Medicare is federal health insurance primarily for people age 65+, but also available to some younger disabled people. This page explains Medicare in plain language and provides guidance for disabled people navigating it.
Medicare is:
- Health insurance: Covers doctor visits, hospital care, prescription drugs, and other medical services
- Federal program: Run by Centers for Medicare & Medicaid Services (CMS)
- Mandatory payroll tax: Funded by FICA taxes (Social Security and Medicare tax)
- Age-based and disability-based: Available at 65+ or earlier if disabled
Medicare is not Medicaid. They're completely different programs.
You can get Medicare if you:
Age requirement:
- You're 65 or older, OR
- You're under 65 and:
- You've received SSDI (Social Security Disability Insurance) for 24 months, OR
- You have End-Stage Renal Disease (ESRD), OR
- You have ALS (Lou Gehrig's disease)
Work history:
- You or your spouse worked and paid Medicare taxes for at least 10 years (40 quarters)
Citizenship:
- U.S. citizen or permanent resident (5+ years)
Medicare has different "parts." You don't have to take all of them, but understanding what each covers helps you choose.
Covers:
- Hospital inpatient care
- Skilled nursing facility (short-term, after hospitalization)
- Hospice care
- Home health care (in some situations)
Cost:
- No monthly premium (most people)
- Deductible: $1,660 per hospital stay (2024)
- Copayments/coinsurance for longer stays
When you need it: If you're hospitalized, admitted to nursing home, or need hospice
Covers:
- Doctor visits
- Outpatient care
- Diagnostic tests and imaging
- Mental health services
- Physical and occupational therapy
- Durable medical equipment
- Ambulance
- Many preventive services
Cost:
- Monthly premium: $164.90-$560.50 depending on income (2024)
- Annual deductible: $240 (2024)
- Copay or coinsurance (20% of approved amount after deductible)
When you need it: Regular doctor appointments, preventive care, testing
Covers:
- Prescription medications
- Coverage varies by plan
- Some drugs cost more than others (tiers)
Cost:
- Monthly premium: Varies by plan ($7-$100+)
- Annual deductible: Up to $505 (2024)
- Copay for each prescription: $0-$15 for generic, $0-$100+ for brand name
- "Donut hole" (coverage gap): After you and plan spend $4,150, you pay more until catastrophic coverage kicks in at $7,050 in total drug costs
When you need it: If you take prescription medications
What it is: Private insurance alternative to Original Medicare
- Covers Part A and B services
- Usually includes Part D (drugs)
- Often includes dental, vision, hearing (varies)
- HMO or PPO model (network doctors)
Cost:
- Lower or $0 monthly premium
- BUT: Higher out-of-pocket costs when you use services
- Often network-based (must use certain doctors)
Pros:
- Might have drug coverage included
- Sometimes dental/vision included
- Lower premiums
Cons:
- Limited provider networks
- Higher copays/coinsurance when you use services
- Must get referrals for specialists
- Coverage varies by plan
- Can be hard to switch plans
Initial Enrollment Period:
- 7 months around your 65th birthday (3 before, month of, 3 after)
- Missing this deadline = permanent penalty (1% extra per month delayed)
Automatic enrollment:
- If you get SSDI, you're automatically enrolled in Parts A & B 24 months after SSDI starts
Late enrollment penalties:
- Missing enrollment deadlines = permanent cost increases
- Only exceptions: qualifying life events, creditable coverage from employer
Changing plans:
- Annual Enrollment Period: October 15 - December 7
- Can switch between Original Medicare and Medicare Advantage
- Can change Part D plans
Medicare costs vary based on:
Your income:
- Higher income = higher premiums
- Income thresholds determined by CMS
Your coverage choice:
- Original Medicare + Supplement insurance: Higher monthly cost
- Medicare Advantage: Often lower monthly premium
Prescription drugs:
- Part D premium varies
- Donut hole coverage gap affects costs
Low-income help:
- Qualified Medicare Beneficiary (QMB): Covers Part B premium
- Specified Low-Income Medicare Beneficiary (SLMB): Covers Part B premium
- Medicaid (in some states) covers cost-sharing
- Extra Help program for Part D: Reduced drug costs
| Feature |
Original Medicare |
Medicare Advantage |
| Provider choice |
Go to any doctor |
Network doctors only |
| Referrals |
Don't need referrals |
Often need referrals |
| Out-of-pocket maximum |
None (can be unlimited) |
Usually has maximum |
| Prescription drugs |
Part D separate |
Often included |
| Extra benefits |
No |
Sometimes (dental, vision) |
| Switching |
Can switch any time |
Limited to enrollment periods |
| Cost predictability |
Varies by service |
More predictable |
Supplemental insurance helps pay costs Medicare doesn't cover.
Who should get it:
- If on Original Medicare
- Have predictable healthcare costs
- Want coverage predictability
Plans A-N: Different levels of coverage
Cost: $100-$300+ per month depending on plan
Where to buy: Private insurance companies (Medicare.gov has tool)
¶ Medicaid and Medicare
Medicare + Medicaid (Dual Eligible):
- If you qualify for both, you get benefits from both
- Medicare is primary
- Medicaid covers cost-sharing and fills gaps
- States run Medicaid, so coverage varies
Interactions:
- Eligibility for each determined separately
- Income and resource limits different
- Both can cover same service (usually Medicare pays first)
If you work before 65 and become disabled:
Before 24 months of SSDI:
- Work incentives let you earn without losing SSDI
- Trial Work Period: 9 months of unlimited earnings
- Medicaid continuation possible
- Extended eligibility period
After 24 months (when Medicare starts):
- Medicare continues even if you work and earn above SSDI limit
- Healthcare covered even if SSDI stops due to work
Disabled people on Medicare often:
- Need more healthcare than general population
- Have complicated medical needs
- May need assistive technology and equipment
- May need mental health and behavioral health services
- May need home health care
Things to understand:
- Medicare has specific rules for medical equipment
- Prior authorization often required
- Coverage can be complex
- Appeals possible if coverage denied
If Medicare denies a service or medication:
Process:
- Reconsideration: Request within 180 days
- Hearing: Administrative Law Judge hears case
- Appeals Council: Medicare's appeals council reviews
- Federal Court: Can file lawsuit in federal court
Getting help:
- Medicare.gov has appeal forms
- Patient advocates available
- Legal aid organizations
- Medicare beneficiary counseling (free, in every state)
What helps:
- Medical documentation
- Doctor's statement about medical necessity
- Evidence policy decision was wrong
- Patient advocate assistance
¶ Finding Doctors and Services
Medicare.gov search tool: Find doctors accepting Medicare
Questions to ask:
- Do you accept Medicare?
- What's your copay/coinsurance?
- Do you take Medicare Advantage plans (if you're on MA)?
- How do I get a referral if needed?
Mental health: Mental health professionals may be limited
- Find providers at Medicare.gov
- May have copays or coinsurance
- Different rates for individual vs. group therapy
Part D (prescription drugs):
- Compare plans at Medicare.gov
- Different plans cover different drugs
- Copays vary by "tier"
- Check if your medications covered before enrolling
Costs during coverage gap ("donut hole"):
- You pay negotiated price for drugs
- After spending $4,150 total on drugs (2024)
- Coverage resumes after $7,050 total out-of-pocket
- Manufacturer discounts help some people
Low-income help:
- Extra Help program: Reduced Part D costs
- Medicaid (in dual-eligible states)
- Manufacturer patient assistance programs
¶ Assistive Technology and Medical Equipment
Medicare covers assistive technology and medical equipment when:
- Doctor orders it as medically necessary
- Specific requirements met (varies by item)
- Usually Part B (20% coinsurance after deductible)
Examples:
- Wheelchairs and scooters
- CPAP machines
- Oxygen
- Walkers and canes
- Bathroom safety equipment
- Speech-generating devices (sometimes)
Requirements:
- Prescription from doctor
- Often prior authorization needed
- Specific supplier requirements
- May have rental vs. purchase rules
¶ Advocacy and Support
Getting help:
- State Health Insurance Assistance Program (SHIP): Free counseling (1-800-MEDICARE)
- Medicare.gov: Comprehensive information
- Disability Rights organizations
- Patient advocates
Dispute coverage:
- Medicare beneficiary ombudsman
- Legal aid organizations
- Disability advocacy groups
- Patient advocates
Myth: "Medicare covers everything"
Truth: Medicare has gaps; coinsurance, deductibles, and uncovered services mean costs
Myth: "You can only get Medicare at 65"
Truth: Disabled people can get it earlier if they meet requirements
Myth: "I lose Medicare if I work"
Truth: Medicare continues; working may stop SSDI but Medicare continues
Myth: "Original Medicare is always better"
Truth: Medicare Advantage works better for some people; depends on needs and budget
Myth: "I can change Medicare plans anytime"
Truth: Generally limited to annual enrollment periods; exceptions for life events
- Check eligibility: Call 1-800-MEDICARE or visit Medicare.gov
- Understand your options: Compare Original Medicare vs. Medicare Advantage
- Enroll during correct period: Don't miss deadlines (permanent penalties)
- Choose prescription drug plan: Part D required if taking medications
- Get help: Call for free counseling if confused
Have you navigated Medicare as a disabled person? Know about resources that should be included? Have coverage tips?
We welcome contributions from disabled Medicare beneficiaries, healthcare advocates, and Medicare specialists.
Contribute →
Last updated: [Date]
Maintained by: DisabilityWiki Benefits Team
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Need immediate help? Call Medicare: 1-800-MEDICARE (1-800-633-4227) | TTY: 1-877-486-2048