Medicare

All individuals 65 years of age or older who have been legal residents of the United States for at least 5 years are eligible for Medicare. People with disabilities under 65 may also be eligible if they receive Social Security Disability Insurance (SSDI) benefits. Some medical conditions may also help you become eligible to enroll in Medicare.

If you are under age of 65, you must be approved for Social Security Disability Income (SSDI) to receive Medicare. Individuals with end-stage renal disease (ESRD) are automatically eligible for Medicare.

As mentioned above, you must receive SSDI benefits to be eligible for Medicare. SSDI benefits are based on work credits earned through Social Security, Railroad Retirement or Medicare-covered government employment. If you do not have enough credits and do not qualify for SSDI, you may qualify for Supplemental Security Income (SSI). For more information, see Supplemental Security Income.

To qualify for SSDI, you must be unable to work because of a medical condition(s) for at least 12 month. Once you are approved for SSDI, you must wait five months for your income benefits to begin, and an additional 24 months before Medicare benefits begin.

However, there are 2 exceptions:

· Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease). If you have Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease), you are eligible to receiveMedicare the first month you get SSDI monthly income benefits.

· End-Stage Renal Disease. If you have end-stage renal disease (ESRD), you are eligible to receive Medicare within 3 months of your first dialysis treatment, regardless of whether you apply and qualify for SSDI. You are eligible for Medicare solely on the basis of having ESRD.

If you are unable to work because of ESRD or other disabilities, you can apply for SSDI benefits. If you qualify, you will also be eligible for Medicare under an additional category of eligibility after 29 months, as long as your disability continues. If you have another disability (in addition to ESRD) or later develop other health conditions that qualify you for disability benefits, the Medicare benefits you receive due to disability will continue, even if you have a successful kidney transplant and lose Medicare coverage based solely on your ESRD eligibility.

The Social Security reviews eligibility for SSDI. If your condition improves or you have a successful kidney transplant, you can lose your SSDI benefits and Medicare. However, if you no longer qualify for SSDI because your condition improves or you successfully complete a trial work period, you may still be able to keep your Medicare benefits. If you lose your eligibility for SSDI and Medicare, and you have another qualifying condition, you may be eligible for Medicare coverage without the 29-month waiting period described above. However, you must apply for SSDI within five years of your original qualifying condition.

Medicare has four parts, Parts A through D:

  • Hospital insurance (Part A) helps pay for inpatient hospital care and certain follow-up services.
  • Medical insurance (Part B) helps pay for doctors’ services, outpatient hospital care and other medical services.
  • Medicare Advantage plans (Part C) are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through a provider organization under Part C.
  • Prescription drug coverage (Part D) helps pay for medications doctors prescribe for medical treatment.

Medicare Part A premiums are waived if:

  • You are 65 years or older and a U.S. citizen or have been permanent legal resident for 5 continuous years, and you and your spouse (if applicable) have paid Medicare taxes for at least 10 years.
  • You are under 65, disabled, and have been receiving Social Security Disability Insurance Benefits (SSDI). You must receive SSDI for at least 24 months from the date of entitlement (first disability payment) before becoming eligible to enroll in Medicare.
  • You get continuing dialysis for end stage renal disease (ESRD) or need a kidney transplant.
  • You are eligible for Social Security Disability Insurance and have amyotrophic lateral sclerosis (known as ALS or Lou Gehrig’s disease).

If you are 65 or older, you must pay a monthly premium to remain enrolled in Medicare if you or your spouse have not paid Medicare taxes over the course of 10 years while working.

Individuals with disabilities who receive SSDI are eligible for Medicare while they continue to receive SSDI payments. These individuals may lose eligibility for Medicare based on the disability if they stop receiving SSDI. The 2 year exclusion means that people who become disabled must wait 2 years before receiving government medical insurance, unless they have one of the listed diseases or are eligible for Medicaid or medical.

In some states, for example California, for individuals who have limited resources, Medicaid will pay the beneficiaries’ Part B premium as well as coveringany prescription drugs that are not covered by Part D.

Medicare Part A covers inpatient care at hospitals. Part A also covers the cost of a blood transfusion if the hospital must purchase blood for the patient, for up to 100 days per each benefit period in a skilled nursing facility, and hospice care for those with a life expectancy of six months or less due to a terminal illness. Part A coverage costs nothing for the patient, except deductibles or copayments, and coverage gaps. These items must be paid by you or covered by other insurance.

Medicare Part B covers doctors visits and services, outpatient care, rehabilitative care under a physical therapist, occupational therapist, or speech-language pathologist, and some preventative services such as flu shots and mammograms. The premium for Part B coverage depends on your resources. Most individuals will pay the standard Part B premium.


Please visit http://ssa.gov/pgm/medicare.htm for more information about medicare.