Medicare and people with disabilities: an overview

Eligibility for Medicare Disability Benefits

Eligibility for people under age 65

For adults aged 18 to 64, eligibility for Medicare is tied to eligibility for Social Security Disability Income (SSDI) benefits. One exception is people with end stage renal disease (ESRD). These people are eligible for Medicare solely on the basis of having ESRD. See below.

You must qualify for and receive SSDI monthly income benefits in order to be eligible for Medicare. SSDI benefits are based on work credits earned through Social Security, Railroad Retirement, or Medicare-covered government employment.

To qualify for SSDI, you must be unable to work for a least a year because of a qualifying physical or mental impairment, or combination of impairments, or be expected to die as a result of an impairment.

Apply for SSDI at your local Social Security Administration office. Once you have been approved for SSDI, you must wait 5 months before your SSDI monthly income benefits begin, and an additional 24 months before Medicare benefits begin.

Amyotrophic lateral sclerosis (ALS) (Lou Gehrig's disease)

If you have amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease, you can get Medicare the first month you get SSDI monthly income benefits.

End-stage renal disease (ESRD)

If you have end-stage renal disease (ESRD) — permanent kidney failure — you can get Medicare within 3 months of your first dialysis treatment.

If you are unable to work because of ESRD, or if you have other disabilities, you can file for SSDI to get monthly income benefits. If you qualify for those benefits, you will also be eligible for Medicare under an additional category of eligibility after 29 months, as long as you continue to have a disability. Again, people with ESRD are eligible for Medicare solely on the basis of ESRD, regardless of whether they have any other qualifying disability.

If you have or you later develop other health conditions, the Medicare benefits you receive due to disability will continue, even if you have a successful transplant and lose Medicare based solely on your ESRD eligibility.

Some people with ESRD without any other disability continue to work and don't file for SSDI benefits.

Ongoing eligibility for Medicare and SSDI

The Social Security Administration periodically reviews eligibility for SSDI. If your condition improves, or if you have a successful transplant, you can lose your SSDI benefits and Medicare.

However, if you no longer qualify for SSDI because your condition improved or you successfully completed a trial work period, you may still be able to keep your Medicare benefits. Newly enacted federal legislation (known as the Ticket Act) will, for the first time, allow a person with a disability who continues to be eligible for Medicare and who returns to work to keep their Medicare benefits (Part A free) for at least 8.5 years.

Even if you become ineligible for SSDI and Medicare, if you have another qualifying condition and apply for SSDI within 5 years, you may be eligible for Medicare again without the 29-month waiting period.

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 Social Security Disability Income (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 the State of California's Medi-Cal health benefits, not by Medicare.

Note: Some SSDI beneficiaries who had a short or small work history can be eligible for a small SSDI cash benefit and an SSI cash benefit to supplement it. For more information on SSI, see our section on Medi-Cal.

Your health care rights

People younger than age 65 who have Medicare frequently have unique problems obtaining specialized Medicare-covered services, equipment, and supplies.
While some younger people with Medicare are relatively healthy individuals who have a disabling condition, others have serious physical or mental conditions requiring coordinated care from highly trained specialists. Some also need unusual or customized equipment. Getting needed care may depend on your or a family member's ability to advocate for that care. If you need help, contact your local Health Insurance Counseling and Advocacy Program (HICAP) office (1-800-434-0222) for free counseling and information.

People with disabilities may have greater needs for specialized equipment and supplies, and these may not be covered by Medicare.

Medical providers cannot refuse to treat you because you have a disability. But they can refuse to take you as a new patient if they are turning away 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.

The Americans with Disabilities Act of 1990 (ADA), other federal legislation, and California state law all prohibit discrimination on the basis of a disability. However, those rights are limited in a number of ways, and they don't require insurance companies to sell you health insurance. If you think a physician or health care plan is denying your disability rights, you can file a complaint with your medical group, your plan, and the Department of Justice at 202-353-1555. Your local Health Insurance Counseling and Advocacy Program (HICAP) office (call 1-800-434-0222) may know of other resources in your area.

Services, equipment, buildings & access

You have the right to assistance or equipment to provide you with equal access to services and facilities. For instance, if you have a hearing, speech, or language problem, 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 it can't create an "undue burden" on the financial resources of the provider to do so.

Your access to buildings that provide medical services should not be impeded or limited by physical barriers. However, older buildings may not have to meet the same standards as newer buildings. You should, however, expect that elevators be in working order and easily accessible, and that bathrooms be able to accommodate wheelchairs.

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Page updated April 29, 2008