By Andrea K. Kovar, Attorney, Generation Law

Medicare was established in 1965 to provide health insurance for Americans aged 65 and over, but it also covers more than eight million people with disabilities under age 65. Qualifying for Medicare is a process that begins with an application for Social Security Disability Insurance (SSDI) benefits.

The Social Security Administration (SSA) must first determine whether you are unable to engage in “substantial gainful activity.” That is, you are unable to work for a period of at least one year due to a qualifying physical or mental impairment, a combination of impairments, or a terminal condition resulting from an impairment. In addition, SSDI benefits are based on work credits earned through Social Security, Railroad Retirement, or Medicare-covered government employment. If you do not have work credits and do not qualify for SSDI on your own work record, you may be able to qualify as a widow or widower under age 65 with disabilities based on your spouse’s work credits or as a disabled adult child of a retired, deceased, or disabled worker. You can apply for SSDI at your local SSA office.

Once you are approved for SSDI, you must wait five months before SSDI payments begin, followed by a 24-month waiting period before Medicare coverage can begin. There are two exceptions to the five-month waiting period requirement. Individuals diagnosed with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) immediately qualify for Medicare.

The cost associated with original Medicare (Parts A and B) is the same for individuals aged 65 and over and disabled individuals under 65. Most Medicare beneficiaries, including disabled beneficiaries under 65, purchase public or private supplemental insurance to help cover Medicare’s coverage gaps (Medigap). However, there is a big difference in the cost of Medigap policies between the two groups. Medigap policies are much pricier for disabled Medicare beneficiaries under 65 than for individuals aged 65 and over. This cost differential forces many disabled beneficiaries under age 65 to rely on Medicaid to supplement Medicare health coverage. Medicaid helps with Medicare premiums and deductibles, coinsurance, copayments, or similar charges. Further, Medicaid covers services needed by many people with disabilities that Medicare does not provide, particularly long-term services and supports.

You may be able to return to work and keep your Medicare coverage if your disability responds to treatment. If this occurs, you should speak to a representative at your local SSA office about how many hours you are allowed to work and retain your SSDI benefits. If the SSA deems your return to work to be substantial gainful activity, your SSDI payments will end but you will remain eligible for Medicare for a period of seven years thereafter. If your new employer provides health insurance benefits, your employer-provided policy will become the primary payer (if there are more than 100 employees) and Medicare will become secondary (but still available in case your circumstances change).