Medicare for People with Disabilities: An Overview

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Medicare is our only national health insurance program, serving approximately 44 million Americans. It provides health benefits to nearly 7 million people younger than age 65 who have disabilities or chronic conditions.

Here, we review the 3 primary ways people with disabilities receive Medicare as well as their rights to health care, and access to services and equipment.

Topics on this page:

  1. Eligibility for Medicare Disability Benefits
  2. Your Health Care Rights
  3. Services, Equipment & Access

1. Eligibility for Medicare Disability Benefits

If You Are Under Age 65 — Social Security Disability Insurance (SSDI)

If you are age 18 to 64, your eligibility for Medicare is tied to your eligibility for Social Security Disability Income (SSDI) benefits. One exception is for people with end-stage renal disease (ESRD), who are automatically eligible for Medicare solely on the basis of having ESRD.

You must qualify for and receive SSDI monthly income benefits to be eligible for Medicare. SSDI benefits are based on work credits earned through Social Security, Railroad Retirement or Medicare-covered government employment. Note: If you don't have work credits and don't qualify for SSDI, you may qualify for other income benefit programs such as Supplemental Security Income (SSI). For more information, see If You Don't Qualify for SSDI.

To qualify for SSDI, you must be unable to work for a least one year because of a qualifying physical or mental impairment, a combination of impairments or a terminal condition resulting from an impairment. You can apply for SSDI at your local Social Security Administration office. Once you are approved for SSDI, you must wait 5 months for your income benefits to begin, and an additional 24 months before Medicare benefits begin.

However, there are 2 exceptions:

  1. Amyotrophic Lateral Sclerosis (Lou Gehrig's disease)

    If you have Amyotrophic Lateral Sclerosis (Lou Gehrig's disease), you can get Medicare the first month you get SSDI monthly income benefits.
  2. End-Stage Renal Disease

    If you have end-stage renal disease (ESRD), you can get Medicare within 3 months of your first dialysis treatment, regardless of whether you apply and qualify for SSDI. You are eligible for Medicare solely on the basis of having ESRD.

    If you are unable to work because of ESRD or other disabilities, you can apply for SSDI benefits. If you qualify, you will also be eligible for Medicare under an additional category of eligibility after 29 months, as long as your disability continues. If you have an another disability (in addition to ESRD) or later develop other health conditions that qualify for disability benefits, the Medicare benefits you receive due to disability will continue, even if you have a successful kidney transplant and lose Medicare coverage based solely on your ESRD eligibility.

    Note: Some people who have ESRD and no other disabilities continue to work and don't file for SSDI benefits. See our fact sheet Medicare & People with End-Stage Renal Disease (ESRD) (PDF) for more information.

Ongoing Eligibility for Medicare and SSDI

The Social Security Administration periodically reviews eligibility for SSDI. If your condition improves or you have a successful kidney transplant, you can lose your SSDI benefits and Medicare (unless you also have another disability or chronic health condition that qualifies you for SSDI).

However, if you no longer qualify for SSDI because your condition improves or you successfully complete a trial work period, you may still be able to keep your Medicare benefits. Federal legislation known as the Ticket Act allows a person with a disability who is eligible for Medicare and returns to work to keep his/her Medicare benefits (including free Part A coverage) for at least 8 1/2 years. See the Social Security website for more information.

If you lose your eligibility for SSDI and Medicare, and you have another qualifying condition, you may be eligible for Medicare coverage without the 29-month waiting period described above. However, you must apply for SSDI within 5 years of your original qualifying condition.

If You Don't Qualify for SSDI

Many people with disabilities, including children, are not eligible for Medicare benefits because they do not have the work credits to qualify for SSDI benefits. Children with disabilities and adults who are not eligible for SSDI are often eligible for Supplemental Security Income (SSI) benefits. People with SSI benefits are covered by Medi-Cal (California's Medicaid Program), not Medicare.

Note: Some SSDI beneficiaries who had a short work history are eligible for a small SSDI income benefit and a supplementary SSI income benefit. For more information on SSI, see our Medi-Cal section.

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2. Your Health Care Rights

The Americans with Disabilities Act of 1990 (ADA), federal legislation and California state law all prohibit discrimination on the basis of a disability. However, these laws are limited in a number of ways, and they don't require insurance companies to sell you policies.

Medical providers cannot refuse to treat you because you have a disability. But they can refuse to accept you as a new patient if they are refusing other Medicare patients, or if they don't treat anyone with Medicare. Medical providers are also permitted to refer you to another provider if the care you need is not within the scope of their practice.

If you think a physician or health care plan is denying your disability rights, file a complaint with your medical group, your plan and the U.S. Department of Justice (202-353-1555). If you need help, contact your local Health Insurance Counseling & Advocacy Program (HICAP) office (1-800-434-0222) for free counseling and information.

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3. Services, Equipment & Access

People younger than age 65 who have Medicare due to a disability occasionally have difficulty obtaining specialized Medicare-covered services, equipment and supplies. While some younger people are relatively healthy despite their disabilities, others have serious physical and mental conditions that require coordinated care from highly trained specialists. Some people also need unusual or customized equipment. In addition, certain specialized equipment and supplies may not be covered by Medicare. Getting the necessary services, equipment and supplies you need may depend on your (or a family member's) ability to advocate for it. This may involve a great deal of persistence.

You have the right to assistance or equipment that provides you with the same access as others to services and facilities. For example, if you have a hearing, speech or language disability, you have the right to an interpreter or some other method or equipment for communicating with medical providers. You have the right to accessible equipment, such as examination tables and mammography equipment that can accommodate wheelchair users. However, it must be reasonable for a medical provider to supply these accommodations, and doing so cannot create an "undue burden" on the financial resources of the provider. The U.S. Department of Justice, Civil Rights Division oversees these issues.

Your access to buildings that provide medical services should not be impeded or limited by physical barriers. Older buildings may not be required to meet the same standards as newer buildings, but they should have easily accessible elevators in working order, and their bathrooms should accommodate wheelchairs.

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Updated Feb. 27, 2009

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