Most Medicare beneficiaries enroll in Medicare when they turn 65, or after if they are working and then subsequently when they retire. However, there are situations when you can enroll in Medicare before your 65th birthday.
Social Security Disability Insurance
If you have received Social Security Disability Insurance benefits for 24 months before turning 65, then you are eligible to enroll in Medicare Parts A and B. Your Medicare coverage will begin on the first day of the 25th month. In most cases, you will be sent your Medicare card automatically. If you do not receive your Medicare card, you can contact the Social Security Administration (SSA) for further assistance.
End-Stage Renal Disease (ESRD)
You're also eligible for Medicare prior to the age of 65 if you have been diagnosed with end-stage renal disease, requiring dialysis. Keep in mind that waiting periods may vary, depending on the course of treatment that is being pursued. You’ll also need to satisfy other requirements including:
- You’ve worked as a government, SSA, or Railroad Retirement Board (RRB) employee for the required amount of time
- You’re already receiving or are eligible for RRB or SSA benefits
- You’re the spouse or dependent child of a qualifying person who meets either of the above requirements
The complication when you are diagnosed with ESRD is that your Medicare coverage can begin with different coverage dates, based on a variety of factors.
If you qualify for Medicare as a result of ESRD, your coverage can be retroactively set so that your coverage date goes back 12 months in the past. For example, if you are eligible for Medicare in March due to ESRD and you don’t apply for Medicare until August, then your Medicare coverage can begin in March.
Kidney Transplants: Medicare coverage begins the month you’re admitted to a Medicare-certified hospital for a kidney transplant. If the surgery is delayed more than two months after you're admitted to the hospital, or you require health care services prior to your transplant, it will begin two months early.
Dialysis: If you are receiving dialysis, there is a three-month waiting period until Medicare coverage becomes active. When you enroll in Medicare due to ESRD and receive dialysis, your Medicare coverage typically begins on the fourth month of your dialysis treatments.
Important Note: As of 2021, ESRD patients have the unrestricted right to enroll in Medicare Advantage at the time that their Medicare coverage begins or annually — during the Annual Election Period — which runs from October 15 through December 7. Minimizing out-of-pocket costs will depend on choosing a Medicare Advantage Plan with a dialysis center that is either in-network (in the case of HMO) or accepts original Medicare (in the case of a PPO, where the carrier may charge a higher coinsurance or copay if the dialysis center is out of network).
Enrolling in Medigap before the age of 65 is possible, but will depend on the state, which governs Medigap eligibility rules. In addition, the Medigap premium can be notably higher than in situations when you qualify for Medicare while turning 65, or are retiring and have health insurance coverage from an employer. You may also have limited Medigap Plans to select from based on your state regulations.
For further details, you can refer to this page on the official Medicare website.
Amyotrophic Lateral Sclerosis (ALS)
People under age 65 who have been diagnosed with amyotrophic lateral sclerosis (ALS) — otherwise known as Lou Gehrig’s disease — are eligible for Medicare Parts A and B without delay. However, you need to apply and be accepted for Social Security Disability Insurance benefits. Once you are accepted, your Medicare coverage begins the first day of the month after you apply.
Medicare Prior to 65 and Insurance
When you become eligible for Medicare Part A, the Part B and Part D late enrollment penalties will begin to apply when you are deemed to be eligible for Part A.
In these instances, you must have health insurance, which may be provided by an employer (or COBRA) or purchased privately. If you are eligible for Medicare, then you cannot simultaneously receive the Advance Premium Tax Credit (APTC) and be enrolled on the federal marketplace (healthcare.gov) or your state-sponsored health insurance portal.
In addition, you must also be enrolled in a prescription drug benefit program that is deemed to be creditable coverage. For those on disability, this can be missed, especially when another party — for example, an auto insurance carrier — pays for ongoing medications as part of a claims agreement. Compensation by another party is not the same as having a prescription drug benefit plan that is deemed to be creditable coverage as defined by the Center for Medicare and Medicaid Services, commonly known as CMS.
The key point to remember is that if you are eligible for Medicare Part A at any point, then you could be subject to both Part B and Part D late enrollment penalties. In order to avoid these late enrollment penalties, you need to be covered by health insurance. Separately, you need to be covered by prescription drug benefits that qualify as creditable coverage, a term used by the CMS, which translates to “as good as Medicare.”
Other Coverage in Addition to Original Medicare
Medicare Advantage is available to all Medicare beneficiaries. When you become eligible for Medicare Part A, then your Medicare Advantage Initial Coverage Election Period has begun and will last for seven months — three months before you turn 65, the month you turn 65, and three months after that. If you do not enroll during this period, then you can enroll during the Annual Election Period.
Alternatively, obtaining Medigap prior to 65 years old — along with a stand-alone prescription plan (Part D) — may be possible, but Medigap availability and affordability can be restrictive to many, except for the six-month window when Medigap is guaranteed during your Medigap Open Enrollment Period. That will depend on your location, because your state of residence ultimately governs insurance matters separately, and certain states have expanded rights. Note that all Medicare beneficiaries will always have the ability to apply for, and be accepted, by Medigap carriers during the Medigap open enrollment period, when a Medicare beneficiary turns 65 years old.
How Can We Help?
Qualifying for Medicare prior to 65 is complicated, especially since the person will have qualified due to an extreme health situation. Suddenly, you would be subject to language or terms and conditions that may seem familiar, but the actual eligibility and access to health insurance options will work differently, from a practical point of view. We’re here to help! For more information, please call us at (844) 910-2061 to speak to a licensed insurance agent who would be happy to assist you.
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