Medicare is a health insurance program associated with Social Security Disability Insurance. And since the majority of SSDI recipients are disabled people in financial need, you may wonder whether SSDI recipients have to pay for their Medicare benefits.
If you’ve been enrolled in Medicare as an SSDI beneficiary, you will be required to pay for the premiums that come with the Medicare plan. This includes Part A and Part D premiums. Rejecting Medicare Part A may also result in the termination of your SSDI benefits.
Read below for more information on Medicare costs when on SSDI.
Medicare Eligibility for People with Disabilities
Before you can get Medicare benefits based on a disability, you must first become eligible for Social Security Disability Insurance.
For Social Security Disability Insurance, there are two primary requirements: a qualifying disability and a job history. You must wait two years after receiving SSDI before becoming eligible for Medicare (with the exception of certain circumstances).
What is a Qualifying Disability?
There are some conditions that do not qualify for Social Security Disability Insurance benefits. The Social Security Administration lists the following as prerequisites for receiving SSDI benefits:
- You are unable to work or engage in other “substantial gainful activity” due to a medical condition.
- You are unable to perform previous work or learn new skills to adapt to new jobs.
- Your health condition has been present for at least one year, is expected to remain present for at least one year, or is expected to result in death.
SSDI Work Requirements
In order to be eligible for SSDI, you need to have a sufficient work history. You become eligible for these benefits by collecting “work credits” in the Social Security system. Depending on how much you make each year, you could earn up to four credits.
In 2023, you will receive one credit for every $1,640 in earnings or revenue from self-employment. Therefore, if you earn a total of $6,560 during the year, you will receive all four credits.
The majority of candidates for SSDI are required to have a minimum of 40 Social Security work credits. If you were to earn all four credits every year, you would need a work history of ten years to earn the total amount of credits.
Your job history also needs to be recent. You need to have worked for at least 20 credits (equivalent to five years) in the decade prior to the year your disability began. If you are under the age of 31, you may be eligible for Social Security Disability Insurance with a lower number of recent work credits.
What is the Medicare Waiting Period?
There is a 24-month waiting period before Medicare eligibility for those receiving SSDI who are younger than 65. Within that time frame of 24 months, you may be eligible for other forms of medical aid, such as:
Medicaid
If you receive Supplemental Security Income, you may be eligible for Medicaid in your state. The Medicaid eligibility requirements vary from state to state because each state runs its own Medicaid program.
Private Insurance
You can also look for private insurance. Note that your Social Security Disability Insurance income will be included in the calculation of whether or not you are eligible for reduced-cost coverage.
Medicare’s standard 24-month waiting period does not apply to those with certain preexisting conditions. If you have end-stage renal disease, also known as ESRD, you may be eligible for Medicare beginning on the first day of your fourth month of dialysis treatments.
Medicare coverage for kidney transplants begins the month of admission to a Medicare-approved hospital for the transplant or related treatments. However, the insurance only applies for the two months immediately preceding your transplant.
If the transplant is postponed or you have to wait longer than expected for it, you may be eligible for Medicare coverage beginning two months before the new date.
If you are approved for Social Security Disability Insurance benefits because you have amyotrophic lateral sclerosis (ALS), then you are eligible for Medicare the first month you get your disability benefits.
Medicare Coverage — What Options Are There?
There are four components to Medicare coverage:
- Part A: Hospital coverage
- Part B: Medical Coverage
- Part C: Medicare Advantage
- Part D: Prescription Coverage
SSDI recipients are only eligible for Parts A and B of Medicare. Medicare Parts C and D require different enrollment procedures. If you miss the opportunity to enroll in one of these plans during the initial Medicare enrollment period, you will have another chance during the yearly open enrollment period, which runs from October 15, 2023, through December 7, 2023.
You will also have to sign up separately if you wish to add or change any of the following options:
- Medicare Advantage plans, referred to as Medicare Part C
- Medicare Part D prescription drug plans
- Medicare Supplement Insurance, or Medigap
- Medicare special needs plans
Do I Have to Pay for Medicare on SSDI?
Medicare provides disabled people with access to medical treatment, but it comes at a cost. You will be required to pay premiums for the various parts.
If a person has not worked at least 40 quarters (10 years) of taxed employment, then they are required to pay premiums for Medicare Part A.
Part B premiums are required to be paid by all participants; the exact amount is based on the participant’s income. If you want coverage for your prescription drugs, you will also have to pay premiums for Medicare Part D.
You could also choose a Medicare Advantage plan instead of these. Medicare Advantage plans cover all of what Original Medicare does (Parts A and B), plus you can opt to have them include Part D as well. These programs, like the rest of Medicare, will require a monthly premium payment.
Should You Decline Medicare for Less Costly Health Insurance?
Medicare isn’t always the cheapest insurance option, and you might find that other plans are more affordable. Plans under the Affordable Care Act seem attractive, but if you enroll in one of these plans, you cannot receive any benefits from Medicare.
If your spouse’s health insurance plan allows for it, you could enroll in that instead of purchasing your own policy to cover your medical expenses. Even better, your service may make you eligible for health benefits from the Veterans Administration or TRICARE.
In situations like these, you might want to reject Medicare in favor of some other form of coverage. After all, nobody likes being required to pay over twice as much in premiums. However, you should be aware of the consequences of turning down Medicare.
Rejecting Coverage Under Part A
Refusing Part A coverage could result in the loss of your Social Security benefits. This may include Social Security Disability Insurance payments or retirement income.
You will not only have to repay whatever Social Security benefits you have already received up until the time you denied Part A, but you will also lose access to all potential Social Security income.
In 2001, a federal district court in the United States issued a judgment on this very question. Three federal employees filed a lawsuit against the government in an effort to cancel their Part
A benefits and switch to the Federal Employees Health Benefit (FEHB) program. They also wished to maintain the present amount of Social Security payments.
The answer can be found in the Social Security and Medicare Act of 1965.
Specifically, Judge Rosemary Collyer ruled that “requiring a mechanism for Plaintiffs and others in their situation to ‘dis-enroll’ would be contrary to congressional intent, which was to provide ‘mandatory’ benefits under Medicare Part A for those receiving Social Security Retirement benefits.”
The decision ultimately came down to the fact that individuals cannot opt out of Medicare Part A without simultaneously having their Social Security or Social Security Disability Insurance benefits terminated.
Should I Get Medicare Advantage if I Am Under 65?
For Medicare recipients under the age of 65 who are disabled, Medicare Advantage plans are the ideal option because many of these plans combine cost savings with convenience, allowing people with disabilities to bypass certain expenditures and enroll in plans suited to their requirements while still receiving their Medicare benefits.
Medicare Advantage plans are “all-in-one” replacements for Original Medicare that typically include coverage for both medical services and prescription drugs covered by Parts A and B. Plans like these replace Original Medicare’s requirement that you buy Part D and supplementary coverage separately.
Unlike Original Medicare, Medicare Advantage plans typically offer limits on annual out-of-pocket costs at roughly $7,550.
This is especially helpful for people who are managing long-term health concerns because it limits the total amount they have to spend on covered healthcare services. A person who is registered for the basic version of Medicare, on the other hand, may be subject to unlimited medical expenses.
Most plans have little or no monthly premiums, making them accessible to people of all income levels. Many of the plans also include supplementary benefits, such as dental and vision care coverage.
Special Needs Plans
Medicare Advantage, in contrast to Original Medicare, provides disabled individuals with access to Special Needs Plans (SNPs). The most common types of SNPs are C-SNPs (for those with chronic conditions) and D-SNPs (for people who are eligible for both Medicare and Medicaid).
If you want to join a C-SNP, your doctor will need to write out a chronic disease verification form. Plans may or may not be available in your county. Some of these plans include arrangements with specialists, like cardiologists and endocrinologists, to provide specialized treatment for members.
D-SNPs are accessible to the dual-eligible population, who are members of both Medicare and Medicaid. The costs associated with D-SNPs are extremely affordable and require very little in the way of copays, deductibles, and other forms of out-of-pocket spending.
D-SNPs are similar to other health insurance programs in that they may cover dental and vision care, and in many cases, they also cover transportation to and from doctors’ visits and home-delivered meals.
The Disadvantages of Medicare Advantage
Similar to Original Medicare, Medicare Advantage plans have some drawbacks of their own. Medicare Advantage enrollees may expect to spend the majority of their annual budget on out-of-pocket medical expenses like deductibles, co-payments, and coinsurance. Because of this, it may be challenging to set aside money for healthcare costs.
Health care spending for copays, coinsurance, and other out-of-pocket costs may be higher for people with disabilities because of their greater use of health care services.
Before signing up for a Medicare Advantage plan, it’s crucial to read the plan’s “Summary of Benefits,” which details how much you’ll have to pay for things like doctor’s visits, hospital stays, and more.
Disability-specific Medicare SNPs are generally Health Maintenance Organizations with constrained provider networks. This can restrict or eliminate your ability to receive care from providers outside of your insurance company’s network, except in extreme circumstances.
This could restrict access to desired or necessary doctors, hospitals, and other medical facilities, such as suppliers of long-term medical supplies. Be sure your preferred doctors and hospitals are part of a plan’s network before signing up.
In spite of these shortcomings, Medicare Advantage plans remain the top choice for Medicare recipients who are disabled.
Finding Help for Medicare Costs
There are Medicare recipients, both young and old, for whom the program’s sky-high expenses present a severe strain on their budgets.
Those who meet the Medicare Savings Program’s income requirements are eligible for financial assistance. All Medicare recipients are eligible to participate in the programs, which, in general, offer support to Medicare recipients who are low-income but do not fall below the Medicaid eligibility threshold.
Some of the available programs are as follows:
- Qualified Medicare Beneficiary (QMB): This program will pay your Part B premiums as well as your Part A premiums if they are required.
- Specified Low-Income Medicare Beneficiary (SLMB): This financial support plan solely covers the cost of Medicare Plan B premiums.
- Qualifying Individual (QI): This program funds the Part B payments, but the maximum income is a little higher than the SLMB program.
Conclusion
In conclusion, if you are an SSDI beneficiary who has recently been enrolled in Medicare, you will be required to pay for the premiums in Medicare. Luckily, there are ways you can find help to cover your Medicare costs.
