Category Archives: Medicare and Medicaid

Why Is There a Two-Year Waiting Period for Medicare for the Disabled?

Question: Because of incompetent social workers in the local office, things were not handled right for my husband. So we are now waiting for his Medicare insurance. Thank God we did finally find the right advocate to help us with his disability. In March 2012 he went through lung cancer surgery and then November the same year brain cancer. He was approved for disability December 2013, EOD.  Now we wait for Medicare. Who ever decided that in our government has no compassion for people. I do not expect an answer. But for sick people to wait 24 to 29 months for Medicare when they can no longer make a income is ridiculous.

Answer: I’m sorry to hear of your husband’s medical problems. I’m surprised your husband didn’t get an earlier disability onset date, with two cancers in the same year (I think you’re saying that your husband’s established onset date of disability was in December 2013). Unfortunately, you’re right, your husband will have to wait at least another year for Medicare coverage. There are two exceptions to this rule: those with permanent kidney failure (known as end-stage renal disease, or ESRD) and amyotrophic lateral sclerosis (ALS) aren’t subject to the two-year waiting period. You would think that metastatic brain cancer and other life-threatening illnesses would also be on that short list, but unfortunately they are not.

Medicare was originally intended for those over 65, and when Medicare was expanded to include persons with disabilities, a very expensive expansion,  the two-year waiting period was added as a cost-saving measure. When Congress expanded Medicare to those with disabilities, it was their hope that, during the two years of the waiting period, disability recipients could either continue under their former employers’ plans under COBRA or qualify for Medicaid. If you’ve ever used COBRA, however, you know that the premiums are very high, especially for someone who no longer has earnings from work. Things may be a little more hopeful on the Medicaid front for some people. About a third of disability recipients receive Medicaid coverage during the waiting period.

In three-quarters of the states, Medicaid has a “medically needy” program, so that individuals with high medical expenses but too much income to qualify for the regular program can still qualify for Medicaid. In these states, Medicaid applicants can subtract their medical expenses from their income in order to meet that state’s Medically Needy Income Limit (MNIL). (Read more about this in Nolo’s article on Medicaid’s medically needy program.)

Unfortunately, over a third of disability recipients don’t have health insurance coverage at some point during the Medicare waiting period. And it can be argued that this is the population that needs medical care the most. Indeed, about 4% of disability recipients die while waiting for Medicare coverage.
Over the last several years, there have been legislative attempts to phase out the waiting period and/or to eliminate it immediately for those with life-threatening illnesses (in addition to ESRD and ALS). Unfortunately, these attempts haven’t been successful, due to the high cost of phasing out and eliminating the waiting period, estimated by some to be about $10 billion per year.

What can I do if Social Security didn’t give me the correct disability start date?

Question: I applied for SSDI in January of 2014 and, although I have been disabled since a major surgery on 01/20/12, SSDI chose 01/20/13 as my effective disability start date. This decision means I cannot receive Medicare benefits until January 2015. This is not a correct decision by SSDI and I cannot find any info on how to appeal the decision. I am hoping you will be able to assist me.   

Answer: Unfortunately, I don’t think Social Security has made a mistake. You may well have met Social Security’s definition of disability in January 2012, but Social Security will pay retroactive benefits going back only so far. In turn, Social Security will assign an “established onset date” going back only so far.

The rule is that Social Security will pay retroactive benefits going back only 12 months before the date you apply. Since you applied in January 2014, you can only receive benefits dating back to January 2013 (your “entitlement date”).  You become eligible for Medicare 24 months after your entitlement date, which in your case means January 2015.

Just to clear up a little confusion, your disability onset date is not the same as the day you become entitled to disability payments. There is a five-month waiting period in between your established disability onset date and when you are entitled to be paid benefits, meaning Social Security will set your disability onset date to be five months before your entitlement date. What this means is that your disability onset date can be no earlier than 17 months before the date you apply for Social Security benefits. In your case, your disability onset date should be in August 2012.

I’m sorry that wasn’t the answer you wanted to hear. You may be able to qualify for Medicaid until January 2015, if your medical expenses are very high and your income and assets aren’t.

Does someone on Social Security disability get free Medicare?

Question: I was approved for SSDI because of multiple sclerosis almost two years ago. I should become eligible for Medicare in early 2014.  Is Medicare free for disability recipients, or will I have to pay premiums? If so, how much?

Answer: You are eligible for Medicare two years after your entitlement date for Social Security Disability Insurance (this is the date your backpay was paid from). Medicare isn’t free for most disability recipients though. There are premiums, deductibles, and copays for most parts of Medicare, and the costs go up every year. Here are the new figures for 2014, and how you can get help paying the costs.

Part A Costs

You will have to pay a premium for Medicare Part A (hospital insurance) if you aren’t fully insured under Social Security. Generally being fully insured means having worked 40 quarters (the equivalent of 10 years) in a job paying FICA taxes. Many disability recipients aren’t fully insured because they became unable to work before getting enough work credits. If you (or your spouse) don’t have enough work credits, you’ll pay a premium of $426 per month, or if you (or your spouse) has between 30 and 39 credits, you’ll pay a premium of $215. (The premiums actually went down in 2014.)

If you need hospital or skilled nursing care, you’ll have to pay the first $1,216 in costs (your deductible) before Medicare will start paying anything. Once you’ve satisfied the deductible, the first 60 days in the hospital (or 20 days in skilled nursing care) are free. If you still need inpatient care after that, you will be responsible for the following copays.

  • Hospital days 61-90: $304 per day
  • Hospital days 91 and beyond: $608 per  day, and
  • Skilled nursing days 21-100: $152 per day.

Medicare can be quite expensive for those on disability who aren’t fully insured, but if you are eligible to be a Qualified Medicare Beneficiary (QMB) because of low-income, a Medicare Savings Program will pay your Part A premium, and possibly other costs as well.

Part B Costs

Most people pay a Part B premium of $104.90 each month. However, if your adjusted gross income is over $85,000 (or $170,000 for a couple), the monthly premium can be over $200. The Part B deductible for 2014 is $147 per year.

Again, if you have low income, there are various programs that can pay your Part B premium and deductible, called Medicare Savings Programs.

Part D Costs

Part D premiums vary depending on the plan you choose. The Part D deductible for 2014 is $310 per year (though some plans waive the deductible).

There are subsidies available to pay for Part D for those with low income (called Extra Help). See Nolo’s article on Extra Help for Part D for when you are eligible.

As for the “donut hole,” when Part D helps you less, in 2014 the donut hole begins after you’ve spent $2,850 on prescription drugs and ends when you’ve spent $4,550. However, in 2014, while you are in the donut hole, brand-name drugs must be sold to you at a 52.5% discount and generic drugs at a 28% discount.

For more details on the 2014 costs of Medicare and Medigap plans, see Nolo’s article on Medicare premiums, deductibles, and copays in 2014.

Eligibility for Medicare: Can I Qualify Before I’m 65?

Question: I was just denied Social Security disability benefits because I didn’t have enough work credits. I was mainly applying to qualify early for Medicare (I’m 60), because I have high medical costs due to kidney problems and other conditions. Now I’m worried I won’t qualify for Medicare even when I turn 65. What can I do?

Answer:  You have some options. There are several parts to Medicare, with different rules for qualifying for each. Part A, Hospital Insurance, is the Medicare coverage that’s premium-free for those who are fully insured with Social Security. Individuals over 65 who aren’t insured with Social Security can pay a premium to get Part A. Anyone over 65 can also get Part B, Medical Insurance (mainly for doctors’ visits), simply by paying a premium.

Here are the various ways to qualify for Medicare.

Premium-free Medicare for those age 65 or older. If you are 65 or older and you OR your spouse worked for long enough in a job covered by Social Security, for a railroad, or for a federal, state, or local government in a Medicare-covered job, you qualify for free Medicare Part A. Generally you need 40 work credits (each representing one calendar quarter of work) to be fully insured by Social Security. That represents about ten years’ worth of work.

To qualify based on your spouse’s work record (or your ex-spouse’s work record), your spouse must be at least 62. Do you have a spouse who will have enough work credits by the time you turn 65?  Check with Social Security to see if your spouse (or ex-spouse) will have enough credits.

Paid-premium Medicare for those over 65 and older. Those over 65 who don’t qualify through one of the above methods can get Part A or Part B by paying a premium. Note though, if you want to get Part A by paying a premium, you also have to pay for Part B. On the other hand, you can just get Part B if you want, by paying the Part B premium. Also, anyone who is entitled to Medicare Part A or enrolled in Part B can get Part D prescription drug coverage by paying a monthly premium.

How much are you looking at having to pay for Part A if you’re not fully insured for Social Security? If you, or your spouse, has 30 to 39 work credits (instead of the 40 required to be fully insured by Social Security), the monthly premium for Part A is currently $225 per month. If not, the monthly premium would be $441 per month (in 2013 numbers). If you have income below a certain level, however, you can get help paying your premiums through one of the Medicare Savings Programs.

Those younger than 65. Unfortunately, there are limited ways to get Medicare if you’re under 65. You can qualify for Medicare if you are approved for disability benefits from Social Security or the Railroad Retirement Board. However, there is a 24-month waiting period after you become entitled to disability benefits before you can get Medicare (except for those who suffer from ALS). You can also get Medicare coverage if you have end-state kidney/renal disease (ESRD). (For ESRD, you or your spouse need only be “currently insured” with Social Security. If you or your spouse earned six credits in the three years before turning before turning 65 or dying, you are currently insured.)

If your income and assets aren’t too high (and you may not need to count money you spend on your medical expenses), you might want to look into applying for Medicaid, especially if your state has opted for Medicaid expansion. Or, check out the new health care marketplaces.

Ways to get more credits. If you are close to the amount of credits you need (at age 60, you need 38 credits to qualify for disability benefits; at age 62 or older, you need 40 credits to qualify for disability or retirement benefits), you might consider going back to work on a very part-time basis. You need to earn only $1,160 to get one credit, and you can earn four credits per year. Getting to 40 credits (or 30, even), can save you thousands of dollars in Medicare Part A costs over the years. Or, if your spouse is close to being fully insured for Social Security, he or she might be able to earn a few more work credits.

Lastly, you can always appeal a Social Security denial. If you can get approved for disability benefits, you’ll automatically be eligible for Medicare two years later or when you turn 65, whichever is earlier.

How Obamacare Will Affect Social Security and People With Disabilities

One way that Obama’s health care reform will help make health insurance accessible to more people is by eliminating preexisting condition exclusions.  This will be a big benefit to those with disabilities, because many will now be able to purchase their own insurance. Having more people eligible for private health insurance will have an effect on Social Security, Medicare, and Medicaid.

Thanks to Obama’s health care reform law, as of January 1, 2014, insurance companies can no longer deny coverage to individuals with preexisting conditions, or charge them higher rates. (See Nolo’s recent article on the ban against preexisting condition limitations.) At the same time, individuals without group health insurance can purchase insurance through the Health Insurance Marketplace; applications can be submitted starting October 1, 2013. Those with low income (less than 400% of the federal poverty level) are eligible for lower premiums, and those with even lower income (250% of the federal poverty level) can qualify for lower out-of-pocket costs like deductibles and copays. (See Nolo’s federal poverty guidelines for exact figures.)

These two provisions of the new health care reform law (called the Patient Protection and Affordable Care Act of 2010) should lower the number of people on Medicare and Social Security disability.  Why? Historically, many folks with preexisting conditions who lost their prior work-based health coverage apply for disability benefits just so they can get health care benefits. They know that an approval for Social Security disability will mean they can either qualify early for Medicare, or, if they have very low income (or somewhat low income and very high medical expenses), they may be eligible for Medicaid. Some of these folks will now decide not to file for disability benefits since they don’t need a disability approval to get health care, now that insurance companies can’t turn down people with disabling medical conditions and disabled individuals have an opportunity to buy affordable health care, more flexibility in choosing a health care plan, and the potential for out-of-pocket savings on their health care needs.

Not only that, but now that more persons with disabilities or chronic medical conditions will have good health care and access to reasonable priced medications, more of them will be able to work despite having physical or mental impairments, and fewer of them will need to apply for disability benefits.

What’s more, those who can’t work for a while due to a temporary disability will be less likely to need to be off work indefinitely, thanks to better health care and access to medications. In fact, fewer people many now qualify for Social Security disability since only those whose medical conditions prevent them from working for at least 12 months are eligible for SSDI or SSI disability benefits. Now, some disability applicants who would have been eligible to receive Social Security while they recuperate from injuries or mental illnesses may recover sooner because of regular doctors’ visits plus the proper medication.

On the other hand, some other folks who would have previously been denied disability benefits or Medicaid benefits are now more likely to be approved. Often disability applicants are denied because they haven’t been seeing a doctor for treatment and don’t have test results to prove their disability. Now that health care is more accessible, more folks who apply for disability will have been seeing doctors regularly and have the proper diagnoses, lab results, and x-rays in their records. This should help eliminate the need for Social Security to send applicants to consultative medical exams and should reduce the number of disability appeals – with the proper medical records, fewer claims will be incorrectly denied disability benefits in the first place. This represents significant potential cost savings for Social Security.

Similarly, despite fewer people applying for disability benefits, Medicaid roles will increase, of course, because in some states Obamacare’s Medicaid expansion will now allow adults with incomes of up to 133%-138% of the federal poverty level to qualify for Medicaid.

But overall, health care reform appears to be a great deal for persons with disabilities.

Why Can’t I Get Medicare Two Years After My Disability Onset Date?

Question: Can you please clarify “disability onset date” in regards to qualifying for Medicare? I became ill in 2007, hoped I would recover but did not, and filed for SSDI last December. Even though Social Security agrees I was disabled since 2007, they say I can’t get Medicare until the end of this year. I thought the two-year waiting period for Medicare started at the disability onset date, and not after you’ve received 24 payments? Can you please clarify, since I have incurred some medical bills that I cannot financially handle at this time?

Answer: Generally, the rule on Medicare eligibility for those who receive Social Security disability insurance (SSDI) is this: Eligibility for Medicare starts in the 25th month after you become eligible to receive  SSDI payments. (Note there are two exceptions to the two-year Medicare waiting period: those with end stage renal disease or ALS can get Medicare benefits sooner.)

But when exactly do you become “eligible” to receive SSDI? Do you become eligible to receive benefits when your SSDI checks start getting deposited in your bank? Or as early as your disability onset date? Or as of your disability onset date plus five months, to make up for the SSDI waiting period?

Social Security calls the date you become eligible to receive SSDI payments your “entitlement date.” Due to the five-month waiting period for SSDI, this date is five months after the date that Social Security establishes your disability began (your “established onset date,” or EOD). You then count 24 months out from the entitlement date to see when you’ll become eligible for Medicare. In other words, you can join Medicare 29 months after your established onset date.

In real life, it takes so long to get a disability hearing that applicants who go to the hearing stage of appeal to get benefits usually need to wait only a few months after their approval to be eligible for Medicare.

But what if your disability onset date was years ago, or 2007 as you say? Unfortunately, unless you applied for disability benefits a long time ago, this won’t help you get Medicare benefits too much faster. If you didn’t apply for Social Security disability until years after becoming disabled, or until 2012 in your case, your eligibility for Medicare won’t start 29 months after the actual onset of your disability. Because of maximums set by federal law, your established onset date can be no earlier than 17 months before the date you apply for Social Security benefits. For example, if you applied for benefits December 1, 2012, the earliest EOD you can receive is July 1, 2011.

In turn, this means your entitlement date can be only 12 months before you apply for SSDI, because of the five-month waiting period. (And Social Security will pay retroactive benefits for no more than 12 months prior to your application date.)  This would mean the earliest date that your date of entitlement could be is December 1, 2011, and the earliest date you could be eligible for Medicare is December 1, 2013. In essence, you can never become eligible for Medicare before two years have passed since you applied for Social Security disability. Moral of the story: If you think you’ll need ongoing medical treatment and can’t afford it, apply for Social Security soon after you become unable to work.

For more information about the complicated interaction between onset date, application date, and waiting periods, see Nolo’s article on how Social Security calculates backpay.