Understanding Medicare and disability insurance

Social Security Disability Insurance (SSDI) benefits provide important financial support to people who cannot work due to a disability. This helps cover expenses like food, housing, and medical care. It can be confusing to determine if you qualify for SSDI and/or Medicare benefits. The following information will help you understand who qualifies for Social Security Disability, eligibility requirements, what Medicare covers, and Medicare disability eligibility requirements.

SSDI explained

SSDI, or Social Security Disability Insurance, benefits are very important for people who are unable to work because of a disability. These benefits give you money each month to help pay for everyday needs. Without SSDI, many people with disabilities would struggle to afford things like housing, food, and medical care.

Disability payments from SSDI can help cover many necessary expenses. This includes paying rent or mortgage, buying groceries, and paying for doctor visits and medications. This money can also help with other costs like utility bills and transportation.

Here are some examples of disabilities that might qualify for SSDI benefits:

• Chronic heart failure
• Certain types of cancer
• Severe mental disorders like schizophrenia, bipolar disorder, and autism
• Multiple sclerosis (MS)
• Spinal cord injury or traumatic brain injury

Medicare explained

Medicare is a federal insurance program for people 65 and older or those with certain disabilities or end-stage renal disease.  It helps cover the cost of medical care, including hospital stays, doctor visits, and prescription drugs. Medicare is made up of four parts: Part A (hospital), Part B (doctor), Part C (Medicare Advantage), and Part D (prescription drug). This program helps ensure that older adults and people with disabilities get the care they need at a cost they can afford.

SSDI Medicare coverage

Medicare benefits are very important for people with disabilities because they help cover the cost of medical care and prescriptions you need to stay healthy. This means you can see doctors, get treatments, and buy medication without having to worry as much about the costs.

To qualify for Medicare through SSDI, you must have a disability and typically receive SSDI benefits for 24 months. However, when you enroll is different for Medicare Part A and Part B.

Medicare Part A covers inpatient hospital stays, stays in a skilled nursing facility, hospice care, and some home health care. SSDI beneficiaries are automatically enrolled in Part A after receiving SSDI benefits for 24 months.

Medicare Part B covers doctor’s office visits, outpatient care, medical supplies, and preventive services. Unlike with Part A, you are not automatically enrolled in Part B. You will be eligible to enroll during your Initial Enrollment Period.

Medicare disability eligibility requirements

Individuals with disabilities can qualify for Medicare, but Medicare is not automatically granted to those with disabilities. There are certain requirements that must be met to be eligible. The following sections will explain the eligibility requirements for SSDI Medicare benefits.

SSDI disability requirements

The Social Security Administration (SSA) evaluates your medical condition, work history, and ability to work when determining if you qualify for SSDI benefits. The SSA has a strict definition of disability compared to other programs. It only applies to total disability. No benefits are given for partial or short-term disability because the SSA is under the assumption that working families have access to other resources during short-term disability periods.

To qualify for SSDI benefits, you must meet the following disability requirements:

• Substantial gainful activity (SGA): You must not be able to take part in substantial gainful activity. This is defined as earning more than a monthly income threshold set by the SSA. This amount changes annually.
• Inability to work: You must have a medical condition that prevents you from doing the work you did before or adjusting to a different type of work.
• Severe impairment: Your condition must be severe enough to significantly limit your ability to perform basic work-related activities like walking, standing, sitting, lifting, or remembering tasks.
• Your medical condition is expected to last for a least one year or result in death.
• Duration of work requirement: You must have worked long enough and recently enough under Social Security to qualify for SSDI benefits.

SSDI work requirements

To get disability benefits from Social Security, you need to have worked and paid into Social Security for a certain amount of time. You earn work credits when you have a job and pay Social Security taxes. Most people need 40 credits, and at least 20 of those credits should be earned in the 10 years right before the disability begins. However, the number of credits needed also depends on your age when you become disabled.

You can earn up to four credits each year, depending on how much you make. The amount needed to earn work credits changes every year.

For more information about credit earning requirements, visit the SSA website.

Qualifying for Medicare disability under 65

For those under 65, you can qualify for Medicare if you are disabled or have certain health conditions. If you are receiving SSDI benefits, there is a standard two-year waiting period before you become eligible for Medicare. However, there are exceptions to this rule for people with very serious health conditions.

You will automatically be enrolled in Medicare if you meet the following criteria:

• Receiving SSDI Benefits: If you receive Social Security Disability Insurance (SSDI) benefits, you become eligible for Medicare after a two-year waiting period.
• ALS (Lou Gehrig’s Disease): If you have Amyotrophic Lateral Sclerosis (ALS), you qualify for Medicare as soon as your SSDI benefits begin, with no waiting period.
• End-Stage Renal Disease (ESRD): If you have end-stage renal disease and require regular dialysis or have had a kidney transplant, you qualify for Medicare after three months of dialysis treatments or immediately upon receiving a transplant.

What happens to my Medicare disability benefits when I turn 65?

When you turn 65, you will continue to receive Medicare benefits. However, your eligibility is no longer based on disability, but is now based on age. Your Medicare benefits will transition, and you will have the same options as other people who become eligible for Medicare at age 65. You will still have Medicare Parts A and B or will automatically be enrolled in Part B if you didn’t previously enroll when you became eligible with disability. You can also choose to add Part D for drug coverage, change to a Medicare Advantage plan, or enroll in a Medigap plan to help cover out-of-pocket costs.

Enrolling in Medicare through SSDI disability benefits

If you are under 65 and receive SSDI, you will automatically be enrolled in Medicare after a 24-month waiting period. The waiting period begins the first month you become eligible for Social Security disability benefits. However, just like Medicare based on age, you will have an initial enrollment period where you can choose what kind of coverage you want. This is a seven-month period that starts the 22nd month you have SSDI benefits.

Learn more about Medicare

Discover more about Medicare and which plan is right for you with our additional resources. 

The four parts of Medicare 

How to choose a Medicare plan

Shop UPMC for Life Medicare plans