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The Basics
Medicare Eligibility Requirements
Medicare´s Connection to SSDI Benefits
When Does Medicare Begin?
When Does Medicare End?
The Details Medicare with Other Insurance or Health Coverage
Dual Eligibility: Medicare and Medi-Cal Services
Medi-Cal´s 250% Working Disabled Program
Aged & Disabled Federal Poverty Level Medi-Cal
Aged, Blind, and Disabled Medically Needy Medi-Cal
Your Assets and Resources and Medi-Cal
Medi-Cal´s Health Insurance Premium Payment Program (Medi- Cal/HIPP)
Other Routes to Dual Eligibility for Medicare and Medi-Cal
PASS - SSI Program´s Plan to Achieve Self-Support
Medicare Savings Programs
This is a Fact Sheet on Medicare for people with disabilities. It provides basic information on the program, including tips and other useful information to help people with disabilities understand and navigate Medicare with other disability benefit programs, learn about other services available to them, and money saving programs related to their Medicare costs.
The Basics
Medicare is our only national health insurance program, serving some 44 million Americans. The program provides health benefits to almost 7 million people under age 65 who have a disability or chronic condition. Entitlement to Medicare for this age group comes via an award for Social Security Disability Insurance (SSDI) benefits, or because someone has End Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS), known as Lou Gehrig´s disease.
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Medicare Eligibility Requirements
If you receive SSDI, you´re eligible for Medicare. Wage replacement SSDI benefits are based on work credits earned through Social Security, Railroad Retirement, or Medicare covered government employment. Many people with disabilities, including children, do not have Medicare benefits because they do not have the work credits needed to qualify for SSDI benefits.
To be eligible for coverage, a family member or the beneficiary under age 65 must have a work history which included FICA tax contributions that pay for Social Security Disability Insurance. In some instances, an individual may qualify for SSDI on the FICA contributions of a parent as a Childhood Disability Beneficiary (CDB) or as a disabled spouse of a deceased spouse. To be eligible for Medicare, a beneficiary must be a legal United States resident. Like most other insurance, Medicare includes beneficiary cost sharing: premiums, co-payments and coinsurance that helps pay for the health coverage services.
Those who do not have work credits or a work history, as well as disabled children and adults who are ineligible for SSDI, can be eligible for Supplemental Security Income (SSI) benefits. People with SSI are automatically eligible for Medi-Cal covered medical services in California. Some SSDI beneficiaries who had a short or small work history can be eligible for a small SSDI cash benefit and an SSI cash benefit to supplement it. SSI and Medi-Cal (Medicaid for California) are not insurance; for the most part, they are publicly funded means-tested programs funded by general revenues. The medical test for award of benefits in SSDI and SSI is exactly the same. The difference in benefit eligibility has to do with the extent of one´s work history, as well as available assets and resources. If you are on Medicare and also receive Medi-Cal services, see our Fact Sheet series for Low Income Assistance.
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Medicare´s Connection to SSDI Benefits
There is a strict test to qualify for SSDI. People from 18 to 62 years of age must show medical evidence that they are unable to work for at least one year at any job in the national economy, because of a qualifying physical and/or mental impairment, or combination of impairments, or be expected to die as a result of the impairment(s). You can apply for SSDI at your local Social Security Administration (SSA) office, or online at www.socialsecurity.gov.
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When Does Medicare Begin?
You must qualify for, and receive, SSDI benefits to be eligible for Medicare. Once approved for SSDI, you must wait 5 months before the SSDI cash benefit begins, then an additional 24 months before receiving Medicare benefits. If you receive benefits because you have Amyotrophic Lateral Sclerosis (ALS), known as Lou Gehrig´s disease, you can get Medicare the first month you receive SSDI payments.
If you have ESRD, you can get Medicare within three months of your first dialysis treatment. You will still have to file for your disability cash benefits to get monthly SSDI payments. When you qualify for SSDI payments, you will then be eligible for Medicare via the SSDI after 29 months under this second category of eligibility, for as long as you continue to be disabled. If you have, or develop, other serious health conditions, your Medicare benefits based on your disability can continue even if you have a successful transplant and lose your eligibility because you no longer have ESRD.
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When Does Medicare End?
Medicare can end before you reach retirement if you medically improve. Social Security periodically reviews all SSDI awards. If Social Security decides that your medical condition has improved, or if you have a successful kidney transplant, and you do not have or develop other health conditions, then you can lose your SSDI benefits and the Medicare health coverage.
For the first time, because of federal legislation known as the Ticket Act, a disabled Medicare eligible person can return to work and keep his or her Medicare benefits (Part A free) for at least eight and a half years after the start of employment, in some cases, longer.
After loss of SSDI eligibility altogether due to earned income or employment, if Social Security determines that you remain disabled according to their medical rules, you can stay eligible and buy into Medicare until you reach 65. At that point Social Security transfers eligibility to your retirement benefits.
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The Details Medicare with Other Insurance or Health Coverage
It is helpful to know that the Medicare program from its start in the 1960s did not provide fully comprehensive health coverage. People with Medicare often combine it with a variety of public or private health coverage options. This can be very helpful in accessing more services or saving money. How Medicare interacts with other private or public health coverage options, however, can have many rules you will need to understand.
People with Medicare under age 65 may have additional health benefits through the active employment of a spouse or a parent. These health benefits pay for services first (as the primary insurer) when the employer has 100 or more employees; Medicare is the secondary and pays only after the employer coverage has paid.
People with End Stage Renal Disease (ESRD) may continue to work and have coverage through their employment. When a person has Medicare because of ESRD, the employer plan must pay primary benefits during a 30 month coordination period, regardless of the size of the group or employment status of the individual.
In other circumstances, a person with Medicare may also have his or her own individual health benefits, or have benefits through an employer group with fewer than 100 employees. In these cases Medicare is likely to be primary and other benefits secondary. In cases where a person with Medicare is making a transition from employer coverage to other benefits such as COBRA, it may be necessary to add Part B and Part D benefits to replace benefits that were formerly covered by an employer plan. Please see our series "Medicare and Other Health Insurance Coverage" (www.cahealthadvocates.org).
Deciding whether other health benefits pay first or whether Medicare pays first is confusing to the covered person, the employer, and the medical provider. In addition, younger people with Medicare don't have the same rights as people 65 or older to a Medicare supplemental insurance policy to cover their co-payments, deductibles, and some services not covered by Medicare. For these issues, review our Fact Sheets "Supplementing Medicare: When You or Your Spouse Work" and "Rights For Purchasing Medigap Policies" (www.cahealthadvocates.org).
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Dual Eligibility: Medicare and Medi-Cal Services
Medicare beneficiaries who also receive Medi- Cal services are known as "dual eligibles". While there are income and asset requirements that must be met, many people with disabilities may be in this "dual eligibility" category without knowing it. If you are medically eligible for Medicare because you receive SSDI, you are already medically eligible for Medi-Cal. The actual Medi- Cal eligibility depends on your living situation, and available income or assets. Medi-Cal has many points of entry and many services not available in Medicare, including financial help with the costs of getting Medicare services.
We outline some of the Medi-Cal points of entry commonly used by Medicare beneficiaries in California. For these people, Medi-Cal can help supplement Medicare services. They may be able to use Medi-Cal to pay for Medicare premiums, deductibles, and co-payments. In some cases, Medi-Cal may be used to pay for private health coverage premiums. Medicare Part D has special rules and economic support for dual eligibles.
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Medi-Cal´s 250% Working Disabled Program
If you are working or planning to work, disabled, and using Medicare, you may be eligible for the little known 250% Medi-Cal Working Disabled Program. An individual can earn $52,092 a year in gross earned income and be eligible for this Medi-Cal Program. To qualify, you must earn some income in the month of application. Medi-Cal regulations do not define what "working" means for this program. You can qualify if you are working part time. You must have assets worth less than $2,000 for an individual ($3,000 for a couple). Any IRS approved retirement fund, like a 401(k) or an IRA, are exempt and not counted in this Medi-Cal program.
An individual who is working, can earn up to $2,128 ($2,853 for couples) in countable monthly income and still qualify for the program. These rules are explained at www.db101.org - See Medi-Cal.
Disability income does not count for the 250% CWD program. This means that SSDI, Worker´s Compensation, California State Disability Insurance, and any federal, state, or private disability benefits are not considered income for this program. If the person has countable unearned income, it must be below the appropriate SSI/SSP benefit rate ($856/month for a single individual in 2007).
The 250% Medi-Cal Working Disabled Program charges an affordable monthly premium for enrollees: $20-$275 for individuals and $30-$375 for couples. The advantages are obvious. Qualifying dual eligibles may be able to work and pay for most, if not all, of their medical care via their access to both Medicare and Medi-Cal - including premiums, deductibles, and coinsurance.
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Aged & Disabled Federal Poverty Level Medi-Cal
If you are aged or disabled, and are not eligible for the SSI program, you may be able to get Medi- Cal through the Aged & Disabled Federal Poverty Level program. You must:
- Be either aged (65+), or disabled (meet Social Security´s definition of disability, even if your disability is blindness).
- Have less than $2,000 in assets ($3,000 for a couple). Like SSI, this program does not count all of your assets.
- Through March 31 of 2008, have less than $1,081 in countable monthly income for an individual ($1,502 for a couple). This Medi-Cal program uses SSI countable income rules with a few extra rules you need to know (See www.db101.org - Medi-Cal).
If you qualify, this program could be a pathway to dual eligibility and its many benefits.
Aged, Blind, and Disabled Medically Needy Medi-Cal
If you do not qualify for free Medi-Cal or the 250% Medi-Cal Working Disabled Program, you may be able to get Medi-Cal through the Aged, Blind, & Disabled Medically Needy (ABD - MN) program, but you may have to pay a share of cost or incur the debt for these costs. A share of cost is a certain amount of Medi-Cal costs you must incur with a medical provider in a month before Medi-Cal begins to pay for services that month. This is not a premium. If you do not use any Medi-Cal services in a month, there is no share of cost for that month. These rules are explained at www.db101.org - See Medi-Cal.
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Aged, Blind, and Disabled Medically Needy Medi-Cal
If you do not qualify for free Medi-Cal or the 250% Medi-Cal Working Disabled Program, you may be able to get Medi-Cal through the Aged, Blind, & Disabled Medically Needy (ABD - MN) program, but you may have to pay a share of cost or incur the debt for these costs. A share of cost is a certain amount of Medi-Cal costs you must incur with a medical provider in a month before Medi-Cal begins to pay for services that month. This is not a premium. If you do not use any Medi-Cal services in a month, there is no share of cost for that month. These rules are explained at www.db101.org - See Medi-Cal.
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Your Assets and Resources and Medi-Cal
To qualify for these three Medi-Cal programs, individuals must meet certain property/resource limits or requirements. These requirements depend on your family size: $2,000 for an individual, $3,000 for a couple, $3,150 for 3 people (add $150 for each additional person). You can own the home you live in and the car you drive. Those two assets are exempt.
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Medi-Cal´s Health Insurance Premium Payment Program (Medi- Cal/HIPP)
There are certain situations when Medi-Cal will pay for your private health insurance premiums. This program - the Medi-Cal/HIPP program - is for people who are on Medi-Cal, have private health insurance, have a high cost medical condition, and have lost (or are about to lose) private coverage. If you are at risk of losing your private insurance, Medi-Cal can either pay for your medical expenses or pay for you to keep the private coverage that is at risk. Medi-Cal will do whichever costs less for them. Medi-Cal should evaluate your eligibility for Medi-Cal/HIPP when you indicate that you have insurance available but haven´t applied for it, that you are about to end your health insurance, or that your policy has lapsed.
If you are eligible for Medi-Cal/HIPP, you will still be on Medi-Cal. The only change will be for those who did not previously have private coverage. If that´s the case, Medi-Cal will become the payer of last resort. If you are accepted into the Medi- Cal/HIPP program you must participate or else you can lose your Medi-Cal eligibility. If a new job opportunity or other occasion presents itself with new health coverage options that require you to pay premiums, Medi-Cal/HIPP may be a good deal for you.
Medicare beneficiaries who are in fee for service Medicare can apply for the Medi-Cal/HIPP program to cover other health insurance premiums. The Medi-Cal/HIPP program does not help pay for the costs of any Medicare services, however, and is not available to those enrolled in a Medicare Advantage plan.
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Other Routes to Dual Eligibility for Medicare and Medi-Cal
Some Medicare beneficiaries may not work so 250% Medi-Cal Working Disabled Program is not the option to consider. They may have higher income or assets that make them ineligible for Medi-Cal. Are they locked out of Medi-Cal altogether? Maybe not. Remember, Medicare beneficiaries have already met one major requirement towards qualifying for Medi-Cal - they have already met the medical eligibility rules.
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PASS - SSI Program´s Plan to Achieve Self-Support
A Plan to Achieve Self-Support (PASS) is an SSI Program. PASS can help those who might otherwise be ineligible for SSI to set aside income or resources in a PASS and so, qualify for SSI. They develop a work goal and a plan to achieve it. It is a way for SSI recipients to set aside and save income and/or resources in a separate bank account to achieve a planned work goal that Social Security approves of. A PASS plan, for example going to college, once approved by Social Security, could take several years to complete. When the PASS is approved, the Medicare beneficiary will also receive Medi-Cal for the entire time that the PASS plan is in effect (see PASS - www.db101.org).
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Medicare Savings Programs
California administers four programs that can pay for Medicare premiums, co-payments, or deductibles for certain low income Medicare beneficiaries. You may be eligible depending on your income or assets such as how much money you have in the bank. These programs are known as Medicare Savings Programs or Medicare Buy-Ins. Each program has specific income limits and pays for different Medicare costs. For more information, see our fact sheet titled "Medicare Savings Programs" (www.cahealthadvocates.org). As noted elsewhere, SSDI has rules that encourage you to return to work. After your SSDI benefit ends, you will still receive free Medicare benefits for 93 months. After that period ends, you may want to consider the last program above, the Qualified Disabled Working Individual (QDWI) program, depending on your health care needs and options at that time.
"The California Work Incentives Initiative (CWII) at the World Institute on Disability (WID) contributed editing and research for this fact sheet for California Health Advocates (CHA); CWII provides health coverage, work and benefits information to people with disabilities in California via community outreach, training and the web at www.db101.org."
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