Social Security Disability Insurance (SSDI) and Medicare Coverage

Social Security Disability Insurance (SSDI) is a program for disabled people with qualifying medical diseases and conditions. Statistics show that about a quarter of today’s 20 year-olds will become disabled before they reach the full Social Security retirement age of 67. That means a lot of people may need to supplement their incomes with SSDI payments.

In addition, everyone who is eligible for SSDI benefits is also eligible for Medicare benefits after a qualifying 24-month period.

Here are several important things to know about SSDI and how they relate to Medicare.

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Social Security Disability Insurance Eligibility

SSDI pays benefits to you and some family members if you worked long enough (and recently sufficient) and paid Social Security taxes. For most people, that threshold is 40 credits (ten years or four credits a year) of wages or self-employment. Your adult child also may qualify for benefits on your earnings record if he or she has a disability that started before he or she turned 22.

Most people are required to have earned 40 credits, and 20 of those must have been earned in the past 10 years ending in the year you became disabled. If you are a younger worker, your thresholds amounts may be different.

To qualify for a credit, you must make a minimum amount of income. That amount changes every year. In 2020, you earn one credit for each $1,410 of income you make. When you reach $5,640, you have earned four credits for the year.

Social Security also pays Supplemental Security Income (SSI) to disabled adults and children who have limited resources and income.

The medical requirement eligibility standards and processes to determine if someone qualifies are the same for both programs.

When you apply for SSDI or SSI, you will be asked about your medical condition, work, and education history to determine if you qualify for benefits.

Applying for SSDI Benefits

You can apply for SSDI the following ways:

Online

By calling Social Security’s national toll-free service at 1-800-772-1213 (TTY 1-800-325-0778) 

Visit your local Social Security office. An appointment is not required, but if you schedule an appointment, it may reduce the time you spend waiting to apply.

Be sure you have the following documents when you apply:

  • Birth certificate or other proof of birth (original copy only)
  • Proof of U.S. citizenship or lawful alien status if you were not born in the United States 
  • U.S. military discharge paper(s) if you had military service before 1968
  • W-2 forms(s) and/or self-employment tax returns for last year (photocopies are acceptable)
  • An Adult Disability Report that collects more details about your illnesses, injuries or conditions, and your work history
  • Medical evidence already in your possession. This includes medical records, doctors’ reports, and recent test results (photocopies are acceptable)
  • Award letters, pay stubs, settlement agreements or other proof of any temporary or permanent workers’ compensation-type benefits you received
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Determining If You Are Disabled

To qualify for SSDI, you must meet the criteria Social Security has in place to determine if you are officially disabled.

Social Security uses a five-step process centered around five questions you must answer.

Are you working? 

If you are working and averaging earnings of more than $1,260 in 2020, you will not be considered disabled in most cases. If you’re not working, your application will be sent to Disability Determination Services (DDS) to decide if your medical condition qualifies for benefits. DDS will ask the remaining four questions.

Is your condition severe?

Does your condition significantly limit your ability to perform basic living tasks such as standing, walking, sitting, lifting, or remembering? These issues must have persisted for at least the past 12 months.

Is your condition found on the Social Security’s list of disabling conditions?

For each of the major body systems, Social Security maintains a list of medical conditions that it considers so severe that it keeps a person from working in a substantial way. If it is not on the list, DDS will have to decide the severity of your condition through added review.

To speed reviews, Social Security maintains a Compassionate Allowances list and a Quick Disability Determinations program. Each of these screens applicants for a high probability of approval.

Can you do the work you did previously?

If you can’t perform the work you have done in the past, this will help your case in seeking benefits. If you can still do the work, your application will probably be denied.

Can you do other types of work?

If you can’t do what you did before, then Social Security will investigate if it’s possible for you to do other types of work instead. Your skills, age, education, and any transferable skills will be reviewed to see if you can do different types of work. If you can, you will not be approved for a qualifying disability.

There are other special situations where you may also qualify. These include:

If You’re Blind Or Have Low Vision 

If You Are The Worker’s Widow Or Widower

Benefits For A Disabled Child

Benefits for Wounded Warriors & Veterans

Eligibility Rules for Disabled Children/Family Benefits

When a child under 18 may or may not be disabled, Social Security doesn’t consider the child’s disability when deciding if he or she qualifies for benefits as a parent’s dependent. The child’s benefits normally stop at age 18 unless he or she is a full-time student in an elementary or high school in which case benefits can continue until age 19, or he or she is disabled.

In some cases, your spouse or child may qualify for SSDI with an amount of up to half of your benefit. There is a limit of 150-180% of your full benefits.

Also, if you get divorced, you may be eligible for benefits based on your ex-spouse’s SSDI if:

  • your marriage lasted for at least ten years
  • you have not remarried
  • your ex-spouse is at least 62 years old
  • you are eligible for Social Security disability or retirement benefits. 

This benefit cannot exceed the amount of money you could receive based on your work history instead of your ex-spouse’s.

If an is adult disabled before 22, he or she may be eligible for a child’s benefits if a parent is deceased or starts receiving Social Security retirement or SSDI benefits. It is considered a child’s benefit because funds are paid based on a parent’s earnings record.

An adult child must be unmarried, age 18 or older, have a disability that started before age 22, and meets the definition of disability for adults.

If a child receives benefits as an adult who has been disabled since childhood, benefits generally end if he or she gets married. However, some marriages are protected. For example, this might be the case if the child gets married to another adult disabled child.

Several rules can qualify for an exemption. If you aren’t sure about your status, contact Social Security to find out more about possible benefits.

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Disabilities That Qualify for SSDI

Medicare publishes a Listing of Impairments that are medical criteria applied to the evaluation of diseases and conditions for adults and children. In some cases, the requirements are the same if the disease progresses similarly for adults and younger children.

The Medicare disability requirements list is dynamic and will change from time to time.

For adults, this list includes:

  • Musculoskeletal system
  • Special Senses and Speech
  • Respiratory Disorders
  • Cardiovascular System
  • Digestive System
  • Genitourinary Disorders
  • Hematological Disorders
  • Skin Disorders
  • Endocrine Disorders
  • Congenital Disorders that Affect Multiple Body Systems
  • Neurological Disorders
  • Mental Disorders
  • Cancer (Malignant Neoplastic Diseases)
  • Immune System Disorders

Childhood listings include:

  • Low Birth Weight and Failure to Thrive
  • Musculoskeletal System
  • Special Senses and Speech
  • Respiratory Disorders
  • Cardiovascular System
  • Digestive System
  • Genitourinary Disorders
  • Hematological Disorders
  • Skin Disorders
  • Endocrine Disorders
  • Congenital Disorders that Affect Multiple Body Systems
  • Neurological Disorders
  • Mental Disorders
  • Cancer (Malignant Neoplastic Diseases)
  • Immune System Disorders

Keep in mind that the Listing of Impairments criteria is just one step in a multi-step process to determine SSDI eligibility.

Compassionate Allowances Initiative

The Social Security Administration has published a list of conditions known as “compassionate allowances” that meet the criteria for SSDI benefits.

The goal is to reduce waiting times for disability determination in cases where a disease or condition meets Social Security’s statutory standards to qualify as a disability. These conditions include some types of cancer, adult brain disorders, and several rare disorders affecting children.

Social Security uses the same rules to evaluate Compassionate Allowances conditions when evaluating both Social Security Disability Insurance or Supplemental Security Income (SSI) programs.

Other conditions may also qualify as well and can be submitted for consideration. Currently, there are more than 200 conditions that are on the Compassionate Allowance list, making it much easier to qualify for benefits.

You can view the complete and current list here.

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When Can You Get Medicare With SSDI?

To be eligible for Medicare and SSDI benefits, you must first get SSDI benefits.

If your SSDI application is approved, you will have a five-month waiting period before you get your first benefit payment. You will receive your first check on the sixth full month after your application is approved.

You will not receive Medicare until you have received SSDI for 24 months. Your five-month waiting period is considered part of your 24-month Medicare waiting period.

During your 25th month of SSDI benefits, you will be automatically enrolled in Medicare Part A and Part B. If you want additional medical coverage, you will need to consider purchasing a Part C Medicare Advantage plan as well.

SSDI Medicare Waiting Period Exceptions

There are two exceptions when the 24-month waiting period is waived.

Because they are so severe, Social Security grants exceptions to those who are diagnosed with end-stage renal disease (ESRD/kidney failure) and amyotrophic lateral sclerosis (ALS/Lou Gehrig’s disease).

Applicants for Supplemental Security Income are not subject to a waiting period. Benefits can begin immediately. So, if you have limited or no income and few assets, you may want to apply for SSI benefits.

When you qualify for SSI, you will not receive Medicare benefits. You will receive Medicaid benefits instead.

What Happens If I Go Back to Work?

Going back to work may or may not change your SSDI. Also, if you are no longer eligible for SSDI, you may or may not lose your Medicare coverage.

If you find a part-time job, you may not necessarily lose all your benefits, but you will probably see a decrease in your benefit check due to the limit on how much you can earn while on Social Security. 

If you overcome your illness or disability and can perform steady work again, you will most likely lose your benefits entirely. 

Or, if you find a “substantial” job, defined as earning at least $1,220 per month (or $2,040 if you are blind), you will lose your benefits.

Social Security provides incentives to get you back into the workforce instead of attempting to live off of SSDI for the rest of your life. Those incentives include:

Trial Work Period – You are allowed to “try” working for up to nine months before you drop Social Security. If you realize within those nine months that you are too disabled to return to work, and you need to keep your benefits, you can stop working and continue to take your benefits.

Work Expenses/PASS – If you are working with a disability, Social Security may pay for assistive items such as taxis or special buses to get you to work, or even counseling and other services that can make your job easier. These expenses may be deducted from your SSDI benefits.

Plan to Achieve Self-Support (PASS) – Through this program, any money that you save up for schooling, job training, childcare, etc. will not be counted towards an income that would force you out of SSDI. Therefore, you cannot lose your SSDI due to your attempts to get back to work. However, Social Security must approve these costs, so make sure you contact them for a PASS application before you overspend.

Extended Eligibility – Once your trial work period is over if you decide to continue working, you have three years to keep receiving benefits unless your job provides substantial income, and you do not require SSDI.

Expedited Reinstatement – If you lose your benefits due to returning to work, you have five years to ask for your benefits to be reinstated without having to go through the entire application process again.

Medicare Continuation – If you are under 65 and you return to work and lose your SSDI, you can still keep your SSDI Medicare plan for up to 93 months as long as you pay your premiums. 

If you’re over 65, you can retain your Medicare coverage regardless of your SSDI eligibility.

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Medicare Benefits

SSDI payments can help offset significant medical expenses when you qualify. After meeting the two-year waiting period, you will also qualify automatically for Medicare Part A and Part B benefits. You may also qualify for Part D Prescription Drug coverage as well.

Here’s a quick look at what these Medicare health insurance benefits provide.

Medicare Part A Coverage

Part A covers hospital services like inpatient hospital stays, skilled nursing facility care, hospice, and certain home health services. If you have full SSDI benefits, you will not have to pay a premium for Part A. The only costs you may be responsible for are deductibles and copayments for hospital stays. 

In 2020, the Part A hospital deductible is $1,408. 

You might also be eligible for a Medicare Savings Program, which can help pay for your Part A and B premiums, deductibles, and copayments.

Medicare Part B Coverage

Part B covers physician services, outpatient hospital services, annual wellness visits, mental health, lab tests, x-rays, ambulance travel, and some medical equipment. 

In 2020, most people with Part B will have a premium of $144.60 per month, but some people with Social Security may have a slightly lower premium. 

A beneficiary’s Part B monthly premium can also be adjusted upward annual income. These income-related monthly adjustment amounts (IRMAA) affect roughly 7 percent of people with Medicare Part B. 

Part B does have a deductible of $198 per year as well as copayments for some services. A Medicare Savings Program can help you cover those additional costs.

Medicare Part D Coverage

People with SSDI may qualify for Medicare Part D savings as well. 

Part D plans are privately owned and operated prescription drug plans. 

You need to enroll separately from your Part A and Part B coverage, and enrollment is not automatic. You may have a separate premium cost for Part D coverage as well.

There is also a deductible of up to $435 in 2020 (the actual amount will vary based on your plan), and once you have paid that amount, you will still need to make copayments.

Some Medicare Part D plans have $0 deductibles. You’re only responsible for a set copayment or coinsurance amount when you pick up your prescription drugs.

To alleviate your prescription costs, you can find out if you qualify for LIS or Low-Income Subsidies. This is also called the “Extra Help” program.

Medicare Supplement Plans if You’re Disabled and Under 65

Regardless of your age, if you qualify for SSDI, you may be able to get a Medicare Supplement plan. They are also known Medigap plans and operate differently from other types of Medicare. 

Private insurance companies offer Medigap plans. They do not offer additional health benefits, but they do provide added coverage for your Part A, B, and D premiums, deductibles, and copayments. 

Some states provide the right to buy a Medigap policy if you qualify for Medicare under 65. Other states provide these rights only to people eligible for Medicare because of disability or only to people with ESRD. Check with your state insurance department to see what the rules are for your state. 

SSDI and Medicare Advantage Plans for Disabled Under 65

No matter your age, those with SSDI can enroll in Medicare Advantage (MA) Part C plans. Medicare Advantage plans are qualified for Medicare plans offered by private companies. 

Because they are privately owned, insurers can offer additional benefits that Parts A, B, and D alone cannot provide. Some common benefits you may find in MA plans are home nurses, telehealth, home modifications, fitness, dental, vision, hearing, and prescription drugs.

You might qualify for an SSDI Medicare Advantage Special Needs Plan. These are specifically for people with certain financial needs or chronic disabilities. While these plans will most likely still require some costs, like copayments, you might qualify for a $0 premium plan. 

Plus, you may qualify for additional assistance through programs like your state’s State Pharmaceutical Assistance Program (SPAP).

Medicare Costs in 2020

In most cases, Medicare Part A is premium-free. If you’re not eligible for premium-free Part A, you could pay up to $458 per month. 

For hospital stays in 2020, you pay: 

  • $1,408 deductible per benefit period 
  • $0 for the first 60 days of each benefit period 
  • $352 per day for days 61–90 of each benefit period 
  • $704 per “lifetime reserve day” after day 90 of each benefit period (up to a maximum of 60 days over your lifetime) 

For a Skilled Nursing Facility stay in 2020, you pay:

  • $0 for the first 20 days of each benefit period
  • $176 per day for days 21–100 of each benefit period
  • All costs for each day after day 100 of the benefit period 

In 2020, the standard premium for Part B is $144.60 per month. It could be higher based on your modified adjusted gross income.

The annual Part B deductible is $198. These are both increases of about 7% over 2019, for the most part, due to rising spending on physician-administered drugs.

Part C and Part D plans will vary by plan and several possible variables.

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Is Medicare Free for Disabled Beneficiaries?

No. You will have to pay still premiums, deductibles, and copayments in many cases. For example, Medicare Part B has a monthly premium of $144.60 for 2020.

However, with SSDI eligibility, you may be able to find ways to cover these costs.

A Medicare Savings Program can help you cover your Medicare premiums, deductibles, coinsurance, and copayments. You can qualify based on your income. 

Also, the Extra Help program can help you cover your prescription drug deductible, premium, and copayments.

Social Security Disability and Medicaid

Social Security Disability Insurance does not qualify you for Medicaid, but Supplemental Security Income (SSI) does. 

SSI is a needs-based program to help old, blind, and disabled people who have little or no income. It helps to provide for basic living expenses such as food, clothing, and shelter.

Medicare is administered by the federal government. But Medicaid programs are administered jointly by the federal and state governments, so programs and coverages will vary from state to state. 

Learn more about Medicaid in your state.

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How to Apply for Medicare if You Receive SSDI Benefits

If you receive SSDI benefits, you’ll automatically be enrolled in Medicare Part A and Part B after a two-year waiting period. Automatic enrollment exceptions include qualified individuals who do not live in the United States or the District of Columbia. If you do live in a U.S. territory, automatic enrollment will be limited to Medicare Part A.

There is no waiting period if you have ESRD or ALS.

You can apply for a Part D Prescription Plan as early as three months before the 25th month you receive SSDI benefits. If you want added coverage through a private health plan, you can also shop for a Medicare Advantage Part C plan.

If you have ESRD, you must enroll in all parts of Medicare manually. 

To enroll, log on to www.socialsecurity.gov/medicareonly or call 1-800-772-1213 (TTY users 1-800-0778), Monday through Friday, from 7 am to 7 pm. 

You can also visit your local Social Security office to enroll in Medicare Part A and Part B.

Let Us Help You Choose an SSDI/Medicare Plan

Even though you will be automatically enrolled in Medicare during your 25th month of SSDI benefits, you can still select a Medicare Advantage or Medicare Supplement plan to add more coverage. 

You’re only automatically enrolled in Part A and Part B, so you probably need more coverage.

We have licensed agents in 38 states who can sell plans from all the major carriers. That means that there is no bias in their sales approach – they can still earn commission regardless of which plan they sell you. 

There is no extra cost to you when you enroll through one of our agents. The plan costs do not change, but you get the chance to go over your options with someone who has studied the plans thoroughly. 

To set up your free, no-obligation appointment, go here or call 833-438-3676.

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