Many people think that Medicare is only for those aged 65 and above. However, if you are under 65 and receiving disability benefits, you also qualify for Medicare. People with amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ESRD) are covered by Medicare as soon as their disability benefits start.
This article will discuss ALS, ESRD, and Medicare with a disability – when coverage starts, benefits you will receive, and additional assistance available.
1. How do you apply for Medicare?
If you have ALS
Regardless of your age, you will be automatically enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance) if you are diagnosed with ALS, otherwise known as Lou Gehrig’s disease.
Other health care coverage for people with disabilities requires a 2-year waiting period. Fortunately, Medicare disability coverage for people with ALS begins on the same month that you start receiving Social Security Disability Income.
You need the following to qualify:
- Be under a treatment plan that was prepared and reviewed by a doctor.
- Receive certification from a doctor stating that you are homebound or unable to leave your home without personal assistance.
- Receive another certificate from a doctor that states that you require part-time skilled nursing care or therapy.
- Be cared for by a home health agency that is approved by Medicare.
You have two choices to receive Medicare coverage if you have ALS: Original Medicare (Parts A and B) or Medicare Advantage (Part C).
It’s also beneficial to enroll in a prescription drug plan (PDP or Part D) to receive coverage for prescription medication needs. If you are enrolled in Original Medicare, you can join a standalone PDP. Many Medicare Advantage (MA) plans have bundled Part D included. Enrolling in a Part D plan will likely help with your ALS treatment.
You can choose to delay your enrollment in Part B in some specific circumstances. For instance, having health coverage from your (or your spouse’s) job allows you to defer enrollment in Part B without facing late enrollment penalties.
If you have ALS and are working past 65 but would like to enroll in Medicare, the same rule applies. You can delay your Part B enrollment if your job sponsors your health coverage.
If you have ESRD
Individuals with ESRD have permanent kidney damage that requires dialysis or kidney transplant. Like Medicare with ALS, if you have ESRD, you are covered by Medicare Parts A and B even if you are under 65. Your eligibility starts as soon as you start receiving disability benefits from Social Security.
If you don’t sign up immediately, you can receive retroactive coverage, which starts up to 12 months before the month you applied to Medicare.
Enrolling in Part B is optional if you have ESRD. However, it is recommended that you enroll in Medicare Part A, Part B, and Part D to get the full benefits of Medicare for your treatment.
If you are receiving dialysis
Your Medicare coverage starts on the first day of the fourth month of dialysis. Let’s say your dialysis begins on February 1. Your Medicare coverage will begin on May 1. However, if you have coverage through your employer, the employer group health plan will typically pay for the first three months of your dialysis.
If you don’t have coverage from your (or your spouse’s) job, one way to be covered from your first month of treatment is to undergo home dialysis. The following are necessary:
- Enroll in a Medicare-certified home dialysis training program during your first three months of dialysis
- Perform self-dialysis treatment after your training, as per instructions provided by your doctor
If you stop self-dialysis and start receiving treatment at a dialysis center, your Medicare benefits will stop. To resume your Medicare coverage, you have to wait until you receive four months of dialysis treatments.
Your Medicare coverage will end 12 months after you stop dialysis treatments. Your coverage will resume if you begin dialysis again.
If you are getting a kidney transplant
Your coverage starts on the month of admission into a Medicare-certified hospital. If your transplant is postponed for more than two months, coverage starts two months before your scheduled transplant.
So, if you are hospitalized for a kidney transplant on March 15, your coverage starts in March. If your transplant is moved to May, your coverage still begins in March.
If you’re eligible for Medicare only because of permanent kidney failure, your Medicare coverage will end:
- Twelve months following the month that you stop dialysis treatments; and
- 36 months following the month you receive a kidney transplant
Just like with Medicare disability benefits for people with ALS, you have two options to enroll in Medicare:
- Original Medicare, where Parts A and B provide coverage for dialysis, kidney transplants, and related drugs.If Part B does not pay for some of your prescription drugs, you can get a standalone prescription drug plan (Part D). You can sign up during the following periods:
- Three months before you qualify for Medicare
- The month you are qualified for Medicare
- Three months after the first month that you are eligible for Medicare
If you have a medical condition lasting more than one year, you may be qualified for Social Security disability benefits. Check this complete list of impairments – classified as neurological, respiratory, or immune system disorders. A few examples are multiple sclerosis, Parkinson’s disease, and lupus.
Once you apply with SSA, it could take five months before you start receiving disability benefits. Then, after receiving benefits for at least 24 months, you become eligible for Medicare (Parts A and B).
You can defer your enrollment in Part B to a later date if you still have health coverage from your (or your spouse’s) employer.
Once you have decided on the type of coverage you want, you can join Original Medicare or a Medicare Advantage (Part C) plan. You should also consider a Part D plan. You should enroll in Medicare during your initial enrollment period (IEP). You can change Parts C and D during the annual enrollment period (AEP).
2. What benefits can you claim under Medicare?
ALS and Medicare Disability Benefits
Part A covers inpatient hospital services (including lab tests and surgery).
If you have difficulty leaving home without extensive effort, you may be eligible for skilled nursing care (if medically necessary), hospice, and other home health care services. To be qualified, you will need a certificate from your doctor. Plus, you should be following an ALS care plan under the supervision of a doctor who visits your residence regularly.
Part B covers outpatient services, durable medical equipment, diagnostic tests, and other services to help treat ALS, like:
- Physical and occupational therapy
- Speech-language therapy
- Medicines used in intravenous infusions
If you have Part D, your private insurer will pay for home infusion treatments.
ESRD and Medicare Disability Benefits
Medicare Parts A and B will cover your:
- Kidney transplant
- Transplant drugs after a covered transplant
- Dialysis-related drugs
3. Do you need help paying for out-of-pocket costs?
Although enrolling in Medicare provides significant benefits to people with a disability, it is not entirely free. You need to pay for out-of-pocket expenses – premiums, deductibles, copayments, and coinsurance.
If you need additional coverage, the following are good options:
- Medigap plans These are supplementary plans for Original Medicare. Medigap plans help to pay for Parts A and B out-of-pocket costs.Some Medigap plans are more popular. If you are under 65, Medigap premiums may be more expensive. You may want to wait until you reach 65 to apply.
- Special Needs Plans (SNP) From its name, Medigap means filling the gap that Original Medicare does not cover. Original Medicare only covers 80 percent of Part B costs. You are responsible for the remaining 20 percent, like deductibles, copays, and coinsurance. Plus, on Original Medicare, there is no maximum cap on how much you need to pay in one year, unlike coverage under the Affordable Care Act (ACA).
- Medicare savings plans (MSP) If you have limited income or resources, you may qualify for these Medicaid-administered programs. Depending on your state’s eligibility requirements, MSPs help in paying your out-of-pocket costs.For those below 65, you may want to check Qualified Disabled and Working Individuals (QDWI). This program helps disabled workers pay for their Part A premiums after returning to work.
- Extra Help or Part D Low-Income Subsidy (LIS) Low-income individuals may qualify for full or partial subsidies to help to cover Part D drug expenses.
- Supplemental Security Income (SSI) Social Security gives cash benefits for disabled people with limited income and resources.
- Veterans Affairs health care program If you are a veteran and had at least 90 continuous days of active duty, you have financial and medical support for ALS from the Veterans Affairs office. Likewise, there are health care services available for veterans with ESRD.
4. Will your disability be covered by Medicare even if you are working?
You will continue to enjoy the benefits of Medicare as long as you are medically disabled. If you decide to return to work, your Part A premium is free for the first 8.5 years. But afterward, you are expected to pay premiums on your own.
If you need help paying your Part A premiums, try applying for QDWI. This program is for individuals with a disabling impairment who continue working.
Many Americans have been diagnosed with ALS, ESRD, and other disabilities. However, there is help available to pay for medical costs associated with these conditions through Medicare. The information provided in this article about ESRD, ALS, and Medicare disability benefits should help you access the right type of healthcare you need to help manage these and other conditions.