• Medical Conditions that Qualify for Medicare Before 65

Since its inception in 1965, Medicare, a federal health insurance program for adults 65 years of age and older, has aided numerous elderly Americans in maintaining good health and accessing necessary medical care.

“Medicare functions similarly to other insurance models, covering the cost of certain healthcare services that are reasonable and necessary,” explains Kathleen Holt, an attorney and associate director at the Center for Medicare Advocacy in Washington, D.C.

However, Medicare can be complex. Let’s review some basics to gain a better grasp of what Medicare is and how it operates.

• Introduction to Medicare

Medicare is comprised of various parts. Part A and Part B, collectively referred to as “Original Medicare,” are the basic elements that cover the majority of costs for approved healthcare services and supplies.

“Part A serves as hospital insurance,” notes Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services (CMS) in Washington, D.C.

Specifically, Part A covers hospital inpatient care, certain home health care or hospice care and skilled nursing facility care.

“Part B includes services provided by doctors and other healthcare providers,” adds Seshamani.

This coverage includes physical therapy, outpatient care, home health care, various preventive services, and durable medical equipment such as wheelchairs and walkers.

Medicare Part C, also known as Medicare Advantage, was established in 2003. Medicare Advantage plans are provided by private companies approved by Medicare. These plans combine Part A, Part B, and usually Part D coverage into one plan. (Part D encompasses prescription medications under Medicare.)

Different Medicare Advantage plans vary in terms of premium costs, covered services, and whether referrals are needed to see specific doctors. All Medicare Advantage plans must cover  urgent care and emergency, as well as nearly all medically necessary services covered by Original Medicare. Holt mentions that some vision, dental, or hearing coverage might also be included in Medicare Advantage plans.

Additionally, there’s a program called Medigap.

“This involves Original Medicare and a supplementary plan that covers the coinsurance deductibles,” explains Holt. “Medigap supplements wrap around the traditional coverage.”

This coverage type helps reduce the out-of-pocket expenses that a Medicare enrollee would otherwise have to pay.

• Enrolling in Medicare

Medicare enrollment comes with specific requirements.

“Individuals approaching the age of 65 who do not receive Social Security retirement benefits must enroll in Medicare if they intend to use it at 65,” says Rebecca Kinney, director for the Administration for Community Living’s (ACL) Office of Health Care Information and Counseling in Washington, D.C.

If you are covered by your own or your spouse’s employer-sponsored health insurance plan, and that plan meets Medicare’s primary payer requirement, you have the option to postpone enrolling

in Medicare. However, if you lack other health insurance, it’s advisable to sign up for Medicare as soon as possible.

The initial enrollment period extends for seven months, starting three months prior to turning 65 and concluding three months after turning age 65. If you don’t enroll during this time or want to modify your choices later without qualifying for a special enrollment period, you’ll need to wait for the next open enrollment period, which takes place yearly from October 15 to December 7. Alternatively, you can register during the general enrollment period from January 1 to March 31.

Medicare might appear daunting, but it’s important to recognize that for older Americans, this federal program has played a pivotal role in aging healthily for over five decades.

Kinney notes that before Medicare, older adults would lose their health insurance upon retiring from their jobs.

“The intention of Medicare was to provide health insurance for retirees,” she explains.

Though there have been adjustments to the program since its inception nearly 60 years ago, the core of Medicare remains providing health insurance to Americans over 65.

“Every U.S. citizen is eligible to enroll in Medicare at age 65,” Kinney affirms.

Accessing Medicare Before 65

Medicare commences at 65 due to the fact that this was the age at which a majority of individuals retired in the 1960s.

Changing the eligibility age for Medicare would require Congressional approval, and thus far, such changes have not occurred.

“Congress raised the actual retirement age to 67, but the Medicare age has not changed,” notes Holt.

However, in 1972, Medicare was expanded to include individuals under 65 who receive Social Security disability benefits, Kinney adds.

“Individuals unable to work due to a disability or illness and needing Social Security disability benefits” can become eligible for Medicare after receiving disability benefits for 24 months, she explains. 

Furthermore, individuals with ALS (Lou Gehrig’s disease) and those with with end-stage renal (kidney) disease are eligible for Medicare regardless of their age. These individuals can enroll in Medicare without having to fulfill the 24-month waiting period.

• Definition of Disability

The term “disabled” encompasses almost any condition that leads to an evident disability

preventing you from performing regular, continuous full-time work and is expected to last at least 12 months, according to Holt.

“It’s not a specific condition,” she emphasizes. “You could have multiple sclerosis and still work. Alternatively, you could have MS and be so incapacitated that you meet the criteria, rendering you unable to work a 40-hour week.”

Becoming eligible for Medicare benefits requires having a medical condition that hinders you from working enough to access employer-sponsored health care benefits.

• The Waiting Period

To qualify for Medicare before 65, you must demonstrate to the Social Security office that you are disabled and require benefits. Only then can you start the process of enrolling in Medicare. However, an extra hurdle comes into play: the 24-month waiting period after you start receiving disability benefits before you become eligible for Medicare coverage.

“It’s important to go through the Social Security application process,” stresses Holt.

Once you are in the system, you will be enrolled automatically in Medicare at the end of the waiting period.

The two-year waiting period can pose difficulties for many individuals, adds Holt. However, during these 24 months, you can access health coverage through the Affordable Care Act, signed into law in 2010.

This program, often referred to as Obamacare, provides private insurance options for individuals outside of traditional employer-sponsored health care. An essential aspect of these plans is that you cannot be refused coverage based on a preexisting condition – a category that your pending Medicare disability would belong to, as per Holt. During the wait for Medicare coverage, you can secure insurance through your state’s health insurance exchange.

Holt highlights that around 15% of Medicare beneficiaries are individuals under 65 with disabilities.

Assistance is Available

Irrespective of disability status or age, many people could benefit from guidance during their initial Medicare enrollment or when making changes during open enrollment. Fortunately, free help is available.

The State Health Insurance Assistance Program (SHIP) is a grant-based initiative in every state, Washington, D.C., Puerto Rico, Guam