What Disabilities Qualify for Medicare Under 65?

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Updated: October 24, 2024

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Eligibility for Medicare before the typical age requirement of 65 primarily hinges on receiving Social Security Disability Insurance (SSDI) benefits for at least 24 months. SSDI is available to those with a long-term disabling condition expected to last at least one year or result in death.

The Social Security Administration (SSA) evaluates eligibility through a five-step process that assesses work status, severity of impairments and the ability to perform past or other work. To qualify, individuals must also have sufficient work history under SSDI, typically requiring 40 work credits, half of which must have been earned in the last ten years.

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Medical Conditions That Qualify Individuals Under 65 for Medicare

If you are under 65 and suffer from a severe long-term medical condition, such as ALS or ESRD, that stops you from working for at least one year, you might be able to get Medicare.

Some qualifying medical conditions, like schizophrenia and severe arthritis, make you eligible for Medicare on the 25th month of receiving the SSDI or Railroad Retirement Board disability benefits. Other conditions allow you to access Medicare benefits as soon as you qualify for Social Security benefits.

Importantly, if you are a federal, state or local government employee not covered by Social Security or Railroad Retirement Board benefits, you may still qualify for Medicare 24 months after your disability benefits start.

Here's more about how you may qualify for Medicare under 65:

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    Severe Medical Conditions

    Certain severe health issues can qualify you for Medicare before age 65. These conditions include but are not limited to Parkinson’s disease, heart disease and multiple sclerosis. Each of these can significantly impair your ability to work, making you eligible for Medicare benefits.

    Certain chronic conditions and mental or neurological disorders that are considered severe health issues by Social Security can qualify you for Medicare before age 65. These conditions include, but are not limited to, Parkinson’s disease, heart disease and multiple sclerosis. Each of these can significantly impair your ability to work, making you eligible for Medicare benefits.

    • Chronic conditions like severe arthritis or chronic obstructive pulmonary disease (COPD) may qualify if they prevent you from working.
    • Severe mental disorders such as schizophrenia, bipolar disorder or severe depression that impact your ability to work can qualify.
    • Neurological disorders like multiple sclerosis or Parkinson’s disease can qualify if they limit your ability to work.
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    ALS and ESRD

    Amyotrophic Lateral Sclerosis (ALS) and End-Stage Renal Disease (ESRD) are two specific conditions for which Medicare rules differ.

    • If you are diagnosed with ALS, you are eligible for Medicare as soon as your disability benefits begin.
    • For those with ESRD, eligibility starts either at the beginning of dialysis treatments or after a kidney transplant, provided certain conditions related to previous employment are met. This coverage can be retroactive up to 12 months, depending on when your dialysis started, if you apply within that time frame.

The Social Security Administration maintains a comprehensive list of medical conditions that qualify for disability benefits, which could qualify you for Medicare by extension. If your condition is not listed, it doesn't automatically disqualify you; it just means your situation might require a more detailed review.

Understanding SSDI Work Requirements for Medicare Eligibility Before 65

 

To qualify for Medicare before age 65 due to disability, you not only need a qualifying medical condition but also sufficient work history under the SSDI program. This program requires you to have accumulated enough work credits, similar to those needed for Social Security retirement benefits.

Each year, work credits are earned based on your income. In 2024, for every $1,730 of earnings, you gain one work credit, and you can earn a maximum of four credits per year if you make at least $6,920.

To qualify for SSDI, most individuals typically need 40 work credits, equating to 10 years of work. Notably, half of these credits, or 20 credits, must have been earned in the 10 years before your disability began.

However, the exact number of credits needed can vary depending on your age. For example, if you're under 60, you might qualify for SSDI with fewer than 40 credits. This system ensures that younger workers who haven't had the opportunity to accumulate decades of credits still have access to disability benefits.

How to Find Out if Your Medical Condition Qualifies for Medicare Under 65

If you're under 65 and wondering if your medical condition qualifies you for Medicare, you'll need to go through a specific evaluation process managed by the SSA. The SSA uses a five-step sequential evaluation process, which involves assessing your work status and whether your condition falls under the list of severe medical conditions.

If you find the process challenging or need specific guidance based on your condition, it’s advisable to contact the SSA directly or seek help from a disability advocate.

Below is a list of factors to evaluate to help you find out if your condition qualifies:

  1. 1
    Substantial Gainful Activity (SGA)

    First, the SSA checks if you are engaged in SGA, where your earnings exceed a specified monthly amount. If you earn more than this limit, you generally won't qualify as disabled under SSA rules unless you have allowable deductions related to your disability.

    In 2024, if you earn more than $1,550 per month ($2,590 if you are blind), it is likely you do not qualify for disability under Medicare, as this amount is considered substantial gainful activity (SGA). If you earn less or are not working due to your condition, your application will be reviewed further by the Disability Determination Services (DDS).

  2. 2
    Severity of Impairments

    Next, the SSA assesses whether your impairments are severe enough to significantly limit basic work activities like lifting, walking or remembering for at least twelve months. If your condition does not limit these activities significantly, you might not qualify. However, if it does, your review will proceed to the next stage.

  3. 3
    Meeting or Equaling a Listed Impairment

    The DDS keeps a list of medical conditions severe enough to stop someone from working substantially. If your medical issue is on this list, you might automatically qualify for benefits.

    If it's not listed, the DDS will compare its severity to conditions that are included. If it matches or exceeds the severity, you might qualify. If not, the review moves to analyzing your previous work.

  4. 4
    Performance of Past Relevant Work

    If your condition doesn't meet the severity of a listed impairment, the SSA then checks if you can perform any of your past relevant work (PRW), i.e., the focus is on whether your condition prevents you from performing any job you held recently.

    The SSA considers your ability to perform past jobs in light of your current impairments. If you can still do any of your past jobs, you likely will not qualify for disability benefits. If you cannot perform any previous work, there's one more step to review.

  5. 5
    Adjusting to Other Types of Work

    In the final step, the DDS examines if you can perform any other type of work despite your condition. This consideration includes your age, education, past work experience and transferable skills. If it's determined you can’t do other work, you may qualify for disability benefits. If you can work in another capacity, your claim for disability will likely be denied.

How to Apply for Medicare if You Are Disabled and Under 65

Applying for Medicare if you are disabled and under 65 involves a series of steps such as verifying eligibility, contacting the appropriate agencies and completing required documentation. Generally, you should start the application process a few months before you meet the 24-month requirement to ensure a smooth transition to Medicare coverage.

You can follow the below steps to apply for Medicare if you are disabled and under 65:

  1. 1
    Confirm Your Eligibility

    Before applying, verify that you have received SSDI benefits for 24 months, which is the typical requirement for Medicare eligibility unless you have ALS or ESRD.

    If your disability application was initially denied but later approved on appeal, your 24-month waiting period will be adjusted retroactively.

    If you lose and then regain SSDI eligibility, all months where you previously received SSDI will count towards the 24-month period, though Medicare coverage does not resume until benefits are reinstated.

  2. 2
    Contact Social Security

    Apply for Medicare through the SSA. You can apply online on the SSA website, by phone (1-800-772-1213) or in person at your local SSA office.

  3. 3
    Complete the Application

    Provide your personal information, medical history and details about your disability. You might also need to submit documentation from your health care providers.

  4. 4
    Review and Receive Approval

    After your application is submitted, it will be reviewed by the SSA. They may contact you if further information is needed. Once approved, you will receive your Medicare card and benefits information in the mail.

Medicare Cost for Individuals Under 65 With Disabilities

For individuals under 65 with disabilities, Medicare costs in 2024 vary depending on the part of Medicare you are enrolled in. Usually, you will pay the same rates for Medicare, Medicare Advantage plans and Part D (Prescription drug) plans as seniors. The cost of Medicare Advantage and Part D plans will also vary by location.

  1. Medicare Part A: Most individuals do not pay a monthly premium for Part A, which covers hospital stays and inpatient care. The deductible for each hospitalization period is $1,632, and daily coinsurance for days 61-90 of a hospital stay is $400. If you need to buy Part A, it could cost up to $505 per month in 2024, depending on how long you or your spouse paid Medicare taxes.
  2. Medicare Part B: The average monthly premium for Part B is $174.70, typically deducted from your SSDI payments. The average annual deductible is $240, with a 20% co-insurance for most medical costs unless covered by another insurance plan.
  3. Medicare Part C (Medicare Advantage): Premiums for Medicare Advantage plans average $27 per month in 2024, in addition to the cost of Parts A and B. Deductibles and co-insurance vary depending on the chosen plan.
  4. Medicare Part D (Prescription Drug Plans): Premiums vary widely, but they are likely to average around $55.50 per month in 2024. The cost can range from $0 to $195 per month, on average, depending on the plan and coverage level. Importantly, insurers cannot charge more based on medical conditions.

FAQ About Disabilities That Qualify People Under 65

MoneyGeek has answered some common questions about what Medicare covers for disabled individuals under 65 to help you find the best option for your situation.

What will Medicare cover for disabled people under 65?
Will Medicare cover your spouse if you are receiving the benefit because of a disability?

About Mark Fitzpatrick

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Mark Fitzpatrick is a Licensed Property and Casualty Insurance Producer and MoneyGeek's Head of Insurance. He has analyzed the insurance market for over five years, conducting original research and creating personalized content for every kind of buyer. He has been quoted in several insurance-related publications, including CNBC, NBC News and Mashable.

Fitzpatrick earned a master’s degree in economics and international relations from Johns Hopkins University and a bachelor’s degree from Boston College. He is passionate about using his knowledge of economics and insurance to bring transparency around financial topics and help others feel confident in their money moves.

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