While most people get health insurance through their employer, someone with a disability may not be able to do so. If you have a disability that prevents you from working, you may be wondering how you can get healthcare.
Know that you have options.
The government’s healthcare program can help you pay for doctor’s appointments and medicine. If you are eligible for disability benefits, you also qualify for government health insurance.
We’ll be unpacking everything you need to know about Medicare in relation to Social Security Disability Insurance (SSDI) in this article.
What is Medicare?
If you have a disability and can’t work, it can be difficult to afford private health insurance. Because it’s critical to have healthcare coverage in the United States, the federal government has provided Medicare to help cover the cost of medical services for those who can’t work due to age or disability.
The first thing to know is that it’s a federal health insurance program. According to Medicare.gov, the program is funded by the Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund set up by the U.S. Treasury.
The HI Trust Fund is funded by…
- Payroll taxes paid by most employees, employers, and those who are self-employed
- Income taxes paid on Social Security benefits
- Interest earned on the HI Trust Fund
- Medicare Part A premiums paid by those who are ineligible for premium-free Part A
The SMI Trust Fund is funded by…
- Funds authorized by Congress
- Premiums from people enrolled in Medicare Part B (Medical Insurance) and Medicare Drug Coverage (Part D)
- Interest earned on trust fund investments
Each of these trust funds pay for different parts of the Medicare program.
Now, when considering your health insurance options, it is important to know exactly who Medicare is for. Medicare was designed for those who…
- Are 65 or older
- Have a disability
- Have End-Stage Renal Disease (permanent kidney failure, or ESRD)
There are three parts of Medicare, a couple of which we mentioned above, that help cover specific services:
- Medicare Part A (Hospital Insurance)
Covers you when you need to care during an inpatient hospital stay or at a skilled nursing facility. It also covers hospice care and some home health care.
- Medicare Part B (Medical Insurance)
Covers outpatient care, such as doctor’s appointments, medical supplies, and preventative care.
- Medicare Part D (prescription drug coverage)
Helps cover the cost of prescription medication. It also covers many recommended shots and vaccines.
If you or your spouse paid Medicare taxes over a long enough time in your work history, you typically do not have to pay the Part A monthly premium. Most people get premium-free Part A. We’ll talk more about that in the next section.
Those who do not qualify for premium-free Part A can purchase Part A. In 2022, you’ll pay up to $499 per month, especially if you've worked less than 30 quarters. Your premium is less if you paid Medicare taxes for 30-39 quarters.
Most people pay the standard premium amount for Part B, which is $170.10 in 2022.
There is an additional charge called an Income Related Monthly Adjustment Amount (IRMAA), depending on your modified adjusted gross income as reported on your IRS tax return 2 years ago. Keep this in mind when considering you health coverage options.
Depending on which plan you get, Part D can come with different monthly premiums. How much you pay for prescription medicine depends on which plan you decide to get.
To find out what Medicare options are available to you, go to the Medicare options search page.
Am I Eligible for Medicare?
What many people don’t realize is that Social Security has a very specific definition of disability. Essentially, your medical condition must impair you such that you cannot work enough to cover your basic needs.
Keep in mind that when you apply for disability benefits that you must meet Social Security’s definition of disability.
We’ve written in some detail on the definition of disability, so you can find out more about whether you qualify by reading our article.
Here is Social Security’s shorter version of the definition of disability:
“The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”
Know that you automatically qualify for Medicare premium-free Part A if you qualify for SSDI.
In addition to meeting the definition of disability, you must have a relatively significant work history of earning Social Security work credits to qualify for SSDI. More specifically, this means that you have worked long enough, recently enough, and paid Social Security taxes.
If this doesn’t sound like it fits your situation, you may want to read up on Supplemental Security Income (SSI). We have an article on what SSI is and how you might qualify.
But if you qualify for SSDI, you may want to know eligibility criteria for Medicare. Below are the requirements for premium-free Medicare Part A according to Medicare.gov:
If you’re 65 or older, you can get premium-free Part A if…
- You already receive retirement benefits either from Social Security or the Railroad Retirement Board.
- You’re eligible for retirement benefits but have not yet filed for them.
- You or your spouse had Medicare-covered government employment
If you are under 65, you can get premium-free Part A if…
- You received Social Security or Railroad Retirement Board disability benefits for 24 months
- You have End-Stage Renal Disease (ESRD) and meet certain requirements.
Let’s talk a little bit more about the requirement of receiving disability benefits for 24 months.
When Can I Get Medicare?
When making a decision about which health insurance plan is right for you, keep in mind that there is a waiting period to receive Medicare.
Typically, it takes a minimum of 6 months to start receiving disability income from the time that you submit your application.
You may be wondering, “How long does it take for Medicare to go into effect one I apply?”
Once you receive a positive disability decision, there is a lengthy waiting period for Medicare coverage.
After receiving approval, you will need to wait 24 months before your coverage starts.
Know that there are a few options to cover your healthcare costs while you wait. You do not have to go uninsured during the 24-month waiting period. Here are the three options typically recommended:
- You may be able to get Medicaid. If you’re eligible for Medicaid, you may continue to be eligible even after you are enrolled in Medicare.
- You can enroll in a private health plan through the Marketplace. You might qualify for lower cost premiums based on the size of your household and your income.
- You may be able to enroll in a medical cost-sharing plan. Please note that this option, also known as a healthcare sharing plan, is not health insurance. Most healthcare sharing programs also tend to be faith-based and some require agreement with a statement of faith.
It’s also important to keep in mind that organizations who offer medical cost-sharing are not bound by the same laws as insurance companies. That said, you may find it a more affordable option depending on your situation.
Note that if you enrolled in a Marketplace health insurance plan before getting Medicare, you can keep your original plan as supplemental insurance when you enroll for Medicare.
However, if this is what you decide to do, know that you will lose your premium tax credits and other savings for your Marketplace plan.
The takeaway here is that if you apply for SSDI, you need to have a plan for how you will cover your healthcare costs for 24 months after you receive an approval.
Can I Work and Get Medicare Coverage?
First, know that you can still do some work and be receiving SSDI benefits. Many people don’t realize this fact when they apply. The key term here is substantial gainful activity (SGA).
You can work and receive disability benefits if you are not engaging in SGA.
This means that non-blind individuals’ earnings cannot exceed $1350 per month in 2022 for SSDI and Supplemental Security Income (SSI). A person with a disability can be working part-time if their earnings do not exceed the SGA limit.
For blind individuals receiving SSDI, the SGA limit is $2260 monthly. The SGA limit does not apply for blind individuals receiving SSI.
What all of this means is that you can still work and receive Medicare.
Though working and receiving Medicare coverage is possible, there are some things to note.
Specifically, your disabling condition must still meet the requirements. If that is still the case, you can keep your Medicare coverage for at least 8 ½ years (which includes the nine-month trial work period) after returning to work.
Another thing to note is that you may no longer be eligible for premium-free Medicare Part A if you return to work. However, you will be able to purchase Medicare once your premium-free Part A coverage ends, as long as you still have a disabling condition.
If you are under 65, disabled, working, and receive coverage through both Medicare and your employer, there are some special considerations.
If your employer has fewer than 100 employees, Medicare will be the primary payer for your healthcare costs.
But if you’re covered by a large group health plan because your employer has greater than 100 employees, Medicare is the secondary payer. This is also the case if your employer joins other employers in a multi-employer plan that has 100 employees or greater.
How to Determine Whether You Qualify for SSDI
Before considering your healthcare options, the first step to getting on the right path is determining whether you qualify for disability benefits.
Most likely, you have already started trying to figure out if you're eligible.
What you may be finding is that there's a lot of information to parse through. Unfortunately, the listings of impairments was written for legal professionals and Social Security disability case workers. The listings often use complicated language to describe the requirements for eligible medical conditions.
For someone who isn't used to dealing with legal language and technical terms, verifying whether your disability is considered severe enough using the listings can quickly get overwhelming.
The easiest way to determine your eligibility is to get an online disability case evaluation from a legal professional. Once you determine whether you’re eligible for SSDI or SSI, you will know whether you qualify for Medicare.
Remember, if you qualify for SSDI, you also qualify for Medicare.
At BenefitsClaim.com we offer a disability case evaluation for free. There are no up-front costs, retainers, or fees for the evaluation. It really is free. All you need to do is take our 1-minute survey and leave your contact information. Someone from our team will be in touch with you to help you get started.
Know that you don't have to figure it all out by yourself. Our mission is to help Americans gets the benefits they need and truly deserve. We would be happy to help you.