficiaries who enroll in Original Medicare. This includes Medicare Part A coverage (inpatient care at a hospital, care in a skilled nursing facility, care in a nursing home, hospice care, and home health care) and Medicare Part B coverage (clinical research, ambulance services, durable medical equipment, and mental health care). These services don’t have to relate to a person’s disability.  Dual Special Needs Plans are a type of Medicare Advantage (Part C) plan that can offer personal care services and nursing home care that Original Medicare doesn’t cover for beneficiaries with certain conditions.

Are There Other Conditions that Can Disqualify Me from Medicare Enrollment?

Technically, no disabilities, illnesses, or underlying conditions disqualify someone from ever being enrolled in Original Medicare. Once someone meets the criteria for becoming Medicare eligible, they can enroll in Original Medicare. Beneficiaries can’t be denied coverage because of a timetable related to their condition or improvement of that condition. This means that people with mental illness, dementia, and other long-term chronic conditions could still possibly enroll in Medicare.

However, it is crucial to understand the eligibility requirements for Medicare and that not all conditions make an individual eligible for Medicare. If someone does not have conditions or disabilities making them eligible for Medicare before turning 65, they will still become eligible when they are turning 65.

Can Medicare Deny “Maintenance Only” Services?

Even if a service is considered “maintenance only,” meaning it is only expected to maintain a condition or slow deterioration, it can still be covered by Original Medicare. Examples of “maintenance-only services” include physical therapy, which may be critical to maintaining a livable variant of a condition. Some conditions are more at risk of being unfairly denied coverage for services than others.

Beneficiaries with conditions such as Alzheimer’s Disease, mental illness, Multiple Sclerosis, Parkinson’s Disease, and other long-term conditions are entitled to coverage if their provider order care that meets Medicare criteria. Consult with your doctor if you feel coverage has been wrongfully denied.

If I Have a Disability, Can I Still Work and Receive Medicare Coverage?

You can still work and receive Medicare coverage because of your disability. However, one must follow many guidelines while needing Medicare coverage while working with a disability. The Social Security Administration breaks this eligibility down into three time frames: Trial Work Period (TWP), Extended Period of Eligibility (EPE), and indefinite access to Medicare.

Trial Work Period (TWP)

If a disabled individual wants to try and work, they can do so and still receive Medicare during their Trial Work Period. The Trial Work Period consists of 9 months within any rolling 5-year period. A month is considered a month of service for a trial work period if it exceeds 2023’s amount of $1050 a month or if they work over 80 hours of self-employment monthly. It’s important to note that these nine months need not be consecutive. The beneficiary’s ability to perform their job cannot be used to disqualify them from receiving Medicare benefits – during the 9-month Trial Work Period. However, the work may be considered in determining the individual’s disability status and Medicare eligibility once the 9-month period has ended.  

Extended Period of Eligibility (EPE)

Beneficiaries whose disability is still active but who’ve earned income meeting or surpassing that of the “Substantial Gainful Activity” level can still receive Medicare coverage after their trial work period is over.

The Substantial Gainful Activity levels are levels of income an individual cannot pass and still receive Medicare benefits. For statutorily blind individuals in 2023, the monthly amount is $2460; for non-blind individuals, the monthly amount is $1470. Read more here.

The Extended Period of Eligibility lasts much longer than the trial work period; it can be extended as long as 93 months after it has ended. The beneficiary will pay no premiums for Medicare Part A; however, they are still responsible for their Medicare Part B premium. An individual’s Social Security Disability (SSDI) cash benefits may also end during this period.

Indefinite Access to Medicare

Suppose an individual remains medically disabled after the Extended Period of Eligibility (8.5 years) is up. In that case, they can still receive access to Medicare benefits if they are still considered medically disabled. They will however be required to pay both the Medicare Part A premium and the Medicare Part B premium. Original Medicare Part A’s premium will be determined by how many quarters you or your spouse worked and paid into Social Security. There is a helpful state-run buy-in program that can help low-income individuals pay these premiums.

Seniorstar Insurance Group can help with any Medicare questions you may have. Contact us today for a free, no-obligation review of your coverage.

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