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Understanding Medicare Special Needs Plans

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SSDI Medicare Coverage

While Supplemental Security Income (SSI) can mean that you qualify for Medicaid, Social Security Disability Insurance (SSDI) can mean that you qualify for Medicare (even if you are under 65). Most people are automatically enrolled in Medicare after receiving SSDI for at least 25 months. Qualifying for SSDI Medicare means that you may have access to affordable healthcare services for a low premium.

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Click the links below to learn more about SSDI:

What is SSDI?

Social Security Disability Insurance is a program for disabled people who have worked and paid Social Security taxes throughout their life. To qualify for SSDI, you must have been legally employed and paying employment taxes towards the Social Security program for at least ten years.

SSDI Eligibility

To be eligible for SSDI, you must pass the following “tests:”

  • “Means” - Do you lack the means to survive? You must be either incapable of keeping a job or incapable of earning more than $1,070 per month (amount subject to change each year)
  • “Severity” - How severe is your disability? Your condition must interfere with basic activities, rendering you unemployable. You must be able to provide medical documentation that proves the severity of your disability.
  • “Work” - You’ll need some form of evidence that you cannot perform the type of work that you did before becoming disabled as well as proof that there is not another form of work that you can take on. Your education, work experience, and age will all be considered.

Family Benefits

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. For your child to be eligible, he must be single and either under 18 or age 18 or 19 and still in high school. Kids over 18 who were diagnosed with a disability before age 22 can also qualify. If your child is working, benefits will be limited.

Additionally, 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 re-married, your ex-spouse is at least 62 years old, and you are eligible for Social Security disability or retirement benefits. This benefit cannot exceed the amount of money you could receive based on your own work history instead of your ex-spouse’s.

Compassionate Allowances

The Social Security Administration has published a list of conditions known as “compassionate allowances” that meet the criteria for SSDI benefits. Other conditions may qualify as well, but there are well over 200 conditions that you can almost guarantee will allow you to receive benefits. Click here for the full list of compassionate allowances.

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When can you get Medicare with SSDI?

If you are eligible for SSDI Medicare, you’ll have to get SSDI first. 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 two full years, but you will be automatically enrolled in Medicare parts A and B in your 25th month of SSDI benefits. Your five-month waiting period is included in those 25 months, so it will feel more like 20 months after you start receiving benefit checks. Keep in mind that you will only be enrolled in “Original Medicare,” which includes hospital coverage (Part A) and medical coverage (Part B). To add other benefits like dental, vision, hearing, and prescription drugs, you’ll want to consider a Medicare Advantage plan, which we will discuss further below.

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What Happens if you go Back to Work?

Going back to work may not change your Social Security Disability Insurance. If you overcome your illness or disability and can perform steady work again, you will most likely lose your benefits entirely. If you find a small 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. However, if you find a “substantial” job, meaning you are earning at least $1,220 per month (or $2,040 if you are blind), you will lose your benefits.

Social Security does provide a few incentives to get you back into the workforce instead of trying to live off of SSDI for the rest of your life:

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.

PASS (Plan to Achieve Self-Support) - Through this program, any money that you save up for schooling, job training, child care, etc. will not be counted towards 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 hold on to your SSDI Medicare plan for up to 93 months (over seven years) as long as you pay your premiums. If you’re over 65, you can retain your Medicare coverage regardless of your SSDI eligibility.

SSDI 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 co-payments for hospital stays. In 2019, the Part A hospital deductible is $1,364. You might also be eligible for a Medicare Savings Program, which can help pay for your Part A (and B) premiums, deductibles, and co-payments.

Social Security Disability Medicare Part B Coverage

Part B covers items like your annual wellness visit with your doctor, mental health, lab tests, x-rays, ambulance travel, and some medical equipment. Most people with Part B will have a premium of $135.50 per month, but some people with Social Security may have a slightly lower premium. Part B does have a deductible of $185 per year as well as co-payments for some services. A Medicare Savings Program can help you cover those additional costs.

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SSDI 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. They are plans that you would enroll in separately from your Part A and B, so you will not be enrolled in Part D automatically. In 2019, the Part D deductible can be up to $415, and you will likely have a premium as well (depending on your plan). 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 for Disabled Under 65

Regardless of your age, if you qualify for SSDI you may be able to get a Medicare Supplement plan. Medicare Supplement plans, also called Medigap, operate differently from other types of Medicare. Medigap plans do not usually offer additional health benefits, but they do provide coverage for your Part A, B, and D premiums, deductibles, and co-payments. Since Medigap plans are not typical benefit plans, they do operate under slightly different rules and regulations. Most importantly, Medigap plans do not have to cover you if you are under the age of 65 - but some do. Therefore, if you qualify for Medicare solely due to your SSDI eligibility, Medicare Supplements may not be right for you, and you should consider Medicare Advantage.

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SSDI Medicare Advantage Plans for Disabled Under 65

No matter your age, those with SSDI can enroll in Medicare Advantage. Medicare Advantage (MA) plans are qualified Medicare plans offered by private companies. Because they are privately owned, they 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 a 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 co-payments, you might qualify for a $0 premium plan. Plus, you may qualify for additional assistance through programs like your state’s “SPAP,” or “State Pharmaceutical Assistance Program.”

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SSDI and Medicare Premiums

Even if you have Social Security, Medicare is not free. You will find premiums (the amount you pay every month towards your plan), deductibles (the amount you have to pay before your coverage kicks in), and co-payments (what you pay when you visit the doctor or pick up a prescription). However, due to your 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. 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. Unlike Medicare, Medicaid programs are different in every state. Click to learn more about Medicaid in your state.

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Help Choosing a 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. Remember, you will only be automatically enrolled in Part A and Part B - 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, click here or call 833-438-3676.

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