Medicare and SSDI for Claimants in Maine and Other States

Medicare is a national health insurance program administered by the Centers for Medicare and Medicaid Services (CMS), an agency of the federal government. Unlike the programs administered by the Social Security Administration (SSA), which mainly make payments to beneficiaries, Medicare is a form of health insurance coverage that helps people manage healthcare costs. Older Americans who have paid above a certain amount into the system through payroll tax deductions are Medicare’s main beneficiaries, but coverage is also available to disabled people who receive benefits through the Social Security Disability Insurance (SSDI) program.

What is Medicare?

Medicare provides health insurance coverage to:

– Individuals who are 65 years old or older, who have been U.S. citizens or legal permanent residents for at least five years, and who worked and paid into the Medicare system for at least 10 years;
Disabled individuals under the age of 65 who have received SSDI benefits or Railroad Retirement Board benefits for at least 24 months;
– Individuals who are eligible for SSDI and have been diagnosed with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease; and
– Individuals who are receiving dialysis treatment or are waiting for a kidney transplant because of end-stage renal disease.

Medicare should not be confused with Medicaid, a CMS program that provides health insurance to low-income individuals and families.

Medicare Parts A-D

Medicare provides four types of coverage. Part A provides coverage for inpatient hospital, hospice, or skilled nursing facility stays, usually for up to 60 days with no copay and then an additional 30 days with co-payment by the beneficiary. Part B provides coverage for medical services like doctor visits, outpatient procedures, x-rays, dialysis, laboratory testing and other diagnostic tests, and durable medical equipment like canes or wheelchairs. The plan typically pays most of the cost of approved services after the beneficiary meets a deductible. Coverage under Part B is optional, although beneficiaries who opt out of Part B and are not receiving health coverage through full-time employment must pay a penalty. Part C, also known as Medicare Advantage, consists of approved private health plans that include much of the coverage provided under Parts A, B, and D. Beneficiaries may participate in one of these plans instead of “Original Medicare” coverage. Part D provides coverage for prescription drugs through certain Medicare Advantage Plans or a separate Prescription Drug Plan (PDP).

Can an SSDI Beneficiary Under the Age of 65 Receive Medicare?

As mentioned above, individuals who have been approved for SSDI benefits are automatically approved for Medicare Parts A and B, but coverage does not become available immediately. SSDI beneficiaries must wait 24 months from the date they begin receiving SSDI benefits to begin Medicare coverage.  That is to say, one is qualified for Medicare coverage on the 25th month of eligibility for an SSDI benefit check.

Previous periods of disability may count towards the 24-month total if the current disability began within 60 months of the last month the worker previously received SSDI benefits, or at any time if current SSDI benefits are based on the same disability as previous benefits.

What Is the Purpose of the 24-Month Waiting Period?

Congress created Medicare in 1965 as a way to ensure that older Americans had access to affordable health care. It expanded the program in 1972 to include people with disabilities. In an effort to control costs and avoid overlaps between private health insurance and Medicare coverage, Congress included a 24-month waiting period.

People with disabilities, who by definition are unable to work to support themselves, need to be able to access medical care during the 24-month waiting period. This means they must often rely on extended employer coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act), which can involve expensive premiums.

Efforts to modify or repeal the 24-month waiting period have not been successful. The Ending the Medicare Disability Waiting Period Act of 2009, H.R. 1708/S. 700, for example, would have phased out the waiting period for people with disabilities and eliminated it for people with “life-threatening conditions.” The bill gained 113 co-sponsors in the House of Representatives and 21 in the Senate, but it never made it out of committee in either chamber.

What Can I Do If I Need Health Insurance During the 24-Month Waiting Period?

People in the 24-month waiting period for Medicare benefits may be able to obtain health care coverage from their former employer through COBRA, but other options may also be available. SSDI beneficiaries who meet the income qualifications for Medicaid may be able to maintain Medicaid coverage after they begin Medicare coverage. SSDI beneficiaries, who would thereby be medically qualified for Supplemental Security Income (SSI) as well, may be eligible for Medicaid. Beneficiaries who cannot obtain Medicaid coverage or SSI can enroll in a private health plan through the health insurance marketplace established under the Affordable Care Act, commonly known as Obamacare, and they may keep that plan as supplemental coverage once Medicare coverage begins.

The Law Offices of Russell J. Goldsmith can help you evaluate your health insurance considerations as you get started on filing your SSDI claim. To learn more, contact us at 1-800-773-8622 today to schedule a free and confidential consultation.

More Blog Posts:

How to Apply for SSDI Benefits in Maine and Beyond, Social Security Disability Lawyer Blog, July 1, 2015

What is SSDI? An Overview for Residents of Massachusetts and Other States, Social Security Disability Lawyer Blog, June 24, 2015

Defining a Medical Disability for Purposes of Obtaining SSDI Benefits in Maine, Massachusetts and New Hampshire, Social Security Disability Lawyer Blog, June 10, 2015

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