Medicare is a federal health insurance program for those 65 or older but may give exceptions to those younger than 65. Medicare is necessary because it provides health coverage for unexpected medical needs.
For example, a broken hip treatment may average about $5,427 out of pocket. With Medicare, you may only have to pay part of the medical bill, having Medicare pick up the rest. In turn, this could limit how much you would be paying out-of-pocket.
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What Disabilities Qualify for Medicare Under 65?
If you’re under 65, you may only be eligible for Medicare if you have one or more of the following:
- End-stage renal disease (ESRD): ESRD occurs when your kidneys fail, and you must receive dialysis or a kidney transplant. In this situation, you’re automatically eligible and may enroll in Medicare by visiting your local Social Security office.
- Amyotrophic lateral sclerosis (ALS): ALS is a nervous system disease that reduces muscle function. Like ESRD, you’re automatically eligible for Medicare the first month after receiving your Social Security Disability Insurance (SSDI) or Railroad Retirement Board Disability check.
- Social Security Disability Insurance eligibility: The purpose of SSDI is to provide monthly benefits to those unable to work due to their disability. You may begin receiving monthly benefits after five months of disability. The Social Security Administration administers this federal program.
- Railroad Retirement Board Disability Benefits Eligibility: Instead of your enrollment going through Social Security, enrollment for disabled or retired railroad beneficiaries may process through the Railroad Retirement Board. At the time of eligibility, you may automatically enroll in Part A and Part B of Medicare.
Children under 20 years old with disabilities may only enroll for Medicare if they’re diagnosed with End-Stage Renal Disease that requires them to receive dialysis or a kidney transplant.
Medicare Waiting Periods for Those Under 65
Those eligible for SSDI benefits may qualify for Medicare after a 24-month waiting period. This waiting period ensures coverage for individuals with severe disabilities that may affect them from working.
In the case that you are denied disability on an initial SSDI application, you may apply for an appeal within 60 days. If you are granted disability after appeal, you may still be eligible for Medicare after 24 months.
Who Can Skip the Waiting Period?
There may be exceptions to the two-year waiting period for those under 65 who have amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ESRD).
Individuals with ALS may need constant medical attention as their disease may progress rapidly. Those with ALS may enroll in Medicare immediately after getting approved for SSDI.
Medicare coverage for individuals with ESRD may begin the first day after their fourth month of dialysis treatment.
How to Enroll in Medicare When You’re Under 65
To enroll in Medicare under 65 years old, you must be eligible for SSDI benefits for two years. You may apply for SSDI benefits online or by phone at ssa.gov. After the Medicare waiting period, you may automatically qualify for Part A and Part B of Medicare.
Individuals with ALS and ESRD are automatically enrolled in Medicare and may skip the waiting period.
What You Need to Enroll in Medicare For Those Under 65
Since you must be eligible for SSDI to enroll in Medicare, the personal and medical information on your SSDI could automatically qualify for Medicare. The Social Security Administration needs updated information about your medical history and disability. If requested, you may have to fill out a disability update report that you can fill out online or by mail.
You may contact your local Social Security Administration for any questions or concerns about your application.
When to Enroll in Medicare For Those Under 65
You could automatically be enrolled in Medicare the first month after your waiting period is up. You receive your Medicare card three months before your effective date of coverage.
If you do not receive your Medicare packet three months before your waiting period ends, you may need to contact your local Social Security office for verification.
Medigap for Medicare Beneficiaries Under 65
Although there are costs that Original Medicare may cover, Original Medicare may not cover all of the expenses. Medicare supplement plans may be helpful, as they work alongside Original Medicare to cover out-of-pocket costs such as coinsurance, deductibles, and copays.
Depending on the state you live in, states make their own rules to provide Medigap for those who are under 65. Some states do not have Medigap plans for beneficiaries under 65, have limited Medigap policies, or require their beneficiaries to have Medigap. To check if your state has or does not have a Medigap policy, visit medicareresources.org.
Medicare Advantage for Medicare Beneficiaries Under 65
Anyone eligible for Original Medicare may also qualify for Medicare Advantage. Medicare Advantage, also known as Part C, provides Part A and Part B of Original Medicare. These plans may offer more benefits, such as transportation from the doctor or hospital, discounted gym memberships, and dental and vision insurance.
You may enroll in a Medicare Advantage during the annual open enrollment date, October 15 to December 7.
Special Needs Plans for Medicare Beneficiaries Under 65
Special Needs Plans (SNP) are Medicare Advantage plans tailored to individuals with specific diseases. These plans work with and offer particular healthcare providers and drug prescriptions for the individual. This plan works for people in the following situations:
- You live in a nursing home or require nursing care.
- You qualify for Medicare and Medicaid.
- You Have End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia.
SNP plans may be a good idea for those under 65 years old if you have any of the above conditions, as they target the individual’s specific needs and provide care coordination services.
Medicare Part D for Medicare Beneficiaries Under 65
Individuals eligible for Original Medicare may qualify for Part D, a prescription drug plan. Part D helps cover the cost of drug prescriptions, which benefits those who take expensive medications. Note that if you have a Medicare Advantage plan offering Part D, you may apply for a separate Part D.
You may change or enroll in Part D during the annual open enrollment period, October 15 to December 7.
Savings Programs for Medicare Beneficiaries Under 65
There are some savings programs to help with the costs of Medicare, but the Qualified Disabled and Working Individuals (QDWI) program is specifically for individuals with disabilities. This program allows you to get help from your state to pay for your Medicare Part A premiums. Other saving programs to help with Medicare are:
- Extra Help: To enroll in Extra Help, you must have limited resources and income. This program helps pay an individual’s monthly premiums, annual deductibles, and copays.
- Medicare Savings Program: You may get help through your state to pay for your Part A and Part B premiums. The Medicare Savings Program program may help pay for your deductibles, copays, and coinsurance in certain circumstances.
- Qualifying Individual (QI) Program: This program helps pay your Part B premiums. To enroll, you must have Part A and Part B and reapply yearly to be in the program.
The Cost of Medicare
Read below to learn how much Medicare could cost you:
You may have to pay a monthly fee for your Part B of Original Medicare, which is Medical Insurance coverage. Since 2022, the cost of Part B has been $170.10 each month. You do not have to pay for Part A of Original Medicare.
Coinsurance is when the insurer pays a percentage of a hospital bill. Part A of Original Medicare does not have coinsurance, but Part B does. In 2022, if your healthcare provider accepts the Medicare-approved amount of your treatment, Medicare may pay up to 80% of the service.
Original Medicare does not have copays, but specific Medigap plans, Medicare Advantage Plans, and Part D may have copays. Copayments are a fixed amount you pay when you see a doctor or pick up your medications. Copays vary by plan.