Having a disability affects Medicare options in two ways:

  1. You can be enrolled automatically (earlier than age 65) if approved by the Social Security Administration (SSA) to receive Social Security Disability Insurance (SSDI) benefits based on certain disabilities. These disabilities includes ALS (also known as Lou Gehrig’s disease) and End Stage Renal Disease (ESRD).
  2. After drawing SSDI for 24 months (2 years), you are automatically enrolled in both Medicare Part A and Medicare Part B (also known as “Original Medicare”) starting at the 25th month and will receive a Medicare card in the mail. In some cases, you can receive Medicare in less than two years if Social Security determines that your disability started before the disability application date.

Five things to understand about SSDI and Medicare

1. Unenrolling or preventing enrollment in Original Medicare

Part A is free for most people, but Part B charges a monthly premium. You cannot decline Part A unless you are willing to pay back all the SSDI benefits you received, so you will most likely need to keep it, even if there is coverage from a spouse’s employer insurance. With employer coverage, you have the freedom to disenroll from Part B. It is important to consult the employer’s human resources office to understand how their plan works with Medicare Part B.

If the company has 100 employees or more, the employer insurance will be primary (i.e. that insurance is billed first, and most likely covers more care than Medicare Part B). If the employer has less than 100 employees, then your Medicare insurance will be primary and you will need to join Part B. If you decide you don’t want Part B, follow the instructions in the Welcome to Medicare packet or call 1-800-772-1213 for help disenrolling from Part B.

2. Copays and deductibles (out-of-pocket costs) for individuals with disabilities

Copays and deductibles will apply unless using an employer’s insurance primary to Medicare – which may result in fewer out-of-pocket expenses. If you don’t have employer insurance and you are enrolled in Original Medicare (Parts A and B), you may want additional coverage.

For most beneficiaries (regardless of their disability status), the choice comes down to deciding between two options, Original Medicare (Parts A and B) combined with an optional Part D plan (prescription drug coverage), and/or an optional supplemental coverage plan to cover the cost gaps in Original Medicare known as Medigap (enrollment is limited for persons under age 65 in many states) and a Medicare Advantage plan (a privately-managed health plan that typically covers all of these services). Medicaid can also be a supplement to pay out-of-pocket costs for those who qualify for low-income benefits; rules vary by state.

Additional questions about coverage choices may be found by taking our free Questionnaire. The tool also provides information for access to free professional Medicare advice from a licensed benefits advisor. Additional resources include your local SHIP (State Health Insurance Assistance Program) or your local Aging and Disability Resource Center.

3. For most beneficiaries (regardless of their disability status), the choice comes down to deciding between two main options

Original Medicare (Parts A and B) combined with an optional Part D plan (prescription drug coverage) and/or an optional supplemental coverage plan to cover the cost gaps in Original Medicare known as Medigap (enrollment is limited for persons under age 65 in many states) or a Medicare Advantage plan (a privately-managed health plan that typically covers all of these services). Medicaid can also be a supplement to pay out-of-pocket costs for those who qualify for low-income benefits; rules vary by state.

4. There are two ways to pay for prescription medications on Medicare

If you are not covered by employer insurance and haven’t signed up for a Medicare Advantage plan that includes prescription drug coverage, you will need to sign up for a Part D (prescription drug coverage) plan to cover your medications. In some cases, you may have been automatically assigned to a Part D plan if you get Extra Help or Medicare Savings Programs. A call to 1-800-MEDICARE will allow you to find out if you have been automatically enrolled. Speak with the representative to ensure all of your medications are covered in your plan, but if they are not, other plans are available. Your local SHIP (State Health Insurance Assistance Program) can also assist.

5. You may be able to return to work if the disability responds to treatment and keep your Medicare

Speak to a representative at the Social Security Office about how many hours you are allowed to work and still retain your SSDI payments. If Social Security Office considers your return “substantial gainful activity” (i.e. a paying job above a certain income level, depending on your disability), you are still eligible for Medicare for seven years. If the new employer provides health insurance, the employer insurance will become the primary payer (if there are more than 100 employees) and your Medicare will become secondary but still available in case your circumstances change.