Medicare & Disability

Medicare & Disability: Things You Need to Know

Not everyone eligible for Medicare is 65 or older. Although the elderly tend to have increased medical needs, the federal government recognizes that many younger individuals also have serious health problems. And people with disabilities are part of this equation.

Now the question arises of what counts as a disability to be eligible for Medicare.

When someone breaks his leg, they can be put in a cast and given medical advice not to bear weight on the leg. 

But is he disabled? 

Maybe in the short term, but with an expected recovery of a few weeks away, it can be a tough argument to make for the long haul. For Social Security disability insurance purposes, the impairments must last at least 12 months.

How Medicare Defines Disability

The definition of disability may vary from person to person, but Medicare guidelines leave no room for interpretation. Therefore, if you fall into any of the following categories, you meet the disability criteria for Medicare eligibility.

Amyotrophic Lateral Sclerosis (ALS)

ALS is also known as Lou Gehrig’s disease. It is a debilitating neurological disease that can cause muscle atrophy, breathing difficulty, and even death. 

It is estimated that sixteen thousand Americans have this disease at any one time. The rapid progression and severity of the disease require a high level of medical care and services. In that case, you qualify for Medicare immediately, and you should apply as soon as possible. There is no waiting period.

End-Stage Renal Disease (ESRD)

According to the Centers for Disease Control and Prevention, estimations have found that about 15 percent of Americans have chronic renal disease. In addition, each year, more than 100,000 people develop kidney failure, also known as end-stage kidney disease. When your kidneys are damaged, your body is unable to remove toxins from the body. As a result, you will need dialysis treatment or a kidney transplant to survive.

Your coverage benefit starts three months after you start dialysis treatment. However, if you have a kidney transplant, Medicare coverage may not remain active for the long term. 

The program will provide 36 months of coverage after a Medicare-approved transplant. After that, if your new kidney remains active, you’ll no longer be eligible for Medicare, and you will also lose your coverage.

Social Security Disability Insurance (SSDI)

Many other medical conditions may qualify as disabilities. To be recognized as eligible for Medicare, the individual must go through the rigorous Social Security Disability Insurance (SSDI) application process. This process can take several months to complete.

It may take 3 to 6 months for the Social Security Administration to approve your application. However, the application process can be accelerated if your medical condition is on the list of Compassionate Allowances Conditions.

After approval of your application, there is a waiting period of five months before you can receive the SSDI benefits.

You will not be eligible for Medicare until you have received SSDI benefits for at least 24 months. Adding up all of these timeframes, you’ll wait at least 29 months, and it can be as long as 35 months in the worst case before you receive Medicare benefits.

Original Medicare With SSDI

Once a person meets the criteria for SSDI, they are eligible for auto-enrollment in Medicare Parts A and B, collectively known as Original Medicare.

Below, a few things to know about the scope and cost of each part.

Medicare Part A with SSDI

Medicare Part A covers inpatient hospital stays, with the costs of:

  • hospitalization, such as the cost of the meals and the room
  • diagnostic testing
  • skilled nursing care
  • medical tests
  • blood transfusions


People receiving Social Security Administration or Railroad Retirement Board benefits and those receiving SSDI benefits for two years do not pay a premium for Medicare Part A.

Part A has a deductible of $1,484 in 2021 for inpatient hospital stays. Once this requirement has been met, Medicare covers the first 60 days of hospital stay. If the stay lasts more than 60 days, additional out-of-pocket charges apply.

Medicare Part B with SSDI

Part B pays for outpatient medical services, such as:

  • visits to a doctor
  • ambulance services
  • mental health services
  • outpatient care
  • durable medical equipment and prosthetics
  • limited prescribed drugs
  • some preventive care
  • physical therapy


Medicare automatically deducts Part B premiums from SSDI payments, although the standard Part B premium is $148.50 for 2021.

An additional cost is the Part B deductible, which is $203 in 2021. Once someone meets their deductible, they pay 20% of the Medicare-approved amount for covered services.

If a person has health care coverage from another source, such as their partner’s employment, they can opt-out of Medicare Part B coverage.

However, a late enrollment penalty may apply if a person does not register in Part B when applying for the first time.

A Pattern of Medicare Beneficiaries Under 65 (With Disabilities) Compared to Beneficiaries Age 65 Or More

Medicare beneficiaries under the age of 65 with disabilities differ from beneficiaries age 65 or older in several ways, including their demographic, socioeconomic profile, and health status.


In 2012, a much more significant proportion of disabled beneficiaries under 65 had lower annual incomes than older beneficiaries. About a quarter (24%) of disabled youth beneficiaries had an income of less than $10,000 a year, and two-thirds (67%) had an income less than $20,000 a year, compared to 13% and 39%, respectively, of old beneficiaries.

Health Conditions

About two-thirds of all younger Medicare beneficiaries (65%) had cognitive or mental impairment in 2012, compared with 29% of older beneficiaries. These include memory loss that interferes with daily activities, such as difficulty making decisions, difficulty concentrating, and loss of interest. 

In addition, nearly 6 out of 10 (59%) said their health condition was fair or poor, and an almost equal proportion (58%) reported having one or more limitations in their activities of daily living, compared to 20% and 34% of beneficiaries age 65 or older, respectively. 

Race/ethnicity and Gender

A more significant proportion of beneficiaries under 65 are black (18% and 8%, respectively) and Hispanic (13% and 9%, respectively), and a more significant share are male (53% and 44%, respectively).

In a nutshell, the beneficiaries under 65 (with disabilities) have been more challenged than beneficiaries of age 65 or older. And this includes being challenged financially as well. Thus, the need for medical coverage becomes obvious.

If you or someone in your family, unfortunately, is dealing with disability or any of the mentioned diseases and facing hardships in enrolling for Medicare, consider giving us a chance to assist you. Our licensed agents specializing in Medicare will educate you about the associated terms, share a suitable plan, and help you get enrolled in Medicare.

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