Medicare or Medicaid and Social Security Disability Benefits

If you have become disabled and are not able to work, you may have lost health insurance coverage that you received through your employment in addition to losing needed income. People with disabilities need help paying medical expenses as much as anyone else, if not more.

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Those who are disabled have access to two types of medical insurance: Medicare for those on SSDI and Medicaid for those on SSI.

Individuals who are disabled have access to two types of medical insurance: Medicare and Medicaid.

Generally, if an applicant is approved for Social Security Disability Income, they will be covered by Medicare; if an applicant is approved for Social Security Income, they will be covered by Medicaid.

Medicare is a federal health insurance program funded by Social Security taxes.

Individuals become eligible when they reach retirement age (65) or become disabled. Medicare is divided into four parts: Part A, Part B, Part C and Part D.

•    Part A covers hospitalization and is free.
•    Part B is similar to regular health insurance plans, covering doctor visits, lab work and emergency room visits. Individuals must pay a premium for this coverage which is deducted from Social Security payments if they are receiving disability or retirement benefits.
•    Part C is private supplemental insurance which provides additional coverage beyond Parts A and B.
•    Part D is prescription drug coverage.

Under most circumstances, Medicare coverage begins for SSDI recipients 24 months after the applicant’s first month of eligibility.

This date, called the entitlement date, is calculated by taking the date the applicant’s disability began (date of onset) and adding a five-month waiting period. For example, if a claimant’s date of onset is October 2020, their entitlement date would be March 2021 and the claimant would not receive Medicare benefits until March 2023.

If you have been denied disability don’t give up! Contact a Disability lawyer at 512-454-4000 for a free consultation and get the benefits you deserve.

However, in some cases where an SSDI application is not approved for several months, the claimant may have already met a portion of the waiting period by the time they begin receiving monthly payments.

For example, a claimant may not file an application until months after becoming disabled, or their claim may be denied and the applicant will need to go through the appeal process. There are exceptions to the 24-month waiting period for individuals with a diagnosis of end stage renal disease or ALS (Amyotrophic lateral sclerosis). These two impairments are considered so life-threatening that Social Security waives the waiting period.

If you are eligible for Medicare because of a disability and have been receiving SSDI or railroad disability annuity checks for 24 months, you should automatically be enrolled in Medicare Parts A and B at the beginning of the 25th month.

Three months before your coverage date you will receive your Medicare card and information explaining the Medicare program.

Medicare Costs

Part A: Hospital Insurance

Cost: Most people under 65 with a disability will be fully insured for free under Social Security. Some SSDI beneficiaries do have to pay a premium for Part A if they have not paid FICA taxes for the previous ten years. Younger workers, or workers who have otherwise not been able to work for a full decade may have to pay a premium. The premium varies, but it is around $506 per month. There is also a $1,632 deductible before Medicare begins to cover costs.
Benefits: Part A covers inpatient care in a facility such as a hospital or nursing home, or home health services. For a hospital stay, after the deductible is paid, the first 60 days in the hospital are free, the 61st-90th days are $408 per day and after the 90th day, each day cost $816 (as of 2024). If you are enrolled in a program to help with your Medicare costs, these costs may be covered as well.

Part B: Medical Insurance

Cost: If you are enrolled in Part A and not paying a premium, you will be eligible to enroll in part B. The standard premium recently increased to $174.70. However, if you were on SSDI through 2024, you may be entitled to stay at your old premium. The deductible is only $240 per year and then any product or service costs 20% of a Medicare-approved rate (usually much less than the normal cost).
Benefits: Part B covers all services deemed medically necessary as well as preventive services such as vaccines. Part B also covers ambulance services and even some prescription medications. Your health care provider should be able to tell you if a specific product or service is covered under Medicare.

Part C: Medicare Advantage

Part C allows private insurers to provide Medicare. Some people chose to purchase Medicare benefits through a Part C Plan. Through the private healthcare marketplace, there are a wide variety of plans available each with different premiums, deductibles and coverage.

Part D: Prescription Drug Coverage

Cost: Part D premiums vary greatly, but are generally under $100 per month and their deductibles vary. Premiums are on the higher end for those with high incomes.
Benefits: Each Part D plan is different, but they all offer significant help paying for medications. In general, generic drugs will be much cheaper than brand-name drugs.

Medicaid

Medicaid is a needs-based health insurance plan run at the state level for those with low-income and paid for by federal, state, and local taxes.

Though there is no age requirement, Medicaid does have income and asset limits. Still, low income will not guarantee eligibility as priority is given to the disabled, elderly, pregnant women and children. Medicaid covers hospitalization, lab services, x-rays, doctor visits, nursing services, medical and surgical dental services and clinic visits with no charge though there may be a small fee for some services. The Social Security Administration handles enrollment for Medicaid in states where SSI recipients are automatically eligible for Medicaid, while other states require a separate application for Medicaid. All SSI recipients in Texas are automatically eligible for Medicaid where an application for SSI is also an application for Medicaid.

If you receive SSI but are denied Medicaid benefits, you should appeal the decision to your state’s Medicaid agency.

The state has to follow federal Medicaid rules in notifying you of the denial and holding a hearing. Medicaid must send out a written notice of denial within 90 days of your application date if you apply on the basis of disability or within 45 days if you apply on some other basis. The denial notice will state that you have the right to a hearing to appeal the denial, give instructions on how to request a hearing, and inform you that you may represent yourself or hire an attorney or another spokesperson. The notice will also state the reason for the denial and what specific rules the decision was based on. Most important, the notice will include an appeal deadline. You must appeal the decision by that date or you will have to justify a late appeal which would be difficult.

It is best to file a written request for an appeal which can be as simple as “I want to appeal the denial notice of 3/01/20.”

If possible, submit the request in person to the Medicaid office and have it date-stamped. Each state has different appeals procedures and your state Medicaid office will send you information about how the hearing will be conducted. You must appear for the hearing in person or on the phone. If your application was denied for a medical reason, the hearing officer may order you to attend a physical exam. If you win the hearing, the state will apply Medicaid coverage retroactive to the date you became eligible, usually the date your application was filed.

Because Medicaid is operated by the states which are permitted to set their own eligibility criteria, some states may have income limits that are higher or lower than Social Security Income, different asset limits, or different requirements for what makes someone disabled.

So, whether or not SSI approval gets you Medicaid depends on what state you live in. Remember, you can seek legal counsel if you need assistance.

Medicare Expansion: What is it and how does it affect you?

The Patient Protection and Affordable Care Act, more commonly known as Obamacare, has been a source of heated controversy well before it was signed into law on March 23, 2010. One of the most contentious aspects of the new law is Medicaid expansion. Obamacare intended to make the eligibility requirements for Medicaid less stringent. However, due to the controversy around the new law and the fact the Medicaid is a state and federal program, states are given a choice as to whether they will participate in Medicaid expansion or not. In the states that have accepted the new program, any citizen between 19 and 65 whose household income is below 133% of the poverty level is eligible for coverage as long as they are not in jail or entitled to Medicare.

If you are disabled and need healthcare coverage, Medicaid and Medicare are not your only options.

You may still be able to obtain coverage through the Health Insurance Marketplace and qualify for premium tax cuts and lower costs. This can be particularly helpful if you have applied for Social Security Disability benefits and are waiting for a decision or you don’t qualify for disability benefits – and you may still qualify for Medicaid. When you fill out your application, be sure to check “yes” when asked if you have a disability; your application will then be forwarded to your state Medicaid agency. You can find more information and help at https://www.healthcare.gov/people-with-disabilities and the Marketplace call center is open 24 hours a day, 7 days a week. There you will find trained helpers who are familiar with disability issues and assisting people with disabilities.

If you are currently enrolled in COBRA, you must notify your provider within 60 days of receiving your SSDI award.

You must send this notification before the initial 18-month COBRA coverage period expires. It is important that you do not wait too long to begin the application process; otherwise you may become uninsured if your COBRA benefits run out before you received Social Security Disability benefits.

Author: Attorney Lonnie Roach has been practicing law for over 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion rated by Martindale Hubbell. Through his extensive litigation Mr. Roach obtained board certifications from the Texas Board of Legal Specialization. Lonnie is admitted to practice in the United States District Court - all Texas Districts and the U.S. Court of Appeals, Fifth Circuit. Highly experienced in Long Term Disability denials and appeals governed by the “ERISA” Mr. Roach is a member of the Texas Trial Lawyers Association, Austin Bar Association, and is a past the director of the Capital Area Trial Lawyers Association (Director 1999-2005) Mr. Roach and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.