Your Local Medicare Help
Can I Get A Part C Plan On Medicare Under 65 Due To Disability?
Of course, you can. In fact, Medicare Part C, also known as Medicare Advantage plans has increasingly become popular among Medicare beneficiaries. In 2019, it accounted for about one-third of Medicare coverage. Over the past 10 years, the number of Medicare Advantage beneficiaries has increased by almost a 100%.
Although popularly known as a federal health program to serve older people aged 65 and above, Medicare coverage is not limited to senior citizens. Medicare makes provision for individuals who are under 65 and need health care services due to certain disabilities.
Statistics show that Medicare covered more than 8 million Americans under age 65 with disabilities as of 2019. If you are under 65, you may qualify for Medicare coverage if you meet any of the following criteria.
You have end-stage renal disease (ESRD)
You have amyotrophic lateral sclerosis (ALS)
You qualified for Social Security retirement benefits and have received Social Security Disability Insurance (SSDI) for at least 24 months (2 years)
You qualified for certain disability benefits from the Railroad Retirement Board for 24 months
You automatically qualify for Medicare once you meet any of the criteria above. Usually, what you get enrolled into is the Original Medicare, made up of Part A and Part B. However, you may enroll in Medicare Part C, also known as a Medicare Advantage plan if one is available in your area. Not only does it cover everything Medicare Part A and Part B cover, but it also may provide extra benefits. For many people under 65, Medicare Part C is the most cost-effective option.
This article discusses how you can qualify and enroll in Medicare Part C while being under 65 and due to disability.
What Disabilities Qualify for Medicare?
Not all disabilities qualify for Medicare for persons under 65. Usually, for younger-than-65 persons with certain disabilities that want Medicare coverage, there may be a 24-month waiting period before they will enrolled in Parts A and B.
These disabilities include:
End-stage renal disease (ESRD)
Amyotrophic lateral sclerosis (ALS)
Another criterion to meet when requesting Medicare is to have qualified or have received disability benefits for at least years. To qualify for Social Security Disability Insurance (SSDI), you must:
You must have worked in jobs covered by Social Security.
You must have a medical condition that’s expected to last at least one year.
The medical condition must significantly limit you from engaging in substantial gainful activity.
You also have to meet earnings requirements based on your work history.
Disabilities that qualify people for SSDI include but are not limited to the following:
Permanent kidney failure also called end-stage renal disease (ESRD)
Amyotrophic lateral sclerosis (ALS)
Depression, bipolar, and related mental illnesses
Autism spectrum disorder
After you apply for SSDI and your application is approved, there is usually a five-month waiting period before you can start receiving disability benefits.
However, there are exceptions. You are exempt from the waiting period if:
You have End-Stage Renal Disease (ESRD) and need dialysis or a kidney transplant.
You have ALS or Lou Gehrig’s Disease and you were approved for benefits on or after July 23, 2020.
You apply at your local Social Security office.
Other things to note include:
If after you apply for disability, it is not approved but then you qualify after an appeal, the approval of your application is backdated to the first month you would have received SSDI. The 24-month waiting period begins on that date.
If after a few months of receiving SSDI, you lose eligibility and regain it after some months or years, all the months and years you should have been collecting SSDI count collectively toward the 24-month waiting period. There is, however, a coverage gap because you will not receive Medicare benefits during the time the appeal is pending.
Medicare Part C for Disabled Under 65
Medicare Part C is also known as Medicare Advantage (MA) plan. It is an alternative way to get Original Medicare (Part A and Part B). However, as opposed to the Original Medicare, Medicare Part C is private health insurance that follows rules set by the government.
For people living with disabilities and under 65, Medicare Part C is a cost-effective Medicare option. Medicare Advantage (MA) plan covers the same services as Original Medicare A and B. In other words, it covers hospital and outpatient healthcare services including hospitalization, inpatient medical services, home care, doctor visits, medical tests, screenings, counseling, emergency care, and preventive care.
It can also provide supplemental coverage depending on your plan. This includes:
Prescription drug coverage (Medicare Part D)
Vision care including glasses and contacts
Routine dental care including x-rays, exams, and dentures
Hearing care including testing and hearing aids
Wellness programs and gym memberships
Non-medical services including meal delivery, home air cleaners, and home modifications.
In addition, Medicare Advantage Plans have out-of-pocket limits on healthcare costs associated with your covered services. Once you reach the limit, you pay nothing for the rest of the year, making it a potential saving option.
Depending on where you live in Michigan or any other State, there may be dozens of Medicare Part C plans that can fit your budget. Whatever premiums, deductibles, and copays you will pay vary depending on your insurance company and the plan you choose.
If you are on Social Security Disability Insurance, depending on your income and assets you may also qualify for your state’s Medicaid program. Being on both Medicaid and Medicare does not stop you from signing up for an Advantage plan.
Medicare Advantage plans could be:
Health Maintenance Organization (HMO) plans
Preferred Provider Organization (PPO) plans
Private Fee-for-Service (PFFS) plans
Special Needs Plans (SNPs)
Medicare savings account (MSA) plans
Medicare Advantage Special Need Plans
Special Needs Plans are made available to individuals who fit into their policy. The people usually meet specific health criteria such as having certain chronic and disabling health conditions or qualifying for both Medicare and Medicaid. These criteria form the two most common types of SNPs. They are Chronic and Dual Eligible Special Needs Plans (D-SNPs).
Condition Special Needs Plans (C-SNPs)
This plan is for those with chronic health conditions. At the time of enrollment, your physician will be asked to fill out a chronic condition verification form.
The availability of this type of SNP depends on the county. This type of SNPs usually has a network including hospitals, pharmacies, physicians, specialists, and other health professionals who specialize in treating the chronic diseases or conditions that affect their members. Examples of such chronic diseases include heart disease, diabetes, and certain lung impairments. In Michigan depending on the county you live in there may be a Chronic Special Needs Plan C-SNP available.
Dual Eligible Special Needs Plans (D-SNPs)
People who are eligible for both Medicare and Medicaid are known as the dual-eligible population. D-SNPs are available to this group of people and are characterized by very low costs in terms of premiums, deductibles, copays, and other out-of-pocket costs.
Many people who are dual eligible find these plans appealing because of the extra’s that many of these plans provide that are over and above what they get with Medicare and Medicaid and usually at no additional cost.
Some D-SNPS, like other managed care plans, may provide supplemental coverage for dental care, vision care, meal delivery, and transportation to and from physician offices. Some plans may even include expanded benefits that cover monthly allowances for Healthy food. Plan availability also varies by the county in Michigan you live in.
How do I enroll in a Medicare Advantage Plan?
To enroll in a Medicare Advantage Plan, you can contact us at "Your Local Medicare Help". Not only will we help you join, but we can also help you choose a plan that will fit into your budget, that your doctor will accept, and that will best cover your prescriptions .
In regards timing, the ideal periods to enroll are:
Initial Enrollment Period
The initial enrollment period refers to the 7-month window you have to enroll in Medicare when you turn 65. This 7-month period includes the three months before the month you turn 65, your birth month, and three months after the month you turn 65.
Medicare Open Enrollment Period
Also known as the Annual Enrollment Period, it runs from October 15th through December 7th every year. During this period, you can join, switch, or drop a Medicare plan. Any plans you choose during that time will go into effect on January 1.
Medicare Advantage Open Enrollment Period
This runs from January 1 to March 31 each year. During this period, you can switch from one Medicare Advantage Plan to another, return to Original Medicare, purchase a Medicare Part D plan, or remove it.
Special Enrollment Period
This enrollment period only happens when there is a qualifying situation or event for it. This may be relocation, having medicare and medicaid, qualifying for Low income subsidy (LIS) or losing other health coverage. In this period, you can enroll in a private health plan or change your Medicare enrollment to another private plan.
What if I go back to work?
According to the SSDI requirements, to qualify for SSDI, you must have a medical condition that’s expected to last at least one year or can lead to death. To receive benefits, that medical condition should impair you and prevent you from engaging in "substantial gainful activity" (SGA).
Social Security has special rules that encourage SSDI beneficiaries to try out part-time or even full-time jobs. SSDI recipients are entitled to a "trial work period" during which they can make more than the SGA amount without losing benefits.
The trial work period (TWP) is a 9-month window over 60 months designed to allow SSDI recipients to test if they can work while receiving their full benefits. This is regardless of whether they make more than the SGA amount.
In 2022, any month where an SSDI recipient works and earns a monthly income of more than $970 is considered a trial work month. For the self-employed (business owners, consultants, freelancers, etc.) SSDI recipient, any month he/she works 80 hours or more is considered a trial work month.
All of your monthly earnings before taxes apply to the $970 TWP threshold. However, you can subtract any impairment-related work expenses that count as out-of-pocket costs. They may be medical supplies, job coaching, and so on. To ensure Social Security accurately calculates all of your earnings, keep receipts of your impairment-related expenses.
However, you may continue to enjoy Medicare benefits even after losing SSDI. So, even if you go back to work, you will continue to receive Medicare benefits for eight and a half years.
At work, if your employer offers health insurance coverage, you get to enjoy two forms of health insurance coverage. If your employer is considered a Large Group Employer, your employer's health coverage becomes your primary insurance provider while Medicare acts as the second provider. If your employer offers health coverage but is considered a small group employer then Medicare will remain your primary while the group coverage will be secondary. You are read more in the article about the differences, “What is the difference between Large and Small Group Employer health coverage 2022 ?”.
Why not Medigap?
People mistake Medigap for Medicare Part C and vice versa. Unlike Medicare Part C which is an alternative to Original Medicare, Medigap is a supplemental Medicare option. Also known as Medicare supplement, it is used to fill in the financial gaps in Original Medicare. In other words, it is purchased to cover out-of-pocket costs that are not covered by Medicare Part A (hospitalization and inpatient care) and Part B (outpatient care).
In most states, Medigap or Medicare supplement plans are not available to Medicare beneficiaries under 65 years of age. There are no federal laws requiring private insurance companies to sell Medigap policies to people under 65. Also, insurers consider disabled Medicare beneficiaries as "high-risk" and as a result, are reluctant to sell Medigap policies to disabled enrollees.
In states where Medigap is available, it is extremely expensive for this population. There are no federal or state laws that regulate how much plans are sold to disabled Medicare subscribers under 65. For example, in Michigan, they would have to get a Guaranteed issue Medigap which is usually between 350-400/mo or more.
These factors make the availability and costs of Medigap plans for the under 65 Medicare population vary from state to state.
Hence, beneficiaries stick to having Original Medicare and buying a drug plan (Part D). This, however, is not cost-effective as beneficiaries often incur more out-of-pocket healthcare costs and exposes them to extreme financial risk.
Unlike Medicare Advantage Plans, there is no maximum out-of-pocket limit and an emergent healthcare service could result in a bill they will pay for years if not the rest of their life.
We are here to help you…
As an unbiased broker, we at “Your Local Medicare Help” assist our clients by figuring out what plans they qualify for, what plans their doctor takes, and helping the client find the most competitive plans, and they never pay us anything. With so many options available, Medicare can be confusing. When you take care of your Medicare plan enrollment with us we also donate to Operation Underground Railroad who is pioneering the fight against child sex trafficking. You care read more information in our Blog, “Save The Children Fund”.
No matter the environment, we have the resources and technology to make enrollment in Medicare plans not only accurate but simple. Our personalized expert guidance is FREE of charge so you can save time and money!