To be eligible for Medicare under the age of 65, typically, you must have a disability that renders you incapable of working for a minimum of one year. Instances encompass specific forms of cancer, respiratory ailments, and musculoskeletal conditions.
The prerequisites for disability stem from the Social Security Disability Insurance program, abbreviated as SSDI. Your initial qualification needs to align with SSDI requirements to establish eligibility for Medicare based on your disability.
The definition of disability outlined by the Social Security Administration (SSA) is known to be stringent. Nevertheless, there are still some avenues available if your condition is not listed officially as a qualifier for SSDI.
Who qualifies for Medicare under 65?
To be eligible for Medicare before turning 65, your qualification hinges on the evaluation carried out by the Social Security Administration to ascertain whether you meet the stipulated disability criteria. Generally, disability is defined as being afflicted by an ailment or condition that is anticipated to persist for a minimum of one year and causes a specific reduction in your monthly income.
The spectrum of qualifying disabilities encompasses various conditions, which may comprise, though are not restricted to, the subsequent ones:
Parkinson’s disease
Cardiovascular disorders
Multiple sclerosis
Mental health disorders
Lupus
Cystic fibrosis
End-stage renal disease (ESRD), commonly known as permanent kidney failure
Amyotrophic lateral sclerosis (ALS)
Recipients of Medicare who are below 65 years of age and classified as disabled obtain identical health insurance benefits to those seniors who are part of the program.
Moreover, it’s crucial to bear in mind that Medicare furnishes coverage on an individual basis, not on a collective one. Consequently, Medicare benefits do not extend to family members.
How to determine whether your condition qualifies
Determining whether your condition qualifies involves a structured five-step procedure designed to establish if your situation meets the requisite criteria for enrollment in the SSDI program. Successfully meeting the criteria for SSDI can subsequently pave the way for eligibility for Medicare based on disability.
The Social Security Administration employs the following five questions as part of their assessment to ascertain the disability status for SSDI applicants:
Are you currently employed?
If you are currently employed, your eligibility for SSDI is subject to an income threshold. As of 2023, your monthly earnings generally cannot exceed $1,470. However, if you are blind, the limit increases to $2,460 per month.
Is your condition considered “severe”?
Your condition must significantly impede your capacity to carry out fundamental work-related activities for a minimum of 12 months due to alterations in attributes like strength, mobility, or memory.
Is your condition included in the roster of incapacitating conditions?
The SSA maintains a catalog of medical conditions, both for adults and children, which it deems potentially serious enough to prevent you from engaging in employment. These are categorized based on body systems.
If your condition aligns with the list and satisfies the initial two questions, it signifies a qualifying disability, and the subsequent questions are not applicable.
If your condition is absent from the list, it doesn’t inherently disqualify you. The SSA must gauge if your condition is as severe as those listed. If it is, you continue through the evaluation process.
Can you perform tasks similar to your prior employment?
If your condition isn’t found on the list, the SSA deliberates on whether it obstructs you from executing tasks you’ve previously undertaken. If it does, you progress through the assessment process.
Can you engage in alternative forms of work?
If your condition prevents you from resuming past job roles, the SSA also investigates if there are other types of work you could potentially undertake. This decision encompasses more than just your medical condition; it encompasses factors such as age, education, work history, and skill set.
Should it transpire that no other feasible work options are available to you, then you possess a qualifying disability under the SSA’s criteria.
Medicare disability work requirements
To access SSDI benefits and subsequently become eligible for Medicare based on disability, it’s imperative to possess a qualifying disability. However, having such a disability isn’t the sole requisite. SSDI also incorporates specific prerequisites pertaining to your employment history.
The evaluation of your employment history is conducted using the same Social Security work credits that are essential for securing Social Security retirement benefits.
Most individuals who seek SSDI typically necessitate accumulating 40 work credits, equivalent to a decade of work, to fulfill eligibility criteria. A work credit serves as a quantifier employed by the federal government to gauge tenure in the workforce; each credit is equivalent to a quarter of a year’s employment, subject to specific minimum income thresholds. Of these qualifying work credits, half—equivalent to 20 credits or five years—must have been earned within the decade preceding the onset of your disability in the given year.
The maximum number of credits achievable per year stands at four. In the year 2023, every $1,640 in wages or self-employment income earns you one credit. To accumulate the maximum of four credits in 2023, your earnings would need to amount to $6,560.
The number of work credits you need depends on your age. If you’re under 60, you can qualify for SSDI with fewer than 40 work credits.
How much time does it take to start receiving Medicare benefits?
For the majority of applicants: 24 months after meeting the eligibility criteria.
Following the acquisition of entitlement to SSDI benefits, there generally exists a waiting period of 24 months before qualifying for Medicare based on disability.
However, there are specific allowances for individuals who are beneficiaries of SSDI and are afflicted by certain conditions.
For those with particular conditions: Sooner
Lou Gehrig’s disease, also known as amyotrophic lateral sclerosis (ALS)
If you are diagnosed with ALS, commonly referred to as Lou Gehrig’s disease, you become eligible for Medicare in the very month when you start receiving SSDI benefits.
End-stage renal disease (ESRD)
If you are dealing with end-stage renal disease (ESRD), you usually attain eligibility for Medicare on the initial day of the fourth month of undergoing dialysis treatments. This timeline could be shorter if you undergo training for home dialysis.
Kidney transplant as a result of ESRD
In the scenario where you have ESRD and are undergoing a kidney transplant, your eligibility for Medicare commences in the month when you are admitted to a hospital certified by Medicare for the transplant. Coverage extends for a maximum of two months before the actual transplant procedure, meaning your eligibility might be subject to change if the transplant is postponed or rescheduled.
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
